Handling over medical care of adolescents to adult teams safely Mignon McCulloch Red Cross Hospital,...
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Handling over medical care of adolescents to adult
teams safelyMignon McCulloch Red Cross Hospital, University of Cape Town Evelina Children’s Hospital (Guys’…and St Thomas’…and King’s )
Introduction
Transition challenges Paediatric and Adult services
Developing countries failure of transplanted kidneys due to non-adherence to:– Medication– Follow-up
NO further renal replacement
‘1 strike and you’re out’
‘Crazy’ cut-off at 13years
Transition is defined as…..
“……a purposeful, planned movement of adolescents with chronic physical and
medical conditions from child centered to adult-oriented healthcare systems”
American Society for Adolescent Medicine 1993
Models of Transition
A dedicated follow-up service provided within adult setting without a combined paediatric-adult clinic and with no direct input or continuity from paediatric services
A ‘seamless’ clinic which begins in childhood or adolescence and continues into adulthood, with both child and adult professionals providing ongoing care as appropriate.
Life-long follow-up within the paediatric setting
Paediatric vs. Adult Care
• Parent focussed• Dependent• Younger kids!• Personal• Bustling & loud• Fun• Large team
•Individual focussed
•Independent
•Elderly patients
•Impersonal
•Quiet and Serious
•Small Team
Transplant Clinics ECH vs. Guys Adults
• 80 transplant patients
2 nephrologists in clinic
1 Clinical Nurse Specialist(CNS)
Clinic held daily; 10 slots
1000 transplant patients
7 nephrologists & 2 surgeons in clinic
2 CNS & nursing team
Clinic with up to 100 appointment slots
“In whatever healthcare setting it is delivered; services need to be
appropriate for both chronological age and development attainment”
Society of Adolescent Medicine 2003
What Does Successful Transition Need?
• Young people!! • Commitment• Planning• Resources
‘‘Collaborating, health professionals who demonstrate ‘mutual professional
respect’’
Watson 2006
Original Pathway
Encourage increasing autonomy, by seeing
nurse and/or doctor alone
Individual
Discussions about
Transfer
Teenage
Groups
Transfer to Adult
Services
Visit to Adult Unit
Objective
Review of Adolescent Clinic at Groote Schuur Hospital(GSH) 2002-2009
Support from Red Cross Hospital(RXH) doctors and clinical social worker
Development of Adolescent Transition Service requires:
Link person in Adult unit – ‘Champion’
Committed Doctor – remembers what it is like to be a teenager?
Nursing staff – Sr ‘Golly’
Social worker + psychologist
Commitment from Administrators
Patients seen in last 2 years @ GSH
0
2
4
6
8
10
J F M A M J J A S O N D
2008
2009
Month per year
Nos
of
pats
per
clin
ic
Results of Program 2002 - 2009
Nos of Adolescents transferred GSH
19
Nos received re-transplant 2
Nos awaiting transplant 2
Nos died after transfer 2
Nos lost to follow-up 0
Deaths at RXH
7 patients in last 5 years died at RXH during adolescent years >13 years of age
Not reflected on the Adolescent stats previous slide
RXH
Active decision NOT to ‘re-list’ some patients
Not transferring those patients
Allowing to stay in ‘familiar environment’ during end-stage disease
Holding back those deemed ‘not ready’ medically or psychosocially
Psychology input
Separate monthly groups at GSH for – Parents/Carers– Adolescents
Motivational events– ‘Graduation ‘ lunches– Welcome meetings/tours at Adult unit
Medically
Don’t transfer in crisis
Making more decisions NOT to transfer
Keeping older patients @ RXH as limitation of slots on adult side
Allocation of organs doesn’t mirror this
Where are we know?
Initially aimed at transitioning backlog of older adolescents(18-21year olds)
Then proceeding to 16-18year olds
Now working with younger groups
Generic Adolescent Workshops
Younger group 13 – 15 year olds of all disciplines with chronic implications
68 Parents and patients attended workshop at April 2009 RXH
Topics addressed
Pregnancy and Contraceptive advice– Termination of pregnancy– Drugs affecting foetus – AECI’s
Recreational drugs and alcohol Crime Non-adherence/compliance/concordance
– Do you take your meds ? how many times per week do you forget?
What is our Collaboration?
• Long term approach• Named individuals • Communication • Adult team in paediatric clinic • Timing of transfer • Paediatric team in adult clinic• Young adult services
Conclusions
Successful adolescent transition is possible
BUT: Requires significant staff input
Ideally medically stable at transfer
Adolescents/Young Adult Clinic