Michael E. DeBakey VA Medical Center - Houston, Texas

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Life Savers: Liver Transplant Program

February 18, 2008

http://nursing.advanceweb.com/Editorial/Search/AViewer.aspx?AN=NW_08feb18_n8p12.html&AD=02-18-2008

Advance for Nurses
By Trudy Schreiner | February 18, 2008
Vol. 6 | Issue 5 | Page 12

Life Savers: An exciting new chapter opens in the availability of medical care for veterans living in the southern U.S.

Physicians at Michael E. DeBakey VA Medical Center, Houston, completed their first liver transplant surgery last November. The recipient, Michael J. Abshire, Webster, TX, and his wife came to the medical center in early January for follow-up labs and physician appointments, something Michael will have to participate in for the rest of his life.

"It's a lifelong commitment to get a liver transplant, so [patients and their caregivers] have to meet a lot of criteria [before and after the surgery]," explained Donna Jackson, RN,C, liver transplant clinical coordinator.

During their visit, the Abshires attended a counseling session with Jackson, who presented them with additional patient information materials, updated his medication chart and reiterated instructions for taking his medications, of which there are many.

"Anytime we change their prescriptions, I update their medication chart. The medications are their biggest postop hurdle, and they need to understand [how and why they should take all those meds as directed]," she said.

Additionally, they discussed returning to normal activities, such as taking a camping trip the Abshires are planning in the spring.

Jackson assured the couple the return to most normal daily activities was encouraged by Abshire's transplant surgeon, John Goss, MD, chief, division of abdominal transplantation, at Baylor College of Medicine, Houston. Goss is collaborating with the medical center to provide transplant services to veterans.

She continued to talk with the Abshires and answer their questions about other aspects of daily life for the recently transplanted. They were happy to be able to find liver transplant services at a VA so close to home.

A few years earlier, they would have been referred to another VA facility out-of-state, possibly Portland, OR, or Pittsburgh.

Making It Happen

In August 2006, the medical center was designated as a liver transplant center by the Veterans Affairs Central Office (VACO). The Houston location is the fifth VA liver transplant center in the U.S., joining Pittsburgh; Nashville, TN; Richmond, VA; and Portland, OR. It's also the first new in-house liver transplant program to be designated by the VA in more than 10 years.

The liver transplant team at the Houston VA medical center virtually had to start from scratch to build the Houston transplant program, from ordering the necessary instruments and supplies for the operating room, to acquiring permissions to order patient-specific items, such as digital blood pressure cuffs and thermometers, and establishing nursing protocols and procedures.

While getting the program in place took concerted effort from many VA personnel, "Developing the program was probably 50 percent nursing," Jackson explained. "It was more administrative and knowing how the VA system works."

And, she said, it requires a certain level of clearance to access the VA computer databases and files.

David Berger, MD, of operative care line, agreed nurses had a critical role in starting the program, "One of the first things we did was hire Donna Jackson, our nurse coordinator, who was one of the people who had the greatest impact. It took almost a year to get everyone in place.

"Dr. Goss and the Baylor team were involved from the very beginning. They helped us with our application to both the VA network and VACO," Berger continued. "Once it was approved, they helped us coordinate the application to the United Network for Organ Sharing."

The transplant team's efforts were put to the test a short 15 months later when, in November, the team was notified a donor organ was available for Abshire.

"The thing that's remarkable about the transplant is it went great. I can transplant a liver, but I can only do it if the infrastructure and the institution are there to make it happen," Goss said. "I think that is what should be recognized how the VA personnel and leadership took the time to make it happen for [the veterans]."

Best-Laid Plans

From the moment the call came, the transplant team geared up rapidly to finally put their training and expertise to the test. Jackson would get to see the fruits of her labors as well, although somewhat sooner than she had anticipated.

Jackson had worked only a few months full time in the transplant coordinator position when the call came; however, during that period she had developed a time line for establishing various aspects of the program, including sending the OR and ICU nurses to St. Luke's Episcopal Hospital, Houston, for training.

"I edited Abshire's [United Network for Organ Sharing] listing on a Wednesday, and I told him at that time, 'You'll be transplanted before the weekend is over,'" Jackson said. "Friday he got a liver. That's how quickly it happened."

Once the surgery was scheduled, all the processes the team had lined up and planned during the past months happened very quickly.

"And it went very well because the OR nurses had already been to St. Luke's for training and the ICU nurses also had been there. We weren't exactly on a lazy river before, but we sped up real quick. I think that reflects very positively on the commitment of the nurses here," Jackson said.

Stepping Up

The OR nurses were asked to submit their interest in joining the liver transplant team to their nurse manager. After hearing Goss speak about the program, many nurses were anxious to participate.

Ultimately, three nurses were selected: Deborah L. Larocca, RN, CNOR, staff nurse and team leader, plastic reconstructive surgery; Nida Papa, RN, CNOR, staff nurse in OR, vascular surgery; and Grace Campos, RN, CNOR, staff nurse and team leader, vascular and endovascular services.

"It's exciting to be in the planning stages [of the transplant program] and be able to do the surgery; it's a new challenge," Larocca said. "That's what is so great about nursing, you have all these incredible opportunities to challenge yourself and increase your knowledge base."

As part of the transplant team, the OR nurses were invited to St. Luke's to shadow the nurse transplant team in the OR during a transplant procedure at that facility.

"We went to St. Luke's for 2 days to observe, but we didn't scrub there; we just went to observe the circulating," Papa said.

The three nurses, having previously worked together on cases, had a great working relationship, so they were excited to be selected for the transplant team. On the initial cases, they will have greater opportunities to work as a team and support each other as they all learn more about the procedure.

Eventually, the three OR nurses will rotate scrubbing in for transplants and regular nurses will be trained to circulate, Campos explained.

The team spirit was extended from the transplant nurses at St. Luke's, who invited the VA nurses to observe the procedures in the OR when a transplant was scheduled at that facility.

And, Grace Mathur, DSN, RN, a VA nurse manager, also was instrumental in working with the OR nurses to allow them the time to attend the training at St. Luke's.

What's Next?

Jackson continues to update existing patient literature and create new brochures as needed. She has many administrative duties at this time including following pre- and postop patients, and she hopes to hire additional nurses in the near future.

She also is writing a training module for the liver transplant nurses as a Joint Commission requirement. After a year or so, the transplant team nurses will be able to sit for the certification examination sponsored by the International Transplant Nurses Society where they can receive the certified clinical transplant nurses rating.

This certification may become a requirement in the future for transplant nurses at the medical center, but the nurses must have worked in the field at least 1-2 years before sitting for the exam.

In the meantime, Jackson is continuing to build her professional relationships with Penny Powers, RN, transplant clinical coordinator, and Shannon Cook, RN, inpatient coordinator, both at St. Luke's.

Powers and Cook have continued checking in with Jackson to make sure she is doing OK and let her know they are available if she has any questions or problems.

"It wasn't a short-term relationship with the St. Luke's transplant team; it's definitely long-term," Jackson said.

Star of the Show

The Abshires stayed at Fisher House, a short walk from the hospital, when they were scheduled for pre- and postop appointments.

During their most recent stay, the Abshires were able to have a brief reunion with Larocca, Papa and Campos. It was a joyous and heartwarming experience for everyone.

"They are like my adoptive family now. I will never forget Mr. Abshire," Campos said.

Like a star, Abshire smiled and posed for the photographer, obviously enjoying every minute of the attention he was receiving from the nurses.

"To see Abshire looking so healthy, it's just so amazing. And we also had a moment to speak with his wife. That is when it really hits home, when you see the family together," Larocca said.

For the moment, the illness and the surgery were forgotten as Abshire got reacquainted with the OR nurses and shared his gratitude for their excellent care.

"It was incredible to see Abshire again. When he was in the OR, he was so sick. When I saw him again and he looked so good, it was very fulfilling. I'm so happy for him," Papa said.

Trudy Schreiner is a regional editor at ADVANCE.

Home Away From Home

Veterans and their families have a place to call home when they most need it, thanks to the Fisher House Foundation Inc. and local donations from the community. When visiting the Michael E. DeBakey VA Medical Center, Houston, they can stay at the Fisher House at no cost while attending appointments or undergoing treatments at the facility.

The foundation was started in 1990 by Zachary and Elizabeth M. Fisher as a not-for-profit organization to help build houses at various military bases and VA medical centers. Houston's Fisher House is the largest with 21 rooms, which can accommodate 40-45 people. The average house has 8-10 rooms.

Fisher House Comes to Houston

Opened in 2005 on the grounds next to the medical center, the house's location allows patients to have easy access to treatment just a short walk away. The houses are kept small to maintain the intimacy of a home atmosphere and allow residents to form support networks with other guests.

"Because we're located so close to the hospital, our guests have an opportunity to get away from the hospital environment for a short time and interact with people from the outside. We try to keep it as much like a home here as possible," said Frank Kelley, manager.

A Home, Not a Hotel

In addition to being veterans, the patient guests must be able to care for themselves because the houses are not staffed to provide medical care. The guests have a private bedroom and bath, and there are community areas such as the kitchen, library, family room and dining room, as well as laundry facilities so they can take care of all their needs. Meals are not provided, except on occasion when a volunteer cooks a special meal for the guests.

"I tell people we're sort of like a bed & breakfast, but we don't do the cooking," Kelley said.

While Fisher House accepts veterans who are visiting the medical center for various reasons, Kelley also works with Donna Jackson, RN,C, liver transplant clinical coordinator, to schedule rooms for candidates who are coming in for transplant screening and later when they are ready to be transplanted.

"Once the candidate is put on the donor list, I keep them on the top of my list until I'm notified they're coming in for a transplant," Kelley said. "They don't have to worry about where their family will stay while they're in the hospital."

For more information about the Fisher House locations or the Fisher House Foundation Inc., visit www.fisherhouse.org *.

* This link will take you outside of the Department of Veterans Affairs Web site and will open in a new window. VA does not endorse and is not responsible for the content of linked Web sites.