BACKGROUND: The low rate of organ donation in Germany has been linked to a deficit in the detection of patients with brain death (BD) in hospitals. It is unclear how crisis-related health system disruptions, such as the COVID-19 pandemic, affect this detection deficit. METHODS: Secondary data analysis of anonymized data from deceased patients with acute brain injury from Saxony, Saxony-Anhalt and Thuringia during the pre-pandemic and pandemic period (01/2019-12/2022). Pandemic phases were stratified according to the predominant SARS-CoV-2 variant. Logistic multilevel models were employed to assess outcomes including diagnosis of BD, deceased organ donations, missed cases with potential BD and organ donation-related interactions with the German Organ procurement organization. Models accounted for regional COVID-19 incidence and first-dose vaccination rates, as well as age, gender and types of brain injuries. RESULTS: A total of 11,100 deceased individuals from 136 hospitals were analyzed. An inverse association was observed between COVID-19 incidence and the determination of BD (adjusted odds ratio [aOR] 0.94, 95%CI [0.91
0.97]
p <
0.001) as well as deceased organ donation (aOR 0.94, 95%CI [0.90
0.98]
p = 0.001). When stratified by pandemic phases, this inverse association was evident for both BD determination (aOR 0.92, 95%CI [0.87
0.99]
p = 0.02) and deceased organ donation (aOR 0.90, 95%CI [0.83
0.97]
p = 0.01) during the initial wild-type phase. In the alpha phase, the association was observed only for BD determination (aOR 0.76, 95%CI [0.59
0.98]
p = 0.03). No association was found in subsequent pandemic phases. CONCLUSION: The initial impact on BD detection during the pandemic highlights the importance of the health system's adaptive capacity in times of crisis.