Recovery after lung transplantation from a patient perspective - proposing a new framework.

AIMS: The aims of this study were two-fold: to develop the concept analysis by Allvin et al. from lung recipients' perspective of their post-transplant recovery process and to identify the recovery trajectories including critical junctions in the post-transplant recovery process after lung transplantation. BACKGROUND: Lung transplantation is an established treatment for patients with end-stage lung disease. The recovery process after lung transplantation is very demanding. Today, patients are expected to play an active role in their own recovery but require ongoing support during the process. DESIGN: A deductive, retrospective interview study using directed content analysis and Allvin's recovery concept analysis. METHOD: Fifteen adult lung transplant recipients who were due their 12-month follow-up were consecutively included and interviewed during 2015. Patients who were medically unstable or had difficulties speaking Swedish were excluded from this multi-centre study. FINDINGS: Allvin's concept analysis is partly applicable to the context of lung transplantation. The recipients' experience of the post-transplant recovery process could be confirmed in the main dimensions of the concept analysis, while several sub-dimensions were contradictory and were excluded. Six new sub-dimensions emerged; symptom management, adjusting to physical restraints, achieving an optimum level of psychological well-being, emotional transition, social adaptation and reconstructing daily occupation. CONCLUSION: The concept analysis by Allvin et al. was possible to expand to fit the lung transplantation context and a new contextual definition of post-transplant recovery after solid organ transplantation was developed. Recovery and health were viewed as two different things.

A randomized controlled trial comparing health and quality of life of lung transplant recipients following nurse and computer-based triage utilizing home spirometry monitoring.

BACKGROUND: Lung transplantation is now a standard intervention for patients with advanced lung disease. Home monitoring of pulmonary function and symptoms has been used to follow the progress of lung transplant recipients in an effort to improve care and clinical status. The study objective was to determine the relative performance of a computer-based Bayesian algorithm compared with a manual nurse decision process for triaging clinical intervention in lung transplant recipients participating in a home monitoring program. MATERIALS AND METHODS: This randomized controlled trial had 65 lung transplant recipients assigned to either the Bayesian or nurse triage study arm. Subjects monitored and transmitted spirometry and respiratory symptoms daily to the data center using an electronic spirometer/diary device. Subjects completed the Short Form-36 (SF-36) survey at baseline and after 1 year. End points were change from baseline after 1 year in forced expiratory volume at 1 s (FEV1) and quality of life (SF-36 scales) within and between each study arm. RESULTS: There were no statistically significant differences between groups in FEV1 or SF-36 scales at baseline or after 1 year.: Results were comparable between nurse and Bayesian system for detecting changes in spirometry and symptoms, providing support for using computer-based triage support systems as remote monitoring triage programs become more widely available. CONCLUSIONS: The feasibility of monitoring critical patient data with a computer-based decision system is especially important given the likely economic constraints on the growth in the nurse workforce capable of providing these early detection triage services.

Time-motion analysis of research nurse activities in a lung transplant home monitoring study.

BACKGROUND: The emergence and subsequent integration of new technologies precipitate changes in roles and work lives of nurses. The nurses' work with home monitoring technologies within a spirometry-based program that transmits pulmonary function data after lung transplantation has characteristics that are distinct from other types of direct patient care. Nurses' changing roles in such programs after transplantation have not been well described. OBJECTIVE: To describe a time-motion study of 2 research nurses in the context of a home-spirometry study to monitor patients' pulmonary status after lung transplantation. METHOD: A detailed list of research nurses' 67 routine work-related activities was developed and validated to monitor and record activities of research home monitoring nurses. Two weeks of observations were completed; recordings of a second observer established reliability of observations. RESULTS: In 48.8 hours of observation, 610 tasks related to monitoring of 45 patients were recorded. Task time ranged from brief seconds (eg, data review) to 39 minutes (eg, clinic visits). Between-observer intraclass correlation (r = 0.96) reflected high agreement in observations of the duration of activities. Agreement for category of activity was strong (kappa = 0.82), with high levels of agreement (96%). Computer tasks were the most frequent (118 tasks/week) and most time-intensive activities. Nurses' face-to-face interactions with health professionals were equally time intensive (both 267 minutes/week), but not as frequent. Data review tasks were the second most frequent (49/week), although less time-intensive (47 minutes/week). CONCLUSION: Findings reveal patterns of effort and time expenditure in nurses' evolving roles in home monitoring of the health status of patients after lung transplantation. These findings highlight the centrality and importance of well-developed data management, computer skills, and interprofessional communication skills of nurses who perform responsibilities in this emerging role in transplantation. Efforts to streamline computerized information access, as through integrated information systems, and methods to enhance efficiency in connecting with patients in the clinic may free up time for nurses to engage in other activities of direct benefit to patients. Strategies to supplement face-to-face meetings among professionals with electronic modalities may reduce the time spent meeting, while maintaining or enhancing communication.

Exploring the translational impact of a home telemonitoring intervention using time-motion study.

OBJECTIVE: Home telemonitoring improves clinical outcomes but can generate large amounts of data. Automating data surveillance with clinical decision support could reduce the impact of translating these systems to clinical settings. We utilized time-motion methodology to measure the time spent on activities monitoring subjects in the two groups of a home spirometry telemonitoring randomized controlled trial: the manual nurse review (control) group and the automated review (intervention) group. These results are examined for potential workflow effects that could occur when the intervention translates to a clinical setting. MATERIALS AND METHODS: Time motion is an established industrial engineering technique used to evaluate workflow by measuring the time of predefined, discrete tasks. Data were collected via direct observation of two research nurses by a single observer using the repetitive or snap-back timing method. All observed tasks were coded using a list of work activities defined and validated in an earlier study. Reliability data were collected during a 2-h session with a secondary observer. RESULTS: Reliability of the primary observer was established. During 35 h of data collection, a sample of 938 task observations were recorded and coded using 46 previously defined and 5 newly defined work activities. Between-group comparisons of activity time for subjects in the two study groups showed significantly more time spent on data review activities for the automated review group. Reclassification of the 51 observed activities identified 15 activities that would translate to a clinical setting, of which 5 represent potentially new activities. CONCLUSIONS: Implementing an intervention into a clinical setting could add work activities to the clinical workflow. Time-motion study of research personnel working with new clinical interventions provides a template for evaluating the workflow impact of these interventions prior to translation from a research to a clinical setting.

A Qualitative Study to Explore the Needs of Lung Transplant Caregivers.

INTRODUCTION: Providing support throughout the lung transplant process is an intensive task, which requires a dedicated caregiver. The needs of caregivers who must relocate with their loved one receiving the transplant are currently unknown. The objective of this study is to explore experiences and perceptions of lung transplant caregivers identified from a satellite clinic to inform the development of educational resources. METHODS: A qualitative study with a phenomenology approach was undertaken with individuals who have taken on the role of a caregiver for lung transplant candidates or recipients and must travel to the specialized transplant center. Semistructured interviews were conducted with 12 caregivers. Interviews conducted by phone were audio-recorded and then transcribed verbatim. NVivo software was used to code the data and identify emerging themes. RESULTS: Ideas were classified into the following 4 themes: (1) the stress of being a caregiver, (2) caregivers undertake a variety of roles, (3) caregivers require support, and (4) satisfaction with health care providers. Even though the caregivers lived an average of 7.1 (standard deviation 2) hours from the surgical transplant center, all expressed satisfaction with the level of care that they received. Caregivers identified several stressors during the transplant process and described various strategies for coping. CONCLUSION: Caregivers shared their experiences on the transplant process. It was evident that being a caregiver was a stressful and supports were necessary for those undertaking this role. These insights will help inform the development of a new educational resource for patients and caregivers.

Extracorporeal Membrane Oxygenation as a Bridge to Lung Transplant: Considerations for Critical Care Nursing Practice.

TOPIC: Candidates waiting for lung transplant are sicker now than ever before. Extracorporeal membrane oxygenation has become useful as a bridge to lung transplant for these critically ill patients. CLINICAL RELEVANCE: Critical care nurses must be prepared to care for the increasing number of lung transplant patients who require this advanced support method. PURPOSE OF PAPER: To provide critical care nurses with the foundational knowledge essential for delivering quality care to this high-acuity transplant patient population. CONTENT COVERED: This review describes the types of extracorporeal membrane oxygenation (venovenous and venoarterial), provides an overview of the indications and contraindications for extracorporeal membrane oxygenation, and discusses the role of clinical bedside nurses in the treatment of patients requiring extracorporeal membrane oxygenation as a bridge to lung transplant.

Management of the patient undergoing lung transplantation: an intensive care perspective.

The postoperative management of a patient undergoing lung transplantation involves many components of care. These components include ventilatory and hemodynamic management, immunosuppression, wound care, rehabilitation, infection control and treatment, and early detection of rejection.

The lived experience of waiting: a Parse method study.

The purposes of this study were to discover the structure of the lived experience of waiting and to generate new knowledge about health and quality of life. The participants in this study were 11 persons who were on a waiting list for a lung transplant. The Parse research method was used to answer the research question: What is the structure of the lived experience of waiting? The central finding of this study was: The lived experience of waiting is arduous constraint arising with anticipating the cherished in fortifying engagements. This finding illustrates waiting as an immensely difficult and agonizing experience of persistently expecting a prized opportunity, finding strength in being with other persons, and engaging in diverse activities. The findings are discussed in relation to nursing knowledge and as to how they inform future research and humanbecoming patient-centered nursing practices.

Lung Transplant for the Critical Care Nurse.

Lung transplantation is an established treatment of select patients with end-stage pulmonary disease. Lung transplantation should be considered for patients with end-stage pulmonary disease who have an expected 2-year survival of less than 50% without lung transplant and an expected 5-year survival of greater than 80% after transplant. This article reviews routine postsurgical intensive care unit management, along with management of complications such as acute kidney injury, atrial arrhythmias, deep vein thrombosis, primary graft dysfunction, hyperammonemia syndrome, and thrombocytopenia. Finally, management of long-term issues, including diabetes mellitus, hypertension, and bronchial stenosis, is discussed.

Bridging to Lung Transplantation.

Lung transplantation is the gold standard for treating patients with end-stage lung disease. Such patients can present with severe illness on the waitlist and may deteriorate before a lung donor is available. Bridging strategies with extracorporeal membrane oxygenation (ECMO) are valuable for getting patients to transplant and provide a chance at survival. The current article describes the indications, contraindications, and techniques involved in bridging to lung transplantation with ECMO.

Perioperative Management of the Lung Graft Following Lung Transplantation.

Perioperative management of patients undergoing lung transplantation is one of the most complex in cardiothoracic surgery. Certain perioperative interventions, such as mechanical ventilation, fluid management and blood transfusions, use of extracorporeal mechanical support, and pain management, may have significant impact on the lung graft function and clinical outcome. This article provides a review of perioperative interventions that have been shown to impact the perioperative course after lung transplantation.

Characteristics, Trends, and Predictors of Specialty Palliative Care Utilization after Lung Transplantation.

Background: Lung transplant recipients who experience serious illness could benefit from specialty palliative care (SPC), but evidence suggests that referral has been rare. Objective: Examine the characteristics of post-transplant SPC encounters, utilization trends, and patient characteristics associated with SPC at a center with established SPC services. Design: Retrospective cohort study of SPC utilization by 597 lung transplant recipients transplanted between 2010 and 2015. We collected data on pretransplant demographics and post-transplant SPC encounters, including timing, location, and referral reasons. Cumulative incidence of SPC and patient characteristics associated with SPC were examined by competing risks methods. Utilization in the first two post-transplant years was compared between subcohorts defined by year of transplantation. Results: SPC cumulative incidence was 27% and 43% at one and five years. More than 60% of encounters occurred in the first post-transplant year including 34% during the index transplant hospitalization. Over 90% of encounters occurred in the inpatient setting. The majority of consults were for symptom management. From 2010 to 2015 inpatient utilization in the first two post-transplant years increased from 23% to 42%, and outpatient utilization increased from 2% to 16%. Accounting for increasing utilization, pretransplant SPC and double-lung transplantation were associated with greater incidence of post-transplant SPC. Conclusions: Lung transplant recipients may have palliative care needs early after transplantation. Increasing utilization suggests greater awareness of or changing attitudes about the utility of SPC for lung transplant recipients. Understanding transplant recipients' palliative care needs and transplant physicians' views of SPC is critical to improving the provision of SPC in lung transplantation.

Brief Overview of Lung, Heart, and Heart-Lung Transplantation.

Lung transplantation, heart transplantation, and heart-lung transplantation are life-saving treatment options for patients with lung and/or cardiac failure. Evolution in these therapies over the past several decades has led to better outcomes with application to more patients. The complexity and severity of illness of patients in the pretransplant phase has steadily increased, making posttransplant intensive care unit management more difficult. Despite these factors and the pervasive complications of immunosuppressive therapy, outcomes continue to improve.

Infections in Heart and Lung Transplant Recipients.

Infections in heart and lung transplant recipients are complex and heterogeneous. This article reviews the epidemiology, risk factors, specific clinical syndromes, and most frequent opportunistic infections in heart and/or lung transplant recipients that will be encountered in the intensive care unit and will provide a practical approach of empirical management.

Renal Complications Following Lung Transplantation and Heart Transplantation.

Renal complications are common following heart and/or lung transplantation and lead to increased morbidity and mortality. Renal dysfunction is also associated with increased mortality for patients on the transplant wait list. Dialysis dependence is a relative contraindication for heart or lung transplantation at most centers, and such patients are often listed for a simultaneous kidney transplant. Several factors contribute to the impaired renal function in patients undergoing heart and/or lung transplantation, including the interplay between cardiopulmonary and renal hemodynamics, complex perioperative issues, and exposure to nephrotoxic medications, mainly calcineurin inhibitors.

Adult cardiothoracic transplant nursing: an ISHLT consensus document on the current adult nursing practice in heart and lung transplantation.

BACKGROUND: The role of nurses in cardiothoracic transplantation has evolved over the last 25 years. Transplant nurses work in a variety of roles in collaboration with multidisciplinary teams to manage complex pre- and post-transplantation issues. There is lack of clarity and consistency regarding required qualifications to practice transplant nursing, delineation of roles and adequate levels of staffing. METHODS: A consensus conference with workgroup sessions, consisting of 77 nurse participants with clinical experience in cardiothoracic transplantation, was arranged. This was followed by subsequent discussion with the ISHLT Nursing, Health Science and Allied Health Council. Evidence and expert opinions regarding key issues were reviewed. A modified nominal group technique was used to reach consensus. RESULTS: Consensus reached included: (1) a minimum of 2 years nursing experience is required for transplant coordinators, nurse managers or advanced practice nurses; (2) a baccalaureate in nursing is the minimum education level required for a transplant coordinator; (3) transplant coordinator-specific certification is recommended; (4) nurse practitioners, clinical nurse specialists and nurse managers should hold at least a master's degree; and (5) strategies to retain transplant nurses include engaging donor call teams, mentoring programs, having flexible hours and offering career advancement support. Future research should focus on the relationships between staffing levels, nurse education and patient outcomes. CONCLUSIONS: Delineation of roles and guidelines for education, certification, licensure and staffing levels of transplant nurses are needed to support all nurses working at the fullest extent of their education and licensure. This consensus document provides such recommendations and draws attention to areas for future research.

Characteristics, interventions, and outcomes of lung transplant recipients co-managed with palliative care.

BACKGROUND: Lung transplantation (LT) recipients carry a high symptom burden. Palliative Care (PC) is a field of medicine focused on symptom control and psychosocial support, but transplant recipients are often referred to PC very late in the disease course, if at all. In our institution, the LT service has increasingly consulted PC to co-manage LT recipients with end-stage graft dysfunction or other terminal conditions. We present the characteristics, PC interventions used, and outcomes of these patients. METHODS: We conducted a single-center, retrospective, cohort study of LT recipients referred for PC consultation between January 2010 and May 2012. We collected patient demographics, timing and location of PC consultation, PC interventions, and patient outcomes. RESULTS: Twenty-four patients met the inclusion criteria. Sixteen (67%) had chronic allograft dysfunction. Reasons for referral were dyspnea (42%), end-of-life planning (42%), pain (29%), cough (4%), anxiety (4%), and depression (4%). Referral was made a median of 3.2 (range, 0.2 to 18) years from transplant and a median 14 days (range, 0 to 227 days) from death. Eighty-three percent of consultations occurred >48 hours from time of death. Ninety-two percent of patients were prescribed opioids over their course of treatment. Among the 12 (50%) who died in our center, 10 (83%) were receiving comfort medications. Eight patients (33%) initially requested full resuscitation at the time of PC consultation, but seven of these patients (or their surrogates) later agreed to a do not resuscitate (DNR) order; the eighth was still alive at last follow-up. No patient in this study received cardiopulmonary resuscitation (CPR) at the time of death. CONCLUSION: LT recipients referred for PC co-management typically receive comfort medications and avoid the aggressive end-of-life care usually reported for this population. The effect of PC interventions on patient quality of life requires further study.