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Discharge and Unscheduled Readmissions
of Adult Patients Undergoing Hematopoietic
Stem Cell Transplantation: Implications
for Developing Nursing Interventions
Marcia Grant, RN, DNSc, FAAN, Liz Cooke, RN, MN, AOCN, ANP,
Smita Bhatia, MD, MPH, and Stephen J. Forman, MD
Key Points . . .
Purpose/Objectives: To describe discharge and unscheduled read-
mission patterns of adult patients undergoing hematopoietic stem cell
transplantation (HSCT). To identify implications for nursing practice from
The retrospective chart review of 100 adult patients undergo-
survey results and the literature that may improve patient outcomes
ing hematopoietic stem cell transplantation in the first six
during and following initial hospital discharge.
months of 2000 indicated infection, gastrointestinal problems,
Design: Retrospective chart review and literature review.
failure to thrive, and graft-versus-host disease as primary
Setting: National Cancer Institute-designated Comprehensive Cancer
reasons for unscheduled readmissions in the first six months
Center.
following initial discharge.
Sample: 100 adult patients undergoing HSCT in the first six months
of 2000.
Allogeneic transplant recipients have a higher infection risk
Methods: Investigator-created retrospective chart-review tool col-
and unscheduled readmission rate.
lected data in three areas: demographic, clinical, and readmissions in
Allogeneic transplant recipients are a vulnerable population
the first six months after discharge.
with needs for significant nursing interventions at and after
Main Research Variables: Demographic variables: gender, marital
status, age, and diagnosis; clinical variables: remission status at trans-
initial discharge.
plant, type of transplant, presence of comorbid or concurrent conditions,
number of infections, number of catheter-related infections, number of
bacteremic episodes, and psychosocial support; readmission variables:
reason for admission, discharge or death data, number of days of each
of transplant experience surrounding the care of these patients.
admission, and length of time between discharge to the next admission.
Some of these advances have occurred in the area of HSCT
Findings: Fifty-one percent had at least one unscheduled readmis-
outpatient management (Horowitz, 1999). Traditionally,
sion, and 80% developed an infection after HSCT. Further analysis
transplantation involved an inpatient admission to complete
comparing autologous to allogeneic transplant recipients indicated that
the process of conditioning therapy (ablative chemotherapy
the allogeneic group had a higher number of readmissions, unscheduled
or radiation therapy) followed by bone marrow or stem cell
readmissions, and infections. Patients who reported an infection within a
month prior to HSCT had a 50% mortality rate after transplantation.
reinfusion, and about 30 4 0 days of inpatient care after
Conclusions: Findings indicate that allogeneic transplant recipients
are a more vulnerable population in regard to infections and readmis-
sions. Developing and testing nursing interventions surrounding the
Marcia Grant, RN, DNSc, FAAN, is a director of nursing research,
discharge period are needed next steps in improving care.
Liz Cooke, RN, MN, AOCN, ANP, is a research specialist, Smita
Implications for Nursing: Knowledge of trends in this vulnerable
Bhatia, MD, MPH, is a director of the Long-Term Follow-Up Pro-
population will guide nursing to plan targeted interventions.
gram, and Stephen J. Forman, MD, is a director of the Division of
Hematology and Bone Marrow Transplantation, all at the City of
Hope Comprehensive Cancer Center in Duarte, CA. (Submitted
T
housands of hematopoetic stem cell transplants
September 2003. Accepted for publication July 14, 2004.) (Mention
of specific products and opinions related to those products do not
(HSCTs) are performed each year, with the number
indicate or imply endorsement by the Oncology Nursing Forum or
of transplants increasing for treatment of malignant
the Oncology Nursing Society.)
diseases (Andrykowski et al., 1999; King, 1996). With this
increase, greater expertise has developed in the four decades
Digital Object Identifier: 10.1188/05.ONF.E1-E8
ONCOLOGY NURSING FORUM VOL 32, NO 1, 2005
E1
transplantation. Today, as a result of changes in the care of
HSCT acknowledged that receiving information allayed anxi-
patients undergoing HSCT and pressure regarding healthcare
ety stemming from uncertainty (Cooper & Powell, 1998).
costs, transplants or parts of the transplant process such as
Comparisons between patients undergoing allogeneic trans-
the conditioning phase or follow-up post-transplant may be
plants and those undergoing autologous transplants reveal
performed in the outpatient setting (Horowitz).
that allogeneic transplant recipients experience more physi-
Along with the increase in the number of transplants and
cal problems, such as dry mouth, tiredness, lack of energy,
the refinement of medical treatment, survival rates after
tension, headaches, decreased sexual interest, irritability,
HSCT have improved steadily since the late 1960s. Current
low back pain, sore mouth, and shortness of breath (Molas-
descriptions of survival rates reveal variations depending on
siotis, Boughton, Burgoyne, & van den Akker, 1995). Also,
the underlying disease, the stage of disease at transplant, and
increased acute complications generally occur during the first
the type of transplant. Mortality rates at 100 days post-trans-
100 days after transplantation. A patient's health status may
plant vary from 5%42% (Loberiza, 2003). With increases
change repeatedly during this phase and for as long as a year.
in the survival rate, physical and psychosocial issues that
For example, organ toxicities such as pulmonary complica-
transplant survivors face after discharge have been identi-
tions, infections, veno-occlusive disease, and GVHD may
fied. Several studies have described a population struggling
occur (Jackson et al., 1998; King, 1996). These complications
with major quality-of-life (QOL) issues in the first year after
may result in unplanned readmissions and frequent use of
transplantation. These issues include physical symptoms
healthcare services.
such as fatigue, pain, dyspnea, insomnia, poor concentration,
Discharge from the hospital to the home setting is recog-
appearance, concern about body image, and physical restric-
nized as a stressful time for patients and families and has been
tions; psychological symptoms such as fear of the future,
pinpointed as a time when patients experience decreased QOL
loss of control, anxiety, and depression; social issues such as
(Andrykowski & McQuellon, 1999; McQuellon et al., 1998;
reintegration into the family, workforce, social roles, sexuality,
Thain & Gibbon, 1996). The move toward earlier discharge
and finances; and existential and religious issues (Altmaier,
of these complicated patients has had a tremendous impact
Gingrich, & Fyfe, 1991; Andrykowski, 1994; Andrykowski et
on nursing responsibilities during this high-risk period (Wag-
al., 1999; Baker, 1994; Baker, Zabora, Polland, & Wingard,
ner & Quinones, 1998). The demands include tracking and
1999; Ferrell et al., 1992a, 1992b; Grant et al., 1992; Johnson
coaching patients and families regarding plans for follow-up
Vickberg et al., 2001; Kopp et al., 1998; Molassiotis, van den
care and emergency plans to address various clinical issues.
Akker, & Boughton, 1997; Schmidt et al., 1993; Wettergren,
Examples of major topics for discharge teaching include right
Langius, Bjorkholm, & Bjorvell, 1997).
atrial catheter care, fluid and nutrition management, signs
The complex survivorship issues in the immediate post-
and symptoms of infection and infection prevention, GVHD,
transplant phase present significant challenges for patients and
organ toxicities, nausea, vomiting, diarrhea, dehydration, and
families, including physical complications and psychosocial
psychological issues such as adjustment after isolation, role
and emotional sequelae for both patients and families (Blume
disruption, and coping.
& Amylon, 1999; Fife et al., 2000; Grant, 1999; King, 1996).
This literature review supports the increasing need for dis-
Transplantation continues to be associated with a substantial
charge teaching and follow-up for patients after transplanta-
risk of mortality and morbidity, increasing the burden on fami-
tion. Information on what postdischarge problems occur in
lies and healthcare providers (Blume & Amylon). Infection
which patients, when readmissions are needed, and reasons for
and organ damage and failure continue to be significant issues
readmissions could provide valuable information for creating
after transplantation. With the current healthcare reimburse-
patient-specific postdischarge teaching approaches. To fill this
ment system and changes in the care of patients undergoing
gap, a retrospective study was proposed to illustrate patients'
transplants, such as the use of peripheral blood stem cells
status at discharge and readmission patterns. Data on patient
and growth factors, patients frequently are discharged with
characteristics, disease, and treatment characteristics also were
complicated care needs (Whedon & Fliedner, 1999). This
needed to explore which groups in the population appear to be
population of patients often is readmitted within six months
at highest risk for complications and readmissions.
to manage a variety of clinical issues, accompanied by psy-
The aim of this study was to combine information obtained
chological issues that are too complex or difficult for patients
from a literature review and a chart review to identify impli-
and families to deal with at home.
cations for nursing practice priorities that may affect patient
Education and management of patients regarding these
outcomes following HSCT in the discharge and follow-up
symptoms represent significant challenges to nurses in the
process.
field of transplantation (Whedon & Fliedner, 1999). Common
Methods
issues in the first 100 days after transplantation are infection,
medication management, graft-versus-host disease (GVHD),
Design
nutritional issues, nausea, fatigue, family role shifting, family
distress, coping, slowly returning to a "new normal," and exis-
A retrospective chart review was conducted on 100 adult
tential issues (Andrykowski & McQuellon, 1999; Whedon &
patients undergoing HSCT during the first half of 2000
Fliedner). Families and patients are dependent on healthcare
to assess demographic variables, clinical variables, and
professionals for their very survival and need to learn ways
discharge and readmission patterns. The cancer center was
to gain more control over their lives during recovery (Fife et
located in southern California and has had a bone marrow
al., 2000). Education, including patients' involvement in deci-
transplantation unit since 1976. Sample size was influenced
sion making, and choices enable patients and families to feel
by resources available, which provided for a part-time nurse
more in control (Fife et al.). Findings from a qualitative study
who identified eligible patients and conducted the chart
reported that patients and families experiencing the process of
review.
ONCOLOGY NURSING FORUM VOL 32, NO 1, 2005
E2
Instrument
the staff nurse goes over the binder with the patient. During
that time, the dietician visits the patient, providing informa-
The retrospective chart-review tool consists of 36 items
tion on the low-bacteria diet. The pharmacist reviews the
created to gather data according to three main areas: de-
prescribed medications with the patient. Either the physical
mographic variables, clinical variables, and discharge and
therapist or the occupational therapist goes over the prescribed
readmission patterns. The questions were developed from
exercise program. Once the patient leaves the hospital, no fur-
demographic and disease and treatment instruments used in
ther contact is initiated by the staff. If patients call in, referral
previous studies of various cancer populations. Demographic
is made to the appropriate person depending on the problem
information included gender, age, ethnicity, and marital status.
identified (e.g., medical questions referred to a physician,
The clinical questions included diagnosis, remission status at
medication questions referred to a pharmacist).
the time of HSCT, type of HSCT, presence of comorbid dis-
ease, presence of concurrent disease, history of infection prior
Procedure
to HSCT, date of diagnosis, history of previous transplant,
Following review and approval by the institutional review
tandem transplant questions, number of infections, number
board, a retrospective chart review was performed on 100
of catheter-related infections, number of bacteremic episodes,
patients undergoing HSCT. Patients were identified from a
number of psychological support visits, disease status at days
list of sequential patients transplanted in 2000. The list was
30 and 100 and at six months, and death, relapse, or persistent
generated by the Biostatistics Department. Patients on the
disease questions. The readmission questions provided data
list were screened for eligibility as follows: adult hematol-
on the number of readmissions and evaluated each readmis-
ogy patients undergoing HSCT for hematologic malignan-
sion for reason, location, discharge data, length of stay, and
cies and followed at the City of Hope National Medical
time to next readmission. The first draft of the instrument was
Center in Duarte, CA, for at least six months. Records from
reviewed by the coinvestigators, and recommendations were
each eligible patient were obtained from computer medical
incorporated into the instrument. A pilot test of 10 patient
record documentation and chart data. During the first six
charts was conducted and verified. The values for variables
months of 2000, 157 adults were transplanted, with the first
such as diagnosis, conditioning regimen, and infections were
100 eligible patients identified between January 1 and June
developed in collaboration with a physician who was formu-
15. Thus, the sample represented 64% of the total group. The
lating the long-term follow-up chart abstraction for a grant.
most common reason for noninclusion was when patients
Comorbid conditions were defined as any additional medical
were part of a contracted health maintenance organization
diagnoses. Concurrent conditions were defined as additional
whose patients were followed in that system after discharge.
medical issues a patient experienced as a part of the cancer
Chart abstraction was performed by one of the investiga-
diagnosis or treatment. Deaths were identified up to 18 months
tors and validated by the primary author. Differences were
after transplantation, and information collected included date
discussed and resolved.
and cause of death.
Psychosocial support was defined as a consultation from
Statistical Analysis
the psychology department. Although psychological support
Data analysis consisted of frequency analysis of all vari-
is provided by many members of the care team (physicians,
ables followed by comparisons among populations regarding
nurses, social workers, and others), psychological support by
infection characteristics and readmission characteristics by
a psychologist requires a physician order and usually repre-
analysis of variance (ANOVA). SPSS (SPSS Inc., Chicago,
sents referral from a physician, nurse, or social worker who
IL) Version 8.0 was used for analysis. Because this was a
oversees a complex psychological problem exceeding those
convenience sample with resources for analyzing only 100
usually seen in transplant recipients. The revised version of
charts, statistical differences are not reported. Differences
the tool was verified by the investigators, definitions clarified,
can be viewed as trends that provide direction for future care
and formatting finalized.
planning.
Usual Care
Usual care for transplant recipients during the time period
Results
used for the retrospective chart review consisted of hospital-
ization for autologous and allogeneic transplants. For tandem
Table 1 reflects the demographic and clinical data for
patients, discharge between the two transplants was usual.
the sample. The majority of patients were male (59%) and
All patients had indwelling central venous access catheters
married (59%), and the mean age was 45 (SD = 13.42). The
and were discharged with them still in place. Criteria for dis-
predominant diagnoses were non-Hodgkin lymphoma (24%),
charge included the ability to ingest 2 liters of fluid per day
chronic myeloid leukemia (18%), multiple myeloma (15%),
by mouth, ability to take medications orally, being afebrile,
and acute myeloid leukemia (14%). The most common type
ability to care for the indwelling central venous access cath-
of transplant was autologous (34%), followed by sibling my-
eter, availability of a caregiver in the home during night hours
eloablative allogeneic (28%). Some patients (12%) received
at a minimum, and availability of transportation to the clinic.
two transplants--a tandem transplant. Comorbid conditions
Discharge teaching generally is performed no earlier than 48
are found in Table 2. Of the 100 patients, 34 had comorbid
hours prior to discharge because patients are too ill before
diseases and 16 experienced concurrent conditions. Referrals
then to learn any new procedures or demonstrate self-care. A
for psychological support occurred in 12 (12%) of the patients
three-ring binder for transplant recipients is distributed prior
(5 autologous, 7 allogeneic). Length of stay for initial hos-
to the transplant in the ambulatory clinic. The binder contains
pitalization for autologous transplant recipients ranged from
information on a wide variety of topics, including self-care,
2530 days, and for allogeneic transplant recipients ranged
complications, and eating hints. During discharge teaching,
from 3035 days.
ONCOLOGY NURSING FORUM VOL 32, NO 1, 2005
E3
Table 1. Demographic and Clinical Variables
Overall death rates were collected up to 18 months post-
transplant and revealed that 30% died of recurrent disease,
Variable
n
%
followed by organ failure and fungal infection. Death rate
during HSCT hospitalization was 11%, during the first
Age (years)
readmission it was 3%, during the second readmission 2%,
X = 45
and during the third readmission 1%. Patients who had
Range = 1973
comorbid diseases before transplantation did not have a
Gender
higher rate of death. However, the eight patients who had
59
59
Male
an infection within one month prior to HSCT had a 50%
41
41
Female
mortality rate.
Marital status
59
59
Married
Readmission Data
24
24
Single
10
10
Divorced
Within a six-month period subsequent to discharge after
04
04
Widowed
transplantation, 51% of the 100 patients had at least one
03
03
Separated
unscheduled readmission, 14% were readmitted twice, 4%
Diagnosis
three times, and 3% four times. Reasons for unscheduled
24
24
Non-Hodgkin lymphoma
readmissions are described in Figure 1. Examples of in-
18
18
Chronic myeloid leukemia
fection-related reasons included sepsis, catheter-related
15
15
Multiple myeloma
infections, cellulitis, disseminated zoster, and pneumonia.
14
14
Acute myeloid leukemia
Examples for readmissions for gastrointestinal problems,
09
09
Hodgkin disease
dehydration, and failure to thrive involved patients who had
09
09
Acute lymphocytic leukemia
07
07
Myelodysplastic syndrome
difficulty with fluid intake, nausea, vomiting, diarrhea, and
02
02
Other
severe nutritional issues. Readmissions for GVHD consisted
01
01
Aplastic anemia
of management of skin, intestinal, or liver GVHD. The
01
01
Chronic myelomonocytic leukemia
"other" category consisted of a variety of reasons, includ-
Type of transplant
ing abdominal pain, shunt bleeding, neurologic symptoms,
34
34
Autologous
hyperglycemia, and mental status changes.
28
28
Sibling myeloablative allogeneic
Of the 100 patients, 12 were scheduled for two (tandem)
17
17
Unrelated myeloablative allogeneic
transplants, with 5 patients scheduled for two autologous
06
06
Sibling nonmyeloablative allogeneic
transplants and 7 patients scheduled for an autologous
02
02
Unrelated nonmyeloablative allogeneic
transplant followed by an allogeneic transplant (see Figure
01
01
Myeloablative syngeneic
12
12
Combined allogeneic and autologous
2). Eleven patients completed both transplants, with seven
Remission status at transplant
patients (58%) able to stay out of the hospital between trans-
26
26
Relapse
plants. Of those readmitted between phases, three were
26
26
Partial relapse
readmitted for infection or fever, and two were admitted for
15
15
First remission
12
12
Chronic phase
09
09
Second remission
Table 2. Comorbid and Concurrent Diseases
05
05
Accelerated phase
02
02
Static disease
Disease
n
%
01
01
Third remission
01
01
Complete response
Comorbid (N = 34)
03
03
Pathology status unclear
15
44
Multiple
History of infection prior to transplant
4
12
Hypertension
92
92
No
3
9
Inflammatory bowel disease
08
08
Yes
2
6
Hypercholesterolemia
2
6
Previous cancer history
N = 100
2
6
Hepatitis
2
6
Spondylitis
1
3
Diabetes
1
3
Graves disease
Eight patients had infections within one month prior to
1
3
Asthma
HSCT. They were infections in a cut finger, facial abscess,
1
3
History of syncopal episodes
genital herpes, fungal infection of the nails, sinusitis, upper
respiratory infection, and staphylococcus epidermis bactere-
Concurrent (N = 16)
mia. Of the 100 patients, 80% became infected with bacte-
5
31
Renal insufficiency
4
25
Multiple
rial, viral, or fungal infections post-HSCT, with one to three
2
13
Deep vein thrombosis
infectious episodes being the most common frequency. Of the
1
6
Hypogammaglobulinemia
patients who had infectious episodes, 34 (34%) did not require
1
6
Pleural effusion
readmission to the hospital but were treated in the ambulatory
1
6
Erythema
clinic. Eleven percent of the infections were catheter-related,
1
6
Tuberculosis
with one individual having three episodes of a catheter-related
1
6
Vancomycin-resistant enterococcus
infection. Thirty-two percent of the individuals had one or two
bacteremic episodes (see Table 3).
Note. Because of rounding, percentages may not total 100.
ONCOLOGY NURSING FORUM VOL 32, NO 1, 2005
E4
Table 3. Infections Post-Transplant
50
Type and Number of Infections
n
%
45
40
Number of infections
19
19
0
35
32
32
1
30
23
23
2
17
17
3
25
1
1
4
20
4
4
5
2
2
6
15
1
1
7
10
1
1
Missing
5
Catheter-related infections
0
89
89
0
First
Second
Third
Fourth
10
10
1
readmission
readmission
readmission
readmission
1
1
3
(n = 44)
(n = 22)
(n = 7)
(n = 3)
Bacteremic episodes
Infection related
68
68
0
Gastrointestinal problems, dehydration, or failure to thrive
29
29
1
Graft-versus-host disease
3
3
2
Relapse
Cardiac problems or hypotension
Organ failure
dehydration or gastrointestinal problems. When readmitted,
Other
patients stayed an average of eight days.
Further analysis involved comparing allogeneic (n = 54)
Figure 1. Reasons for Unscheduled Readmission:
to autologous transplant recipients (n = 34) for unscheduled
Nontandem Transplants
readmissions, number of infections, and length of stay. The
tandem patients (n = 12) were not included in this comparison.
Allogeneic transplant recipients included sibling myeloablative,
Discussion and Implications
sibling myeloablative allogeneic, unrelated nonmyeloablative
allogeneic, and myeloablative syngeneic. The last individual,
for Nursing Interventions
a twin transplant, was classified as allogeneic according to the
usual classification of allogeneic versus autologous (Oudshoorn,
These results reveal trends for the increased risk of com-
Lie, Bakker, Van der Zanden, & Claas, 2004). Comparisons also
plications that allogeneic HSCT patients experience that lead
were made in the allogeneic group, between myeloablative and
to unscheduled readmissions. In addition, for these readmis-
nonmyeloablative. Nonmyeloablative approaches to transplan-
sions, the length of stay was longer for allogeneic transplant
tation included reduced intensity conditioning in an effort to
recipients. When examining which subgroup of allogeneic
decrease treatment-induced toxicities (Hinds & Minor, 2000).
transplant recipients was most likely to be readmitted, the
Unscheduled admissions occurred for treatment of sepsis,
nonmyeloablative patients were at the highest risk. Infec-
GVHD, and other complications.
tions occurred in 80% of the patients but were highest in the
The average number of total unscheduled readmissions was
allogeneic transplant recipients. All allogeneic transplant
fewer for autologous transplant recipients (X = 0.59) versus
recipients appeared to be at higher risk for infection, with no
allogeneic transplant recipients (X = 1.04) (see Figure 3a).
difference in the allogeneic subgroups of myeloablative and
Further breakdown of the allogeneic transplant recipients into
nonmyeloablative.
nonmyeloablative and myeloablative subgroups revealed a
larger difference, with increased unscheduled readmissions
for the nonmyeloablative group (see Figure 3b).
The number of infections for the six-month period postdis-
Completed both transplants
charge was analyzed comparing autologous and all allogeneic
Yes = 11 (92%)
transplant recipients (see Figure 4a). Allogeneic transplant
No = 1 (8%)
recipients had a higher number of infections than autologous
Readmitted between transplants
transplant recipients. When the allogeneic transplant recipi-
Yes = 5 (42%)
No = 7 (58%)
ents were analyzed by myeloablative and nonmyeloablative
Reasons for readmission
subgroups, no differences were evident (see Figure 4b).
Infection or fever = 3
Analysis of length of stay for all first unscheduled read-
Dehydration or gastrointestinal problems = 2
missions revealed longer stays for the allogeneic transplant
Length of stay for readmission
recipients versus the autologous transplant recipients (see
X = 8 days
Figure 5a). This difference was not seen when comparing the
Range = 614 days
allogeneic subgroups of myeloablative versus nonmyeloabla-
Figure 2. Tandem Transplants (N = 12)
tive patients (see Figure 5b).
ONCOLOGY NURSING FORUM VOL 32, NO 1, 2005
E5
14
2.0
12
1.8
10
1.6
8
1.4
13.17
12.97
12.29
14.31
(13.43)
(10.95)
6
1.2
N = 23
N = 30
N=7
1.88
6.25
4
1.0
(1.25)
(4.01)
2
0.8
N=8
N = 20
1.04
0
0.6
0.89
(1.13)
Autologous
Allogeneic
Myeloablative
Nonmyeloablative
(1.06)
0.59
0.4
N = 54
Allogeneic
N = 46
(0.86)
0.2
N = 34
a
b
0.0
Autologous
Allogeneic
Myeloablative  Nonmyeloablative
Figure 5. Mean Length of Stay (and Standard Deviations)
Allogeneic
in Days for First Readmission
a
b
Figure 3. Mean Number (and Standard Deviations)
Physical, psychological, social, and spiritual problems and
of Unscheduled Readmissions
challenges of transplant survivors have been identified and
can be used to describe interventions to be explored and tested
(Broers, Kaptein, Le Cassie, Fibbe, & Hengeveld, 2000; Fife
Primary cause of death for the autologous group was per-
et al., 2000; Keogh, Riordan, McNamara, Duggan, & McCann,
sistent or recurrent disease (87%). For the allogeneic group,
1998). In this population, infection is the most common com-
the primary causes of death included recurrent disease (41%),
plication postdischarge and a reason for readmission. Infection
infection (23%), organ failure (18%), GVHD (6%), and other
is followed closely by gastrointestinal, dehydration, and failure
(12%).
to thrive issues and GVHD. Important aspects of each of these
Information from the literature on transplant survivors
problems need to be part of the teaching and monitoring content
(Baker et al., 1999) combined with information from this
taught at discharge to patients and family caregivers (Smith,
chart review provides the background for identifying implica-
Burcat, & Walker, 1999). Such teaching should include specific
tions for nursing interventions. Demographic distribution of
goals for patients and practical approaches useful in the home
the population whose charts were reviewed identified several
setting. For example, a goal of an oral intake of 2 liters of fluid
areas of interest. The age range included a number of patients
daily is overwhelming to the average patient and needs to be
older than 65, but this transplant population represented a
defined in terms of size and number of glasses and ways to
young cancer population, with a mean age of 45. More than
increase intake creatively (e.g., ice cubes, carrying a liter bottle
half were married and male. Social roles included completing
at all times, graphing input).
educational goals, beginning and carrying out career goals,
Teaching content also should include specific symptoms for
marriage, raising a family, and building a financial future.
patients to monitor and clear reporting mechanisms should
For this group of survivors to carry out these social roles and
symptoms occur. This content should be focused especially
responsibilities, healthcare professionals need to assist them
toward the allogeneic population because comparison of
in maintaining an optimal level of independence. Discharge
the allogeneic and autologous groups revealed trends for
teaching and coaching of adult patients with cancer should
increased readmissions and infections for the allogeneic trans-
include short-term needs and long-term goals.
plant recipients. Teaching content has a potential to affect the
number of readmissions and length of stay for each readmis-
sion. For example, if healthcare professionals target education
on infection prevention and early detection, readmissions may
be avoided, or conditions may be diagnosed early enough to
2.5
make treatment shorter and more effective. Changes in pat-
2.0
terns of readmissions ultimately may affect the outcomes and
1.5
cost of the entire transplantation process.
2.13
2.09
2.09
Psychological problems and challenges are important as
(1.64)
(1.67)
(1.07)
1.0
1.09
N=8
well. The discharge time is one when patients and families
N = 54
N = 46
(0.84)
0.5
are vulnerable to increased anxiety, depression, and stress.
N = 33
Psychoeducational interventions have the potential to decrease
0.0
Autologous
Allogeneic
Myeloablative  Nonmyeloablative
these symptoms; however, few intervention studies have been
Allogeneic
performed on transplant recipients. Studies in the nursing,
medical, and psychological literature covering psychological
a
b
issues are primarily descriptive (Ferrell et al., 1992a, 1992b;
Figure 4. Mean Number (and Standard Deviations) of
Fife et al., 2000; Grant et al., 1992; Keogh et al., 1998; Mc-
Infections Over Six Months
Quellon et al., 1998). Referral for counseling, support groups,
ONCOLOGY NURSING FORUM VOL 32, NO 1, 2005
E6
Conclusions
and literature may assist patients during this transition. Sexual
counseling may be needed to address fertility and intimacy
In summary, data from this retrospective chart review identi-
problems. In addition, if patients and caregivers feel compe-
fied populations with potential discharge problems and higher
tent in newly learned physical aspects of care (e.g., central
readmission risk, specific variables surrounding discharge and
venous catheter care, medication orders), some stress can be
readmission, and post-transplant outcomes potentially amenable
alleviated.
to nursing interventions. These findings parallel those reported
Social problems include designation of a family caregiver
in other studies and clinical papers. This information can assist
to assist with physical care, meals, medication administration,
in planning nursing strategies to improve the discharge process,
and ambulation. This may mean that someone from the fam-
prevent and detect complications early, decrease readmission
ily has to take time off from work or stop working altogether,
rates, and assist patients with information to physically, psycho-
which can have a major impact on family finances. Counseling
logically, socially, and spiritually cope with issues surrounding
from a social worker is necessary to ensure that the processes
transplantation. Findings have prompted the authors to explore
needed to obtain resources such as disability support are un-
ways to improve the discharge process and follow-up support
derstood. The need for assistance from religious or spiritual
at their institution. An appropriate intervention to test would be
advisors cannot be underestimated. Spiritual problems include
to explore patient and caregiver education surrounding the dis-
the persistence of uncertainty about the future, worthlessness,
charge time, prioritizing content, testing patient and caregiver
and hopelessness. Referral for pastoral support is important
learning, and providing resources to patients after discharge. In
and may be provided by an institution or involve contacting
fact, as a further step from this retrospective study, the authors
a church, synagogue, or temple.
have started a pilot nurse educational intervention study to test
Limitations
ways to improve education and patient outcomes in the home
after discharge.
This study has limitations. The first is that the retrospective
study used data available from patient medical records. Thus,
the data are subject to usual errors, primarily omissions that
Author Contact: Marcia Grant, RN, DNSc, FAAN, can be reached
occur in medical records. In addition, all patients came from
at mgrant@coh.org, with copy to editor at rose_mary@earthlink
one institution, reflecting the treatment at that institution.
.net.
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