Successful Transitions in Transplant Between Hospitalization and Outpatient Care

Abstract

Topic Significance & Study Purpose/Background/Rationale: Hematopoietic Cell Transplant (HCT) patient care has increasingly shifted from inpatient (IP) to outpatient (OP) care as transplant centers consider cost containment, outcomes, and patient satisfaction. Approximately 500 transplants (autologous and allogeneic) a year are performed at our academic medical center and outpatient clinic. Patients admitted to the IP HCT services reflect all phases of transplant care, including mobilization, conditioning, stem cell infusion, and management of acute and chronic post-transplant complications. The care needs for HCT patients at time of discharge are complex due to infection risk, transfusions, vascular access device care, medication regimens, financial constraints, and the shift in caregiving responsibilities from hospital staff to the patient, caregiver, and outpatient medical providers. The transition to OP HCT care is facilitated by Transition Nurses (TN) working with multidisciplinary teams in both the IP and OP departments. Methods, Intervention, & Analysis: Daily, the TN bridge the gap of approximately 6miles between two different IP hospital settings (adultandpediatric)andtheOPclinic toprovidepatient and caregiver education, care coordination, and discharge planning. TN participate in IP interdisciplinary rounds to assess care needs and resolve barriers to discharge. Requisite skills are providing education on insulin, hyperglycemia management, subcutaneous injections, home infusion, central venous catheter care, management of symptoms, infection prevention, and navigating the OP clinic. TN assist patients with deciphering insurance benefits, initiate referrals to vendors for home care needs, and provide nursing hand-off communication to the OP clinic. Transfers to SNFs for patients that require additional post HCT care are also facilitated. Data collection is ongoing for quality indicators of transitions such as rates of readmissions, length of stay, patient satisfaction, and infection rates. Findings & Interpretation: The TN provide crucial complex care planning and education to support transfers of care from the IP to the OP. Initial data results shows high patient satisfaction and adult HCT IP length of stay an average of 2 days less than other academic medical centers. Discussion & Implications: Transition Nurses demonstrate an exemplar model of coordination of care delivery integral to HCT patients achieving the highest quality outcomes in all clinical settings.