Bridging Pediatric and Adult Healthcare Settings in a Nurse-Led Cystic Fibrosis Transition Initiative
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.
KeywordsEmerging adult Transfer of care Transition care pathway Adult transition process Quality improvement Cystic fibrosis Retrospective chart review Nurse-led transition initiatives
British Columbia Children’s Hospital
Cystic Fibrosis Transition Care Pathway
Cystic Fibrosis Transition Care Pathway, version 2
Medical Transfer Summary
- On TRAC
Youth Transition Model at BCCH
Royal Jubilee Hospital
Nurse (Registered Nurse)
St. Paul’s Hospital
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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