Role of the Clinical Nurse Coordinator

Goal of the Clinical Transplant Coordinator

The goal of the CNC is to successfully guide patients with end stage liver disease through a maze of processes that may ultimately lead to liver transplantation. This maze includes the referral process, transplant evaluation, determination of transplant candidacy in a multidisciplinary committee, financial clearance for transplantation, placement on a transplant waiting list, and follow-up needed to remain on the list. Not only are several steps involved, but multiple health care professionals are also involved at each step. Navigating the steps in this process can be an overwhelming task to patients and their families. To assist with this process the transplant coordinator must be the primary contact for patients and their caregivers. As the primary contact, the CNC actively participates in all levels of the patient’s care, communicates openly with the patient and other members of the health care team regarding patient care issues, takes the opportunity to continually monitor the patient and assesses any educational needs, and finally, advocates for the patient because a patient with end-stage liver disease can often experience significant deterioration before transplantation becomes an option.

The Referral Process

Referral for liver transplantation can come from a variety of different sources, including but not limited to a primary care physician, a hepatologist or gastroenterologist, an oncologist, and possibly an insurance case manager. No matter the source of the referral, it is essential that the CNC obtain accurate and current medical information from the referral source so that decisions on the patient’s care can be made in a timely fashion. This information may be gathered verbally and also through obtaining current medical records. As with many other areas of nursing, with experience a CNC will find that one question leads to the next and to the next, thus giving the pretransplant team a good picture of the patient before arrival at the transplant center. A complete review of a patient’s medical information by the CNC ensures the appropriateness of the referral for liver transplant evaluation and efficient coordination of care.

One consideration is the medical condition of the patient at the time of referral. If the patient is presented as a critically ill patient, the urgency of the referral must be communicated immediately so that physician-to-physician communication can take place. Such communication may prompt urgent financial clearance for transplant evaluation, followed by a hospital-to-hospital transfer in which a medical evaluation can be completed in a matter of just a few hours.

Patients may also be referred for a transplant evaluation very early in the patient’s disease process. A patient in whom liver disease has been diagnosed but who has normal laboratory values and scans without evidence of malignancy may be too early for transplant listing but will need close follow-up to monitor the disease process. Review of the medical information at the time of referral may lead to a hepatology consultation and an opportunity for the patient to be closely monitored by a liver specialist without having to undergo a complete transplant evaluation. This is of great benefit to the patient, who may possibly have an opportunity to be treated with other medical therapies and thus be “in the system” in case transplantation is needed in the future. This practice is also of great benefit to the payer, because unnecessary or too early evaluation for transplantation is a costly practice.

Once the medical information has been obtained, the CNC then works closely with the team of financial experts to obtain clearance to begin the transplant evaluation process. At the same time the CNC begins to build the relationship with the patient and family by laying the groundwork for open communication. This is easily accomplished by an introductory phone call or correspondence to let the patient know that a referral has been received. Other topics discussed with the patient in these early conversations or correspondence include specific information regarding the medical center, available housing, transportation, and any information that is helpful during the evaluation, such as the availability of radiology films or biopsy slides for review. Once the medical information has been fully reviewed and the payer has given financial clearance, the transplant evaluation can begin.

Evaluation of Patients with End-Stage Liver Disease

Transplant protocols, including a pretransplant evaluation order set, should be developed and approved by both the hepatology staff and the transplant surgery staff. At the time of transplantation, both the medical and surgical physician teams must be satisfied with the information that is known about the patient. This starts with the information obtained during the transplant evaluation. A standard pretransplant evaluation order set should be used. This order set should not be inclusive but should allow for additional testing and consultations to be ordered as deemed necessary by the physician team; however, these guidelines should be followed by the CNC for all patients being evaluated for liver transplantation.