During this phase of the liver transplant process, the RN transplant coordinator is responsible for the transplant candidate from referral to selection committee presentation. The RN coordinator is an integral part in assuring appropriate records are obtained and reviewed prior to the patient’s first visit and throughout the evaluation process, as records become available. Upon review of the records, utilizing critical thinking skills and protocols, the RN coordinator determines if additional information is needed and requests as necessary. Because the RN coordinator is an expert in the inclusion and exclusion criteria for liver transplantation , he/she has the ability to determine the need for additional records. The goal for the RN coordinator prior to the patient being seen is to assure that as complete a medical record as possible is available to the physician – this saves time for the patient and provider and avoids any unnecessary duplication of tests.

Once the patient is determined as an appropriate candidate, the RN coordinator manages the transplant evaluation, similar to a project management. Upon receipt of the physician’s order for evaluation, the RN coordinator works with various departments to schedule appointments and testing. This data is reviewed and prioritized to determine immediate needs and follow-up versus long-term or ongoing needs. For example, a lab value may be abnormal and require immediate action by the coordinator, or an abnormal cardiac test may require follow-up with a cardiac catheterization, which the RN coordinator will then assure, as scheduled, follow-up on those results and report to the appropriate provider. As the evaluation process continues, the RN coordinator collects data in a systematic manner assuring inclusion of the patient and family in this process. While scrutinizing the data, the coordinator identifies patterns in the patient’s history and status providing for a comprehensive assessment of the patient.

Patient education is one of the most important functions of the pre-transplant coordinator. Education of this population is not limited to the patient only but includes the family and others of the support system. Patient education focuses on disease processes; signs and symptoms of liver disease, including those that should be reported to the transplant program; symptom management; and specific information about the transplant process – from evaluation to long-term follow-up. This education is extremely important to the patient and family. Not only does it provide vital information to the patient but allows the formation of the nurse-patient relationship. This bond is vital in transplantation since these relationships are lifelong. The transplant education piece should include an overview of the transplant program, indications and contraindications of liver transplant, the evaluation process, selection committee, candidacy determination (accept, decline, defer for listing), and expectations for remaining or being removed from the list and issues that may lead to inactivation (status 7). Risks and benefits of the surgery should be part of the education process; however, these will be reviewed in depth during the surgical evaluation (American Nurses Association and International Transplant Nurses Society 2009; North American Transplant Coordinators Association 2009b). During this period the Model for End-Stage Liver Disease (MELD) score is described. The MELD score can be confusing to patients, so special attention is taken to explain and assure a basic understanding. Logistical information such as what to do when a liver becomes available, what to bring to the hospital, and expectations for the hospital stay is outlined. While patients and their families may not remember this information in detail, this discussion can help to serve as a reminder when the time comes for the actual transplant. A broad overview of the surgical procedure is provided as are expectations for the family before, during, and immediately after the transplant procedure. Potential complications are reviewed while it is suggested that the patient discuss these in detail with the surgeon.

The designation of a primary support and additional support persons is the most important part of patient education the transplant coordinator can discuss. Based upon programmatic considerations, the transplant coordinator has an in-depth educational session with the support person(s) to assure they have an adequate understanding of their expectations during all phases of the transplant process. The RN coordinator consults with the social worker regarding any issues that may have arisen during this education session providing continuity of care during the evaluation phase.

Medication plans and complications of immunosuppression are addressed at this time as well. Again, this provides an overview in order to manage expectations posttransplant (American Nurses Association and International Transplant Nurses Society 2009; North American Transplant Coordinators Organization 2009b).

There are regulatory requirements mandated by the Centers for Medicare and Medicaid (CMS) and/or UNOS that must be addressed during the pre-transplant phase. Often, it is simpler and more efficient to address these during the educational sessions. The first requirement is the consent for evaluation. The consent for evaluation must be signed by the patient or designee and includes acknowledgement of receipt of information from the transplant team concerning:

Health Resources and Services Administration, Organ Procurement and Transplantation Network (2014a).

Multiple listing (wait-listing for transplant at more than one center) is acceptable according to UNOS policy (United Network for Organ Sharing 2008). However, UNOS allows each center to make the determination as to whether or not they will allow it. Therefore, documentation that multiple listing has been discussed with the patient is mandatory. This is the responsibility of the RN coordinator during the pre-transplant phase. Documentation that education has taken place is required as well and is completed during the pre-transplant phase.

After the evaluation is completed, the transplant coordinator gathers and reviews the testing data. Abnormal results are reported to the provider and a plan is created. It is typically the RN coordinator who implements and follows up on this plan. The evaluation data is collated into a standard format and is reviewed at the selection committee. At this committee, all members of the transplant team speak about their interactions with the patient and family. Once a decision is made, the RN coordinator is responsible for relaying the decision to the patient and for implementing any plans or recommendations brought forward by the committee. This ongoing process can last for months; therefore, organizational and follow-up skills are imperative in this position.

The pre-transplant coordinator lists the patient with UNOS via UNet (United Network for Organ Sharing 2014). The listing is based upon blood type, body size, and MELD score. Per UNOS policy, two identical ABO results with sign-off by two team members are required. Following listing, the transplant coordinator documents in the medical record and sends correspondence to the patient and referring provider. Additionally, the UNOS patient education letter is included in the correspondence (Health Resources and Services Administration, Organ Procurement and Transplantation Network 2014b).

Once the determination of the selection committee is complete, the waitlist management begins. This may be done by the same RN coordinator or some programs have separate waitlist managers. In either scenario, the main focus of the waitlist coordinator is to manage those patients who are awaiting transplant (American Nurses Association and International Transplant Nurses Society 2009; North American Transplant Coordinators Organization 2009b). This can be a daunting task as there are many moving parts to keep a patient activated on the waitlist. Native MELD scores, MELD exceptions, appropriate x-rays, and lab data within required time periods along with symptom and side effect management are some of the main foci of this coordinator.