Good Practices in Transitional Care: continuity of care for patients undergoing liver transplantation

Wachholz, Laísa Fischer; Knihs, Neide da Silva; Sens, Suyan; Paim, Sibele Maria Schuantes; Magalhães, Aline Lima Pestana; Roza, Bartira de Aguiar

doi:10.1590/0034-7167-2020-0746

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Brasil

Revista Brasileira de Enfermagem

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Brasil

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ORIGINAL ARTICLE • Rev. Bras. Enferm. 74 (2) • 2021 • https://doi.org/10.1590/0034-7167-2020-0746 copy

Good Practices in Transitional Care: continuity of care for patients undergoing liver transplantation

Buenas Prácticas en la Atención Transicional: continuidad de la atención de los pacientes sometidos a trasplante de hígado

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

Objectives:

to develop a guide of care recommendations for good practices in care transition for adult patients undergoing liver transplantation.

Methods:

a methodological study, based on the Appraisal of Guidelines for Research & Evaluation in the updated version, II. Care recommendations were sustained by conducting an integrative literature review and qualitative research.

Results:

from evidence, three topics emerged: Care Transition Planning; Health Education for Self-Care; Care Management. Each of the central topics has respective subtopics, totaling six, giving rise to 30 care recommendations. Concerning evaluators’ scores, in all domains the scores were higher than 90%.

Final Considerations:

the proposed guide assists professionals in conducting care transition in liver transplantation, ensuring greater safety for patients in continuity of home care.

Descriptors:
Transplant; Liver Transplant; Continuity of Patient Care; Nursing; Nursing Education

Health Education for Self-Care Axis
Evidence (integrative review)	Category: Self-care
At home, patients present increased appetite, diarrhea or constipation, nausea and vomiting, changes in body image, body sensation, sexuality, decreased libido, altered sleep pattern and wakefulness, and lower limbs edema (Author⁽¹⁶16 Oliveira NSP, Oliveira TM, Corrêa AR, Tiensoli SD, Bonisson PLV, Guimarães GL, et al. Nursing diagnoses of post-liver transplantation patients in outpatient follow-up. Cogitare Enferm. 2019;24:e59149. https://doi.org/10.5380/ce.v24i0.59149 https://doi.org/10.5380/ce.v24i0.59149... ⁾ - level of evidence: V). Daily control should be instructed to patients in hospital discharge for successful transplantation and early detection of adverse events (Author⁽¹⁷17 Beckmann S, Künzler-Heule P, Biotti B. Mastering together the highs and lows: patients' and caregivers' perceptions of self-management in the course of liver transplantation. Prog Transplant. 2016;26(3):215-23. https://doi.org/10.1177/152692481665476 https://doi.org/10.1177/152692481665476... ⁾ - level of evidence: V).	Patient	Participant note
	I feel very tired. I got weight. I don't exercise, I'm inactive, I need to take care of myself. They asked me this. (Patient 4) I was asked to verify the temperature, assess the pee, see weight, diabetes. I had to turn around, do my best to take care of myself. (Patient 14) I had to take care, especially with the use of medications and with food, with food it was too much. (Patient 8)	Virtually no patient scored the development of physical activity (OA). Many patients took care at home for personal hygiene and medication use (OV).
Evidence (integrative review)	Category: Health Education
Clarification on complications to avoid injuries (Author⁽¹⁸18 Bardet JD, Charpiat B, Bedouch P, Rebillon M, Ducerf C, Gauchet A, et al. Illness representation and treatment beliefs in liver transplantation: an exploratory qualitative study. Elsevier BV. 2014;72(5):375-87. https://doi.org/10.1016/j.pharma.2014.05.005 https://doi.org/10.1016/j.pharma.2014.05... ⁾ - level of evidence: IV) Nurses should provide information to patients and family members about status of employment and possible problems after transplantation (Author⁽¹⁹19 Moayed MS, Ebadi A, Khodaveisi M, Toosi MN, Soltanian AR, Khatiban M. Factors influencing health self-management in adherence to care and treatment among the recipients of liver transplantation. Patient Prefer Adherence. 2018;12:2425-36. https://doi.org/10.2147/PPA.S180341 https://doi.org/10.2147/PPA.S180341... ⁾ - level of evidence: V). Transplant patients may have pre-existing Diabetes Mellitus. For this, it is necessary to teach patients and family to perform the correct control of blood glucose, as well as the application of insulin (Author⁽²⁰20 Wallia A, Illuri V, Molitch M. Diabetes care after transplant. Med Clin North Am. 2016;100(3):535-50. https://doi.org/10.1016/j.mcna.2016.01.005 https://doi.org/10.1016/j.mcna.2016.01.0... ⁾ - level of evidence: V). The main nursing diagnoses for hospital discharge from liver transplantation are Risk for infection, Risk for unstable blood glucose and Risk for impaired liver function (Author⁽¹⁶16 Oliveira NSP, Oliveira TM, Corrêa AR, Tiensoli SD, Bonisson PLV, Guimarães GL, et al. Nursing diagnoses of post-liver transplantation patients in outpatient follow-up. Cogitare Enferm. 2019;24:e59149. https://doi.org/10.5380/ce.v24i0.59149 https://doi.org/10.5380/ce.v24i0.59149... ⁾- level of evidence V). Transition to home is a complex moment, with the increased risk of medication errors due to incorrect or incomplete transfer of information, besides involving multiple actions such as multidisciplinary and interinstitutional action (Author⁽⁷7 Oliveira PC, Paglione HB, Silva e Silva V, Schirmer J, Roza BA. Measurement of non-adherence to immunosuppressive medication in liver transplantation recipients. Acta Paul Enferm. 2019;32(3):319-26. doi:10.1590/1982-0194201900044 https://doi.org/10.1590/1982-01942019000... ⁾ - level of evidence: V).	It's a lot of medication time, it has all kinds of control, food restriction, it's a lot. It was very difficult to know how to do all this. (Patient 3) At first, I had to swallow that bunch of pill. It was about 15 at a time, I was afraid to take it and I doubt ed whether It was right even. (Patient 5) I had to turn around to apply insulin alone. I believe I often mistook the diabetes test. (Patient 12)	The greatest perceived fragility was with mouth hygiene. They have doubts about the frequency and sequence of brushing (OV^* * OV refers to participant observation in the home visit; ). Blood glucose at home was being checked at the wrong times. There was a situation where the device was not calibrated (OV). It was possible to notice little practice of patients regardingusing blood glucose apparatus and the application of insulin (OV). On the return to the outpatient clinic, some controls were not recorded (OA^ OA refers to participant observation in the outpatient clinic. ).

CARE TRANSITION PLANNING	HEALTH EDUCATION FOR SELF-CARE	CARE MANAGEMENT
Support network training: • Identify in the family people with greater affinity to develop home care. • Propose to organize with the family range of caregivers. • Organize with support network and social worker the place to receive patients after discharge; • Promote closer ties of family members, adjusting the relationship with the family. • Organize support network according to each patient's needs.	CAUTION: To start preparing patients for home activities soon after patients' return to the hospitalization unit, after patients are not in pain and able to listen to the guidelines.	Patient: • Patients should check daily if al care was performed in the morning, afternoon and evening. Multidisciplinary transplant staff: • Make contact by technologicalmeans checking if the care is being performed according to guidance. • Make home visit if possible. Primary Care Staff: • Make weekly visits and promote adjustment in care if necessary.
Approach with primary care staff(counter-referral): • Make contact with patients' referral unit, passing all patient information: social data, clinical situation, care needs, need for materials and medications. • Forward via online prescriptions of medications and materials; • Agree with this staff date and time so that a family member can pick up materials and medications. • Schedule with staff the date of home visit that must be carried out by them in the first week after discharge.	Alert for signs of complications: • Clarify to patients about the possible complications (most common) signs and symptoms, such as preventing them, time that these can last and what conducts to adopt in the face of such a situation. • Point out to patients which are the most common possible complications to arise at home (especially rejection and opportunistic infections), signs and symptoms of them, how to prevent them and what behaviors to adopt in face of such situation.	Daily care activities - Food consumption: • Raise awareness and teach about theneed to consume only cooked foods. • Explain clearly and simply how food should be sanitized when arriving from shopping as well as how to proceed with the preparation and how to store. • Explain about fluid intake and adequate daily quantity. Development of physical activities: • Develop a plan of daily physical activities. • Show patients what daily activities they can and should do at home. Socialization with support network: • Explain in detail, in a simple way, that in the first months the orientation is that there is not contact with many different people. However, they may have brief contacts, keeping their distance and in a ventilated place.
Referral of the special medication process (immunosuppressants): • Request with medical staff the completion of the process, prescriptions, forwarding to the health network. • Organize immunosuppressants for home use at doses for one month. • Teach where and when the family member will withdraw the immunosuppressive medications.	Daily care activities - Medications: • Create an enlarged table that provides guidance ontimes, doses and adverse effects. Indicate differently in the table which are the immunosuppressants. Control and daily care: • Develop strategies to teach the development ofhemoglycotest and insulin application, as wellas the times to be performed and normal values. Encourage the performance of this care even during hospitalization so that staff can manage. • Teach in detail how to check vital signs and how to control temperature. • Teach how to measure and store diuresis. • Explain to patients how they should watch for warning signs in the body for edema, itching, blemishes and others. • Develop an individual care plan for each patient regarding their own hygiene. Observation: It is necessary to adapt this plan according to patients' social conditions, educational level and performance capacity.

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[1] Corresponding author: Laísa Fischer Wachholz. E-mail: laisafischer@gmail.com