Bridging Pediatric and Adult Healthcare Settings in a Nurse-Led Cystic Fibrosis Transition Initiative

  • Anna M. GravelleEmail author


The focus of healthcare transition (HCT) for adolescents and young adults with long-term conditions has centered mainly on the pediatric setting; however, it is likely the HCT process ends much later than originally thought. This chapter outlines two nurse-led cystic fibrosis (CF) quality improvement initiatives. The first is a retrospective chart audit to determine if best practices were implemented during the transfer from a pediatric to adult CF clinic, including a measurement of initial adult setting integration. Findings demonstrated that most CF patients were transferred in their 18th year; there was an excellent completion and handover rate of Medical Transfer Summaries; and almost all patients completed a first adult provider appointment. There was a slightly longer than recommended time gap between the final pediatric and first adult provider appointments, and 81% of patients attended at least three adult provider visits in the first year post-transfer. Today there are comprehensive practice guidelines for the transfer period, accessible online. The second project aimed to adapt and implement a transition clinical pathway (TCP) in four pediatric and adult CF clinics in one Canadian province. The TCP was successfully adapted to be CF-specific but after 1 year, only one of the four clinics (which had decades of experience with HCT) was utilizing the TCP due to a lack of professional time and education. Institutional support for the implementation of pediatric and adult-based transition practices is imperative.


Emerging adult Transfer of care Transition care pathway Adult transition process Quality improvement Cystic fibrosis Retrospective chart review Nurse-led transition initiatives 



British Columbia


British Columbia Children’s Hospital


Cystic Fibrosis


Cystic Fibrosis Transition Care Pathway


Cystic Fibrosis Transition Care Pathway, version 2


Healthcare Transition


Medical Transfer Summary


Nurse Clinician


Youth Transition Model at BCCH


Quality Improvement


Royal Jubilee Hospital


Nurse (Registered Nurse)


St. Paul’s Hospital


Social Worker


Transition Care Pathway


Transition Care Pathway, version 2


Victoria General Hospital



The author wishes to acknowledge the support of the following people: the BC Children’s Hospital Transition RN Lead (Mary Paone), CF Clinic Director (Dr. Mark Chilvers), and full CF multidisciplinary team; the St. Paul’s Hospital CF Clinic Director (Dr. Pearce Wilcox); and the CF RNs and SWs from St. Paul’s Hospital, Royal Jubilee Hospital, and Victoria General Hospital in British Columbia, Canada.


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Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  1. 1.Cystic Fibrosis Nurse ClinicianBC Children’s HospitalVancouverCanada

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