Survival Skills: Post-transplant education at the bedside. Mara Saunders, RN, NP-BC

Transcription

1 Survival Skills: Post-transplant education at the bedside Mara Saunders, RN, NP-BC

2 Objectives: 1. Outline the primary goals of post-transplant education, and common teaching approaches used in the acute care setting 2. Describe individual and systems-level challenges to effective post-transplant education 3. Highlight areas for improvement, and discuss patientcentered approaches to promote knowledge and empowerment after transplant

3 What s at Stake? National Transplant Statistics *(OPTN/SRTR data as of 9/14/12) Annual Transplants (2011) vs. Current Waiting Candidates Kidney: 16,813-93,413 Liver: 6,342-16,010 Pancreas: 287-1,239 Kidney-Pancreas: 795-2,153 Average Wait Time (in days, by blood type) ( ) Kidney: 855 (AB) - 1,935 (B) Liver: 76 (AB) (O) Pancreas: 281 (AB) (O) Kidney-Pancreas: 264 (AB) (B) Percent of Candidates Transplanted (at 2-year point, by blood type) ( ) Kidney: 19.9% (O) % (AB) Liver: 54.5% (O) % (AB) Pancreas: 52.0% (O) % (AB) Kidney-Pancreas: 48.4% (B) % (AB)

4 What are Survival Skills? Complex medication management: Many new medications green card, multiple daily or weekly dosing, dosing windows, BP/HR parameters, hold for lab days, no grapefruit Preventing infection and rejection: Avoidance of common pathogens, frequent urination, no live vaccines, lab monitoring, daily monitoring of temp/bp/weight, recognizing signs and symptoms, clinic visits, when to call for help Routine health maintenance: Cancer prevention & screening, abx for dental work, nutrition, exercise, sunscreen Recovering from surgery: Wound care, rest, exercise, driving, working, sex Bonus points: JP care, foley care, blood glucose monitoring & insulin dosing

5 What s at Stake? Kidney: Dece ased Donor Kidney: LivingDonor Pancreas Alone Pancreas After Kidn ey Kidney-Pancreas Liver: Dece ased Donor Liver: Living Donor Organ and Su rvivaltype Follow-up Per iod 3 Months 1 Year 3 Years 5 Years 10 Years Tx Tx Tx Tx Tx GraftSurvival 95.6% 91.7% 81.8% 70.8% 44.9% PatientSurvival 98.3% 96.0% 90.0% 82.7% 62.0% GraftSurvival 98.0% 96.5% 90.5% 82.8% 61.2% PatientSurvival 99.5% 98.6% 95.8% 91.6% 77.6% GraftSurvival 85.0% 74.8% 62.6% 52.0% 35.1% PatientSurvival 97.9% 96.9% 92.0% 89.7% 77.6% GraftSurvival 86.9% 80.4% 66.2% 55.3% 36.8% PatientSurvival 98.2% 95.9% 93.4% 85.9% 68.9% Kidney Graft Survival 95.8% 92.9% 87.0% 79.1% 60.5% Pancreas GraftSurvival 89.7% 86.1% 79.5% 73.2% 56.1% PatientSurvival 97.9% 96.0% 92.1% 87.8% 72.0% GraftSurvival 91.7% 85.2% 75.1% 68.5% 54.8% PatientSurvival 94.6% 88.9% 79.9% 73.6% 60.4% GraftSurvival 91.3% 88.2% 80.1% 74.6% 59.6% PatientSurvival 94.6% 92.0% 84.7% 80.8% 67.4%

6 What s at Stake? High rates of non-adherence to medications and clinic visits (kidney), and relapse to drugs/etoh/cigarettes (liver) Leading causes of late morbidity & mortality (graft rejection, cancer) Increased health care costs ($33K), decreased quality of life Increased risk of mortality (78%) with return to HD after transplant Non-adherent behaviors may prevent patient from being re-listed First 6 months is predictive of long-term outcomes Opportunity to interact with a variety of HC professionals in one setting Patterning behaviors, overcoming barriers Future opportunities for education and support may be limited Captive audience while in the hospital

7 Common Approaches Pre-transplant preview Orientation class pre- or post-listing, pre-transplant binder or packet mailed to home Face-time with team members post-transplant Nurses, coordinators, MDs, pharmacists, dieticians, diabetes specialists Education integrated with daily RN care, 1-2hr class with coordinator Post-transplant checklist to standardize approach Involving support systems Caregivers attend pre- and post-transplant education sessions Support groups in the hospital with caregivers, past patients Homework Post-transplant binder/handbook, med card Handouts on drain care, foley care, diabetes care References to websites

8 Barriers to Education ANNA Transplant Special Interest Group Topic (2008) Inadequate literacy/health literacy Compressed time due to mandate for decreased length of stay Sedating effect of pain medication Distractions (pain, fatigue, anxiety) Language barriers Information overload Cultural differences Lack of repetition of concepts Low participation of patients in their own care Depression Failure of caregivers to attend education sessions

9 Barriers to Education Individual-Level Inadequate literacy/health literacy Sedating effect of pain medication Distractions (pain, fatigue, anxiety) Cultural differences Language barriers Information overload Low participation of patients Depression, Anxiety, PTSD Avoidant behaviors, Poor coping mechanisms Lack of family/community support Failure of caregivers to attend Caregiver burnout Systems-Level Heavy reliance on printed material Mandate for decreased length of stay Lack of repetition of concepts Standardized approach to education Translated materials & interpreters N/A Lack of designated RN time for education Regulations limit teaching tools Limited resources to address MH issues No RN training around MH barriers Lack of support for caregivers Provider-centric model Limited outreach, telecommunication use Poor/inconsistent quality of info online

10 Avenues for Change Early and continued outreach and education More use of pre-transplant teaching tools (e.g. videos/handouts at HD centers) Consistent education throughout evaluation and waiting phase More home visits and community-based outreach post-transplant Leverage internet and cell technology (develop organization/reminder apps, text communication, internet portals) More follow up for patients at greater risk (due to MH, substance abuse, etc.) Increased support for caregivers and family Caregiver-specific classes pre-transplant offering anticipatory guidance Support groups or regular check-ins with caregivers post-transplant More emphasis on participatory/empowering approach for caregivers Widen the net identify other caregivers/resources within the community (e.g. peer advocates, community health workers)

11 Avenues for Change Prioritize education, and customize to meet patient s needs Designate discrete themed teaching sessions to avoid information overload and allow for repetition Train nurses around teaching/learning styles, working through barriers Pre-screen patients for MH/behavioral barriers, learning style, risk factors Develop a comprehensive teaching curriculum that is shared between providers Schedule interpreters for discrete teaching sessions Greater emphasis on patient involvement and empowerment ( teach back method vs. didactic, developing organization, routine, problem-solving skills) Improve quality of online and printed materials Review websites and offer list of vetted resources Develop more institutionally-sponsored websites Translate written materials into more languages Develop more non-written education materials (e.g. videos, pictorial handouts)

12 Promising Approaches Ruppar et. al (2009) Qualities of successful kidney recipients Qualitative study of 19 kidney recipients with grafts lasting >25 years 4 common themes identified: reminder methods, obtaining medications, maintaining routines, problem-solving strategies Tong et. al (2008) Caregiver support intervention Systematic review of 3 interventions directed at caregivers of patients with CKD (pre and post-transplant) Caregiver training reduces cost and burden, and improves long-term psychosocial outcomes for caregiver and patient Participatory and empowerment approaches are most effective Russell et. al (2011) TIMELink Study RCT of a continuous self-improvement intervention involving 30 adult kidney transplant recipients Continuous self-improvement approach shows promise in increasing medication adherence, and could be delivered in inpatient setting Focus on working actively with patients, identifying individual challenges, resources, and solutions, and providing continuous feedback

13 Promising Approaches Suggestions??? Thank You!

14 References Fredericks, E.M. & Dore-Stites, D. (2010). Adherence to immunosuppressants: How can it be improved in adolescent organ transplant recipients? Current Opinions in Organ Transplantation, 15(5), Hanif, F., Read, J. & Gibbs, P. (2009). The internet as a tool for patient-centered care in transplantation. Experimental and Clinical Transplantation: Official Journal of the Middle East Society for Organ Transplantation, 7(4), Jin, S., Yan, L., Xiang, B., Li, B., Wen, T., Zhao, J., Xu, M. & Yang, J. (2012). Posttraumatic stress disorder after liver transplantation. Hepatobiliary & Pancreatic Diseases International, 11(1), Neyhart, C.D. (2008). Education of patients pre and post-transplant: Improving outcomes by overcoming the barriers. Nephrology Nursing Journal, 35(1), Organ Procurement and Transplantation Network (OPTN) and Scientific Registry of Transplant Recipients (SRTR) Annual Data Reports. Accessed 14 September, 2012 at: Ruppar, T.M. & Russell, C.L. (2009). Medication adherence in successful kidney transplant recipients. Progress in Transplantation, 19(2), Russell, C., Conn, V., Ashbaugh, C., Madsen, R., Wakefield, M., Webb, A., Coffey, D. & Peace, L. (2011). Taking immunosuppressive medications effectively (TIMELink): a pilot randomized controlled trial in adult kidney transplant recipients. Clinical Transplantation, 25(6), Stilley, C.S., DiMartini, A.F., devera, M.E., Flynn, W.B., King, J., Sereika, S., Tarter, R.E., Dew, M.A. & Rathnamala, G. (2010). Individual and environmental correlates and predictors of early adherence and outcomes after liver transplantation. Progress in Transplantation 20(1), Tong, A., Sainsbury, P. & Craig, J.C. (2008). Support interventions for caregivers of people with chronic kidney disease: a systematic review. Nephrology Dialysis Transplantation, 23, UCSF Data Center Transplant Summary CY2012 M. Lalonde, UCSF Inpatient Liver Transplant Coordinator, correspondence: 9 Septemeber 2012 L. Wedge, Beth Israel Deaconess Med Ctr Liver Transplant Coordinator, correspondence: 12 Septemeber 2012 A. Phelps, UCLA Inpatient Kidney/Pancreas Transplant Coordinator, correspondence: 29 August 2012