Role of the Posttransplant Clinical Nurse Coordinator

Considerations in the Posttransplant Clinical Nurse Coordinator Care Process

Liver transplant programs throughout the world differ greatly in patient volume, resources, and management styles. The PTCNC’s role in patient care is defined by many factors that differ from one program to the next. One important factor in the PTCNC’s role is the division of tasks throughout the continuum of patient care. In programs with high patient volume and an adequate number of nurses, the skill mix of the PTCNC can be highly specialized. The PTCNC can focus on either inpatient care or outpatient care. PTCNCs may specialize only in patient education, outpatient surgical clinics, or outpatient hepatology clinics. In smaller programs the PTCNC may be responsible for both inpatient and outpatient care and thus requires a broader individual skill mix with less specialization.

The responsibilities of the PTCNC are also defined in large part by the surgical and medical management philosophies specific to the institution. The point at which surgical management of the transplant recipient ends and medical management of the recipient begins can differ greatly from program to program. Some programs transition the care of their patients completely to community hepatologists and gastroenterologists; other programs continue the management of patient care by the transplant center indefinitely. The greater the degree of patient follow-up conducted by the transplant center, the greater the job scope and responsibilities of the PTCNC.

Regardless of the management style or size of the transplant program, the allocation of coordinator responsibilities and resources should always be acuity driven. A patient acuity system is needed to distribute the workload equally, monitor changes in work volume, justify additions or deletions of job positions, and allocate critical resources. Patient characteristics that increase the work required for care and follow-up can be identified and used to define the acuity of each patient ( Table 83-1 ). The most common method of workload distribution is determined by dividing the patient population alphabetically by last name. Great variances occur in patient last names because of the ethnic diversity found in each transplant center’s geographical location. End-stage liver disease caused by diseases more commonly found in one ethnic group compared to another will also skew the caseload alphabet. An acuity system detects these variances and ensures an equitable distribution of the patient population throughout the PTCNC team.

The complexity of the PTCNC patient care process requires a large amount of ancillary resources for the process to produce successful patient outcomes. Outside stressors such as budget reductions, increasing medical costs, growing patient volume, nursing shortages, and increased patient complexity all act to create an environment that requires the PTCNC to perform more tasks with fewer resources. Any tool that can increase the productivity and efficiency of the PTCNC will help alleviate the effects of these stressors. Improving communication is an essential step in improving PTCNC performance. Institution of an electronic patient record will solve data management problems, improve documentation, and streamline communication between all members of the transplant team. The database should encompass all aspects of the transplant process from transplant referral to postoperative outpatient follow-up. Because many PTCNCs are involved in collecting data for research, the database should be designed to allow comprehensive data entry and expedient data queries. The PTCNC should be equipped with a point-of-service device that allows access to the database from any location where work is performed, including the home if the PTCNC has 24-hour patient care responsibilities. When information on all aspects of the transplant process is continually available to every transplant team member, delivery of patient care is expedited, work performance and efficiency are improved, and superior patient outcomes are the observed result.

In addition to adequate data management and communication resources, the PTCNC requires sufficient support from ancillary staff and adequate physical resources to deliver the complex level of patient care required by this patient population. The PTCNC’s support network should include transplant physicians, administrative assistants, financial counselors, dietitians, social workers, ambulatory care nurses, nurse practitioners, physician assistants, and any other specialty team member needed to fulfill the skill mix requirements that exist within the transplant environment.

Adequate physical resources include office space, equipment, and supplies in sufficient quantity to allow for the program’s growth and accommodate increasing staffing needs. The physical location of the transplant team should remain in close proximity to the inpatient transplant units and the outpatient clinics. An adequate amount of inpatient beds should exist to accommodate all transplant patients in one area so that the boarding of patients in non–transplant service beds can be avoided. A 23-hour observation unit dedicated to transplant patients is also required to prevent transplant patients from boarding in the emergency department or postprocedure areas. A centralized physical space that provides close proximity of all team members will encourage pooling of common resources, decreased duplication of job tasks, improved communication, and increased efficiency. Local hotels, skilled nursing facilities, rehabilitation facilities, and long-term acute care facilities should be identified and used for patient care after discharge from the hospital.