Advanced Achievement in Transplant Management Getting Prepared Part 2 Section Overview This section of the AATMC will address the aspects of transplant management from a managed care nursing perspective. The world of transplantation is changing daily with new technology and protocols utilized for advancement in the field. This poses many challenges for nurse case managers to stay current in this ever-evolving specialty. The patient who has been advised that a solid organ or bone marrow transplant may be their best treatment option needs a nurse case manager advocate by their side. As the nurse case manager, you will be of assistance to and a sounding board for the patient as he/she makes healthcare decisions of which among the first will be selecting a transplant program or possibly looking at the attributes of the recommended transplant program. The goal of Getting Prepared is to provide tools and information to ensure a successful transplant management plan of care. In Part 2 we will begin with the pre-transplant phase and end with the patient at home post transplantation. Section Objectives At the end of this session you will be able to: Understand the nurse case manager s role in each transplant phase of care. Describe the components of a well planned discharge to ensure a successful transition to the outpatient setting. Pre-Transplant Phase
When the transplant is approved, the patient is placed on the waitlist through the United Network for Organ Sharing (UNOS). Wait times vary by organ, blood type, age, region in the country, and other variables. The patient continues with their current medical regimen. The nurse case manager will be the conduit and have ongoing discussions with the patient and their caregiver, PCP, and transplant team to ascertain that the patient is adhering to their current treatment plan, all testing is complete and document signatures are on file. It is imperative that all necessary components are in place so when the patient receives the call that a suitable donor is identified they are prepared to proceed immediately to transplantation. Transplant candidates require close monitoring of their co-morbidities to make sure they are in as best condition as possible for their upcoming transplant. During this period, education of the patient and caregiver continues to optimally prepare them for their transplant event. The nurse case manager will anticipate and plan for post-transplant care that includes ancillary services. A post-discharge plan of care should be in place when the transplant event occurs. The pre-transplant phase for the BMT candidate in terms of preparation may mean additional chemotherapy, stem cell collection for autologous candidates and donor testing of siblings or unrelated donor/cord blood search. Transplant Phase What a monumental event for the patient and their family. After months of clinical care and logistic planning, they have reached the long awaited moment, transplantation. For many solid organ patients, the wait could have been many years. Most BMT patients will have thei r transplant in the range of three to four months after their evaluation. Although BMT is a planned event, the days leading up to the transplant are no less stressful or physically challenging for individuals facing bone marrow transplantation. Let s focus on the transplant inpatient admission. Upon identification of a donor, the patient is admitted for their solid organ transplant. Inpatient length of stay varies but generally ranges from five to fifteen days for solid organ transplants the exception being intestine transplantation. As is the case with all surgical patients, the immediate post operative period focus is frequent assessment and close monitoring of the patient s overall physical and neurological status for signs of potential complications.
BMT patients are admitted when they are to begin their ablative therapy regimen. Nonmyeloablative transplants may be done on an outpatient basis. Inpatient length of stay is one to six weeks. In most instances the shorter length of stay correlates to the autologous BMT patient and longer stays the unrelated allogeneic and cord blood patients. The BMT Protocol treatment regimen is laid out in a day sequence. For example, protocol states ablative therapy to start Day -7 (read day minus 7) means 7 days prior to transplant. In the BMT world, Day 0 is transplant day (infusion of stem cells or bone marrow). Going forward from Day 0, days are displayed Day +1, Day +2 and so forth. The treatments required before and during bone marrow transplantation can have serious side effects. Prior to the BMT admission, the transplant coordinator will make the patient and their caregiver aware of the most common side effects (e.g., diarrhea, nausea, vomiting, mouth sores) as well as the types of treatments that are available to improve comfort. After reinfusion of the stem cells, the patient s blood counts will be monitored for marrow recovery engraftment. Engraftment can occur as early as 10 days after transplant, although 15 20 days is common for patients. Cord blood recipients usually require 25 35 days for engraftment. As the patient s immune system recovers and gets stronger, she/he will require supportive care in terms of irradiated blood products (platelets, packed cells). Patients who undergo bone marrow transplantation are at an increased risk of infection for many months following transplantation. Again, the transplant coordinator will teach the patient and their caregiver signs and symptoms infection, graft versus host disease. Patient education and discharge planning are initiated and continue throughout the transplant stay with the patient and their caregiver. The primary educator is the transplant coordinator. There is a tremendous amount of information to be communicated to the patient and caregiver. That is why education reinforcement is such a vital component to ensure the transplant patient and their caregiver is successful in the areas of self-care and self-monitoring. Discharge Teaching Plan: When to call the transplant center Recognizing signs and symptoms of infection and rejection (solid organ, allogeneic and cord blood patients) Monitoring blood pressure, pulse, temperature, weight Medication education immunosuppressants and other meds
Diet and activity recommendations Follow-up clinic appointments Required lab tests Post-Transplant Phase Unless the patient lives in close proximity to the transplant center, the patient will be discharged to transplant designated facility housing with their caregiver by their side. The post-transplant will continue at the transplant clinic. Transplant programs require the patient to remain in close proximity to the transplant center at a minimum of one month for kidney, kidney/pancreas, liver, heart and autologous bone marrow transplant patients. Lung, heart/lung, intestine, allogeneic related and unrelated, and cord blood transplant patients are required to remain at the transplant center typically three months or longer because of their complex care requirements and to ensure their medical condition has stabilized. Initially, the patient will be seen in clinic 1 to 2 times weekly or sometimes in the case of a BMT patient, daily. The number of visits per week is dependent upon the transplant type and treatment, in addition, taking into account each individual s clinical picture. The frequency of clinic visits will lessen as the patient progresses farther and farther out. Let s examine the role of the nurse case manager in the post-transplant realm. Communication will continue with the multidisciplinary team members as displayed on the Optimizing Communication Wheel. Most likely the nurse case manager's primary interactions will lie with the patient and their caregiver, transplant coordinator and reinsurer. The nurse case manager s conversation with the patient and their caregiver should center on these areas: Self-management of immunosuppressant therapy Follow-up clinic appointments Ordered blood work and other tests Nutrition Activity Caregiver support
Assessment of ancillary support When to call the transplant center Transition to Home The patient given the green light to return home is a milestone indicator the patient is stable from both a physical and psychosocial standpoint. Once home, the patient is required to contact the transplant coordinator to self-report current status on the following: vital signs, weight, current medication list (dose, amount, and frequency), lab dates and results, nutrition status, activity level, and appointment dates with PCP. Other areas the transplant coordinator will assess are the patient s general well-being, caregiver support system and interactions with family and friends. The nurse case manager will be working with the patient and their caregiver along with the transplant coordinator to ensure patient adherence. The nurse case manager serves as the liaison for the patient and their family, provides and reinforces transplant education. The first year post transplant the patient will return to the transplant center at designated time frames. The nurse case manager's role changes from management of the case to monitoring and reporting. After one year of decreasing monitoring, the case is closed and final reports prepared.