Renal transplantees have special education needs
Renal transplantees have special education needs
Classes cover key issues in short period of time
One of the challenges of reducing length of stay (LOS) for renal transplants is making sure patients receive appropriate education about their diagnoses before they leave the hospital.
At Shands Hospital at the University of Florida in Gainesville which has provided renal transplants for more than 30 years practitioners successfully found a way to reduce the average LOS from 15 to eight days from 1994 to 1996, says renal transplant nurse practice coordinator Nancy Upthegrove, RN, MSN. But she says education of post-transplant patients had to be strengthened, which was accomplished by holding regular classes for especially on their medications.
Upthegrove says the eight-day LOS is lower than the mean LOS of 9.9 days reported by the University HealthSystem Consortium (UHC) in Chicago, a group of 90 teaching hospitals. In fact, in 1996, an analysis of Shands’ outcomes indicated that half the patients on the renal transplant pathway were being discharged by postoperative day four.
One way the hospital decreased LOS was by having patients bypass the surgical intensive care unit (SICU), and admitting them directly to the post-anesthesia care unit (PACU).
"The renal transplant team had streamlined their protocol so much that patients didn’t need [the SICU stay]," says Upthegrove. "They also found that patients didn’t have complications frequently enough to warrant that high level of care."
Patients still require intensive monitoring postoperatively for fluid and electrolyte levels, for example. (See sample clinical pathway, pp. 49-50.) In the 1996 analysis of 30 patients who bypassed the SICU, Upthegrove says outcomes were good. "We found there were no physical consequences to the patient," she says. "The nurses took very good care of the patients, and the patients did well." She estimates that the pathway saves about 30% of previous costs.
But the study also found that patients sometimes were ready to go home before they had achieved all of their educational objectives. "When you’re looking at a length of stay of only five days or so, and when you used to have a week to 10 days [of patient care], you have to streamline your education and get it done sooner and quicker," Upthegrove says.
The multidisciplinary renal transplant team then looked at ways to improve education. They decided to start having patient classes three times a week. Most classroom teaching revolves around medications, especially cyclosporine.
"The medications have to be taken correctly, and the patient has to understand that if they don’t take them, they’ll lose their graft," Upthegrove notes. "They also have to understand that they’ll have to take medications for the rest of their lives, and they should know the side effects of the medications, such as weight gain with prednisone."
Nurses learn how to teach
The transplant coordinator and staff nurses who have completed a competency module on transplant education teach patients. "The module not only teaches the nurses about education, but it teaches them how to teach," she says.
The module contains objectives, such as nurses will be able to explain post-transplant expectations related to activity, medications, and incision care. The portion of the module on medications, for example, explains the action, dose, possible side effects, and nursing implications for each drug the patient must take.
Patients also are given a booklet, "You & Your Kidney," which explains all aspects of their transplant, from what to expect after surgery to dietary changes and sexual functioning. An audiocassette tape and a large-print copy of the booklet are available to the visually impaired, and interpreters knock down language barriers.
Counselor explains medication costs
Education also focuses discharge education on obtaining medications, Upthegrove days. The costs of the medications are high about $900 to $1,200 a month during the first months after transplant, and about $600 to $1,000 a month thereafter, she says. To ensure patients are prepared for those costs, a pharmacy financial counselor sees patients before surgery to explain the costs and how much their insurance, Medicare, or Medicaid coverage will reimburse for medications.
Patients also are seen after surgery by outpatient pharmacists and financial counselors who explain reimbursement for medications, and which pharmacies will fill their prescriptions. Some patients elect to have prescriptions filled at the Shands outpatient pharmacy; others who live out of town may be able to use their neighborhood retail pharmacy, Upthegrove says.
"Before we did this, patients were sometimes ready to leave the hospital with no idea where they were supposed to go for their medications," she says. "Some of them had to come up with a couple of hundred dollars for their medications. Now, we’re trying to get them prepared for [arranging to get their] medications when they’re discharged. So when they get their discharge prescriptions, patients know exactly what to do with them."
Longer LOS for delayed graft function
Not all renal transplant patients can leave the hospital after eight days because of delayed graft function, Upthegrove adds. "Those patients have a longer length of stay because we have to rule out rejection," she explains. "The signs they have after their transplant, such as an increased creatinine [level] and in some cases, no urine output can also resemble rejection."
Upthegrove says the renal transplant team is developing a protocol for delayed graft function patients, and then the renal transplant pathway team will develop a clinical pathway for that diagnosis.
"We’re hoping we can get them down to about a seven-day length of stay," she says. "We need to rule out rejection, which may require biopsy."
Upthegrove recommends that other hospitals seeking to reduce LOS for renal transplant patients rely on a multidisciplinary group of clinicians to develop a pathway. "Try to find an objective facilitator, and let the group brainstorm," she advises. "A lot of your ideas for changes will come from within. Participants can usually identify for themselves what opportunities for improvement exist."
She also recommends looking for benchmarking data from other hospitals in your area or from groups such as UHC to determine comparative LOS data. "Then set up some targets, and have the group brainstorm again about how they can get there," Upthegrove says.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.