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Responses to a survey on the perceived barriers to effective discharge planning in renal transplant recipients.

When the kidneys fail, three possible treatments are available: hemodialysis, peritoneal dialysis, and kidney transplantation. Of the three, kidney transplantation is typically the best option, offering the patient a greater quality of life and an increased life expectancy. When compared with dialysis, "successful kidney transplantation is associated with improved survival, improved quality of life, and healthcare cost savings" (United States Renal Data System [USRDS], 2015, p. 227). Many transplant recipients can lead very productive lives; and a high number actually return to the workforce. Transplant recipients also have a survival benefit, extending to all age groups (Wu et al., 2008).

Nonetheless, the cost of kidney transplantation is high, and an increase in hospital length of stay (LOS) can mean the difference between the transplant center generating a profit and incurring a loss. For this reason, finding an effective optimum patient stay in the transplantation unit is a crucial issue, and seeking workable ways to decrease the total length of hospital stay has significant cost-savings potential.

There are some significant barriers to consistently achieving a timely discharge. These barriers include the rarity of available kidneys, the pre-operation assessment of the patient's financial situation, the existence of a clear clinical pathway at the hospital, the patient's age, the existence of multiple patient co-morbidities, the need for post-operation patient education, family or care-giver preparedness and cooperation, the existence of postoperative patient accommodation, and the postoperative involvement of the social worker and the pharmacist (Wu et al., 2008).

A first barrier is the relative rarity of available kidneys for use in transplantation. Transplantable organs are a scarce commodity, and little can be done to change the quality of the donor pool. Optimal kidneys come from young donors who do not have hypertension, diabetes, or other chronic condition. An example of an optimal kidney donor would be a 22-year-old person who dies as a result of a motor vehicle accident. In consequence, kidney transplantation is a complex and stressful concern. For example, prospective patients often remain on the waiting list for several years. High-risk surgical candidates may warrant more frequent assessments then the minimal yearly assessment required by the Unites Network for Organ Sharing (UNOS). In addition, a comprehensive pre-operative assessment of the patient is imperative to ensure the individual is an appropriate surgical risk.

Up until December 4, 2014, using expanded criteria donor kidneys was one way to increase the limited pool of available organs (Serur & Charlton, 2012). "Expanded criteria kidneys" were defined as "older kidneys" (retrieved from a donor who was older than 60 years) or "problem kidneys" (retrieved from a donor aged between 50 and 59 years who had two of the following three features: hypertension, a serum creatinine value of over 1.5 mg/dL, or who had suffered death from a cerebrovascular accident).

Unfortunately, expanded criteria kidneys often caused a delayed graft function, which typically resulted in a more complicated postoperative course. For example, the use of expanded criteria donor kidneys sometimes extended the overall LOS by several days.

Since the implementation of the new policy from UNOS, however, expanded criteria kidneys are no longer used in this way. Instead, a new formula based on the Kidney Donor Profile Index (KPDI) was adopted, which uses donor data to calculate the probability of the kidney longevity using a measure that takes into account a variety of factors, including the donor's age, weight, ethnicity, and terminal serum creatinine. This study was completed before the new guidelines were introduced.

A second barrier in achieving a timely discharge is the need for a pre-operation assessment of the patient's overall financial situation. In addition to the costs of the actual medication, patients on limited budgets may encounter issues paying for transportation to and from the transplant center post-operatively. The patient's inability to arrange for transportation to the transplant center and to obtain grants for medical coverage may delay a timely discharge.

A third barrier relates to whether or not the transplantation center has implemented a clear clinical pathway. Clinical pathways aim at standardizing procedures already in place. Without the standardization and uniformity associated with the regular use of a clinical pathway, the transplantation center may be unable to achieve cost-saving measures or to improve overall patient care.

The fourth barrier in achieving a timely discharge is the patient's age. The older the patient, the more likely it is that he or she will be in frail condition. Preoperative frailty is one of the leading causes of an extended hospital stay. Older patients are also more at risk for cardiovascular events and infections post operatively (Wu et al., 2008). Further, a retrospective study by Veroux et al. (2012) demonstrated that older adult recipients had a significant lower graft and patient survival, as well as a significantly higher risk of graft loss and patient death. Regardless, although many older patients may not meet the criteria for a timely discharge, advanced age alone is not a contra-indication to successful transplantation (Wu et al., 2008).

A fifth barrier, and one closely related to the age of the patient, is the existence of multiple comorbidities. Multiple comorbidities may occur with a patient at any age, although they tend to be more frequent the older the patient's age. Older patients with multiple comorbidities are at higher risk for surgical complications (McAdams-DeMarco et al., 2014).

A sixth barrier is the lack of supplementary patient education regarding insulin administration and diet. Many insurance companies do not cover extensive diabetic teaching and follow-up post-transplantation; therefore, it is imperative that the patient and family are educated about the required diet and insulin administration before the hospital discharge.

A seventh barrier is the lack of a supportive family or designated caregiver. The family of the patient needs to be an integral member of the healthcare team because a timely discharge will often depend on their preparedness and cooperation (Toledo et al, 2013).

After the transplant, the patient will require frequent follow-up visits at the center. For example, the patient may be required to be in the clinic three times a week for assessment and blood tests. Driving under the influence of narcotics is prohibited; therefore, patients must have a family member or members who can consistently take responsibility for driving them to their postoperative follow-up appointments.

An eighth barrier is the absence of suitable postoperative accommodations for the post-transplant patient. Most transplant centers are located in big cities, and some patient families may find the cost of staying for an extended period prohibitive. Due to the complexity of the post operative care, some, but not all, large transplant centers in the United States now have transplant hotels or living accommodations adjacent to the hospital. This allows patients to be discharged from hospital, while still allowing for frequent follow-up sessions.

The final barrier is the absence of the postoperative involvement of a reliable social worker and a knowledgeable pharmacist. The role of the social worker is crucial in assisting patients and families in achieving optimum functioning in the psychological, emotional, and social areas of their lives. The social worker draws on knowledge of community resources in order to assist with issues, such as accommodation, transport, and finances. Not all medications are covered by the individual's healthcare plan; thus, the clinical pharmacist needs to be able to counsel patients concerning their medication therapy. The clinical pharmacist should be an expert in finding generic equivalents of the more expensive branded medications. The pharmacist should also be well versed in pharmokenetics and able to advise the patient these cheaper generic therapies may interfere with immunosuppressive medications.


The research commenced with searches of several databases, including the Cochrane library, Medline, CINAHL, and Ovid, to uncover recent scholarly literature in the form of systematic reviews, randomized controlled trials, and cohort studies examining barriers to effective discharge in renal transplantation. The key search terms used were kidney transplant, kidney disease, chronic kidney disease treatment, clinical pathways, clinical protocols, care maps, length of stay, discharge planning, and readmission. The project was approved by the Troy University Internal Review Board (IRB), and return of the survey was used to imply consent.

The transplant centers targeted to receive the survey were required to have performed at least 20 kidney transplants in the previous year. The healthcare agencies included both for-profit and not-for-profit facilities. Six centers were affiliated with large university systems. The centers performed both living donor and deceased transplants. All centers were Medicare-approved facilities. The recipients were all adults over 19 years of age.

Surveys were sent to 10 centers with a request that coordinators or nurse practitioners at the center complete the survey. At four centers, both the nurse practitioner and the coordinator completed the survey. This fact explains why the surveys went to 10 transplant centers, but there are 18 responses in total. Survey Monkey was used to distribute the survey.

The survey, entitled "Post-Operative Management of Adult Renal Transplant Recipients," contains four sections. The first section consisted of questions about the respondent's clinical role, the respondent's region of practice, the number of years in practice, and the practice setting. The second section consisted of questions about the average LOS and the destination of the patient immediately post-surgery. The third section consisted of questions about whether or not a clinical pathway was used. The fourth section consisted of a qualitative question to identify the perceived facilitators in the effective discharge of the transplant recipients.


Data were obtained from 18 respondents, although not all participants answered every question. The responses to the 17 survey questions were summarized in the form of descriptive statistics, including frequencies, percentages, and charts. The obtained data were then described using SPSS v. 21.0 and a Survey Monkey output.

Table 1 shows the characteristics of the project sample. The majority (67%, n = 9) of respondents were nurse practitioners; a little over one-quarter of these were direct care nurses (28%, n = 5). One-half of the participants were based in the Southeast (50%, n = 9). Although participants were anonymous and could not be identified, approximately one-tenth of respondents (11%, n= 2) chose not to disclose their location.

The primary location for the transplant centers was a university/academic hospital (61%, n= 11). A little less than half (44%, n = 8) performed between 151 to 200 transplants annually, and one-third (33%, n = 6) performed over 200.

Table 2 shows the frequencies for the transplant guidelines/procedures. Most transplant centers reported admitting patients to their ICU. This was also the same number that reported using a set of guidelines for ICU admission (56%, n= 10). Around 90% (n = 16) of all centers utilized some sort of invasive monitoring, and almost 65% (n= 11) utilized a clinical pathway to guide postoperative care.

The survey asked specifically whether the transplant centers initiated the use of tacrolimus (Prograf[R]), which is the original drug from Astellas. Prograf is an antirejection medication used after an organ transplant to reduce the risk of organ rejection. Only 26% of centers reported initiating tacrolimus on postoperative day 1, while the majority of centers initiate it on postoperative day 2 or when there was a 50% drop in creatinine level. This result should be treated with a certain amount of caution because some transplant centers might be more familiar with the generic name of tacrolimus

When asked what had the greatest impact on facilitating discharge, approximately 35% (n = 6) of the respondents said the biggest impact on expediting patient discharge was the immediate postoperative involvement of the social worker and the pharmacist. Two respondents believed it was imperative to have more social work involvement pre-transplant. They recommended that members of the patient's support system should sign an agreement outlining their responsibilities with regards to patient care. Three respondents emphasized the need for a complete review of the patient's insurance and financial obligations preoperatively so there were no unforeseen postoperative issues.

Even though data collected seemed to indicate that increasing familial support would facilitate discharge planning, the lack of family support rated the lowest in terms of factors increasing LOS. Only 12% of respondents had postoperative onsite accommodations for their post-transplant recipients, and 88% of respondents stated that patients were responsible for their own accommodations. As one coordinator pointed out, this financial burden added additional stress on the family unit.

Most centers (n = 9) initiated insulin therapy when blood glucose levels were over 200 mmol/L. This result is significant because the addition of insulin therapy frequently results in an additional day in hospital because patients need supplementary education regarding insulin administration and diet.

Delayed graft function extended patient stay at every center; 6% of centers stated it resulted in one additional day in the hospital whereas 35% stated that it extended the stay by two days. An additional 59% believed that days of hospitalization increased by three or more days.

According to 83% of respondents, the average LOS post-transplant with a functioning kidney was between four to six days; 17% of the respondents indicated that their average LOS was between six and eight days. The reason for these discrepancies is likely because larger centers that do more transplants take more marginal kidneys, and marginal kidneys typically take more time to become functional.


Transplantable organs are a scarce commodity, and little can be done to change the quality of the donor pool. However, it is essential that the recipient be an appropriate surgical candidate. Advanced age correlates with an extended LOS (Martin et al.,, 2010).

Although advanced age is not an absolute contra-indication for transplantation, it may be necessary to evaluate older recipients more frequently to ensure that they remain surgical candidates.

The literature also suggests that multiple comorbidities extend the LOS. When an older adult patient encounters a complication in the postoperative period, this can lead to diminished quality of life, extended hospitalization, and potentially death (Martin et al.,, 2010).

As a consequence, comorbidity data should be used to identify groups that require more frequent medical assessment and intervention in both the preoperative and postoperative periods. The inclusion of specialists, such as cardiologists, in the immediate postoperative period can help minimize the complications and maximize the positive outcomes.

Family support is imperative for the renal transplant recipient. A supportive, informed family network not only expedites discharge planning, it also prevents needless readmission. Finally, although many centers used a standardized order set or clinic pathway to standardize existing procedures, only 50% of respondents to the survey were found to do this. Clinical pathways are an important means for providers to reduce costs and inefficiencies, as well as provide better evidence-based care. Because transplantable organs are a limited commodity, every resource needs to be in place to ensure the functionality and sustainability of each organ.


In the United States, the growing number of individuals affected with renal failure is a major social concern. When the kidneys fail, kidney transplantation is typically the best option, offering the patient a greater quality of life and an increased life expectancy. However, kidney transplantation costs are high, and transplantation centers need to manage their costs effectively. Using expert transplant clinicians employed by 10 large transplant centers, this project aimed to identify some key cost-effective variables that interfere with a patient's timely discharge after a kidney transplant.


Martin, M.A., Segev, D.L., Pronovost, PJ., Syin, D., Bandeen-Roche, K., Patel, P, ... Fried, L.P (2010). Frailty as a predictor of surgical outcomes in older patients. Journal of the American College of Surgeons, 210(6), 901-908.

McAdams-DeMarco, M.A., Law, A., King, E., Orandi, B., Salter, M., Gupta, N., & Segev, D.L. (2014). Frailty and mortality in kidney transplant recipients. American Journal of Transplantation, 15(1), 149-154. doi: 10. 1111/ajt. 12992

Serur, D., & Charlton, M. (2012). Expanded criteria living donors: How far can we go? Progress in Transplantation, 22(2), 129-133.

Toledo, A.H., Carroll, T., Arnold, E., Tulu, Z., Caffey, T., Kearns, L.E., & Gerber, D.A. (2013). Reducing liver transplant length of stay: A Lean Six Sigma approach. Progress In Transplantation, 23(4), 350-364. doi:10. 7182/pit2013226

United States Renal Data System (USRDS). (2015). 2015 USRDSannual data report: Epidemiology of kidney disease in the United States. Bethesda, MD: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases. Retrieved from http://www.usrds. org/adr.aspx

Veroux, M., Grosso, G., Corona, D., Mistretta, A., Giaquinta, A., Giuffrida, G., ... Veroux, P. (2012). Age is an important predictor of kidney transplantation outcomes. Nephrology Dialysis Transplantation, 27(4), 16631671. doi: 10.1093/ndt/gff524

Wu, C., Shapiro, R., Tan, H., Basu, A., Smetanka, C., Morgan, C., ... Unruh, M. (2008). Kidney transplantation in elderly people: The influence of recipient comorbidity and living kidney donors. The American Geriatric Society, 56(2) 231-238. doi: 10.1111/j.1532-5415.2007.01542.x

Keeley Haas DNP, ARNP, is a Pulmonary Critical Care Nurse Practitioner, Veterans Affairs Hospital, Orlando, FL

Statement of Disclosure: The author reported no actual or potential conflict of interest in relation to this continuing nursing education activity.

Note: The Learning Outcome, additional statements of disclosure, and instructions for CNE evaluation can be found on page 526.
Table 1
Description of the Sample (N = 18)

Characteristic                    n     %

Primary role
  Nurse practitioner              12   66.7
  Physician assistant              1    5.6
  Bedside registered nurse         5   27.8
Region (a)
  Northwest                        1    5.6
  Northeast                        1    5.6
  Central                          3   16.7
  Southwest                        2   11.1
  Southeast                        9   50.0
Number of transplants per annum
  101 to 150                       4   22.2
  151 to 200                       8   44.4
  >200                             6   33.3
Type of hospital
  Community                        2   11.1
  Non-teaching                     5   27.8
  University/academic             11   61.1

(a) N = 16.

Table 2
Frequencies of Transplant Center Guidelines/Procedures (N = 18)

                     Variable                         n     %

Are recipients transferred to ICU?
  Yes                                                 10   55.6
  No                                                  8    44.4
Are there guidelines for ICU admission?
  Yes                                                 10   55.6
  No                                                  8    44.4
Type of invasive monitoring used
  CVP monitor and arterial line                       9     50
  CVP monitor                                         7    38.9
  None                                                2    11.1
Factors increasing length of stay (a)
  Preoperative frailty                                8    44.4
  Delayed graft function                              7    38.9
  Lack of family support                              2    11.1
Delayed graft function increases length of stay (a)
  One additional day                                  1    5.6
  Two additional days                                 6    33.3
  More than two additional days                       9    55.6

(a) N = 17.

Notes: CVP = central venous pressure, ICU = intensive care unit.
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Author:Haas, Keeley
Publication:Nephrology Nursing Journal
Article Type:Report
Date:Nov 1, 2016
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