Care Transition for Liver Transplanted Patients During the Covid-19 Pandemic

Abstract

Objective: to submit the experience lived in the care transition for hospital discharge of patients undergoing liver transplantation due to the COVID-19 pandemic. Method: an experience report on hospital discharge planning and care transition for patients undergoing liver transplantation at a teaching hospital. Results: after COVID-19 pandemic has been declared, several technological means were used to support self-care strategies at the time of the hospital-home transition, as well as remote care for patients focusing on doubts about the routine of care and treatments. In addition, new counterreferral strategies were structured, prioritizing safety and social isolation. Conclusion: the adjustments in care transition with the support of the technologies provided transplanted patients access to all the information that guides self-care. Likewise, they regulated the flow of the support network and the health network, decreasing the possibility for COVID-19 spread, infection and development.

Transition and continuity of care after hospital discharge for COVID-19 survivors

“…An evidence-based model was recommended for use with COVID-19 patients upon discharge from hospital to go home, including several actions that ensure patient-centered care, with preferences and goals taken into account in care plan as well as health education of patients and caregivers for symptom management and treatment compliance (5) . Despite the limitations imposed by the pandemic, such as restricted visits, which prevent the provision of guidance on care for caregivers throughout hospital admission, health teams used communication and information technologies to develop discharge education actions, such as online appointments, educational videos and podcasts, video calls, among others (19) .…”

The experience of patients undergoing liver transplantation in the transition of care

“…A equipe deve planejar com cautela e atenção como será repassada cada informação, sendo prudente avaliar o grau de escolaridade, o estilo de aprendizagem, o tempo de hospitalização, as condições clínicas do receptor e a presença do cuidador, além de ter um olhar atento para as individualidades de cada paciente. Além disso, sugere-se que a equipe de saúde providencie material escrito para a consulta, além de vídeos e outros recursos que possam ajudar o transplantado a resgatar as informações dadas no momento da alta hospitalar (14) .…”

“…À vista disso, a equipe assistencial precisa conhecer a realidade de cada paciente, direcionando suas ações para criar e estruturar a rede de apoio, antes mesmo de o paciente sair de alta. Tais estratégias são fundamentais e contribuem para a adesão ao tratamento e o estado emocional deste paciente (2,7,(12)(13)(14) .…”

Práticas de enfermeiros de um hospital universitário na continuidade do cuidado para a atenção primária

“…A continuidade do cuidado dirige-se aos pacientes, familiares e cuidadores e aos profissionais da saúde que prestam a assistência. Trata-se de um processo que requer, sobretudo, coordenação e comunicação entre diferentes profissionais e pessoas, considerandose suas experiências e habilidades 4 , aspectos relevantes para a transição do cuidado de um ponto da rede de cuidado para outro, especialmente em tempos de pandemia, quando a segurança, o distanciamento social e a realização dos cuidados necessários devem ser priorizados com cautela 6 .…”