Canterbury DHB

Discharge and Follow Up

Discharge to Other Centres

This refers to the transfer of care to a referring centre and not discharge from the B6. Patients may remain under the care of the Transplant Programme while an out-patient prior to discharge.

Discharge criteria will vary according to the local expertise at the referring centre:

1. Centres with a specialist haematology service and 24/7 cover, including a dedicated in-patient unit and haematologists with experience in post-transplant follow up, e.g. Dunedin Hospital.
2. Centres providing a part-time haematology service capable of specialist out-patient follow-up, but without a dedicated in-patient unit, e.g Nelson Hospital.
3. Centres providing a general medical service without any specialist haematology service, e.g. Invercargill, Timaru, Ashburton, Blenheim. Note: These patients may have general physicians with considerable experience and some training in the care of transplant patients.
4. Centres with family doctor cover and remote from a general hospital, e.g. some rural centres on West Coast and Central Otago.

Exceptions:

These policies may not apply to patients who are being treated with palliative intent or when social circumstances dictate that patient's overall best interests are served by returning to their home/whanau.

Autologous Patients

General considerations for autologous patients before discharge:

• All patients will have a discharge summary detailing pre- and post-transplant complications and schedule of follow up (known as the "transplant protocol").
• All patients will have a named transplant specialist in Christchurch with ultimate responsibility for the patient’s post transplant care.
• Blood counts: ANC >1.0, platelets >50.
• Hickman line: Generally removed before discharge.
• Nutrition: Adequate fluid and caloric intake.
• Mobility: Independently mobile.
• ADL: Independent.
• Follow up: Not requiring more than once weekly follow up or blood tests.
• Antimicrobial prophylaxis: Documented plan of drugs and duration for HSV, VZV, PCP and hyposplenic prophylaxis.
• No evidence of organ failure and/or stable organ function.
• Transfusion requirement: Not more frequently than once weekly transfusion of blood or platelets.
• Patient able to comply with medication and instructions.
• Patient has access to transport and be able to travel to follow-up appointments.
• Patient has access to safe accommodation.

Allogeneic Patients

As above for autologous transplant patients, with the additional requirements;

• GVHD prophylaxis and/or treatment: Less than 1 mg/kg prednisone or equivalent; oral medicines; stable, therapeutic immuno-suppressive drug levels or tapering dose; documented plan for withdrawal of immunosuppression.
• Antimicrobial prophylaxis: As above plus documented plan for CMV, EBV, toxoplasmosis prophylaxis.
• Chimerism: Documented plan of testing.
• GVHD: No organ severity greater than grade 2.
• Venous access: Patient has access to nurses trained in use of in-dwelling venous catheters if not removed prior to discharge.
• Patient has access to relevant laboratory services for specialist monitoring, e.g. cyclosporin levels, EBV and CMV PCR.

Shared Protocols and Documentation

The receiving centre is to receive a copy of the patient’s transplant protocol and discharge summary.

GVHD follow up must be recorded at approximately 100 days, 6 months and yearly post-transplant. Use the transplant programme forms and fax or email a copy back to the BMT Coordinator; fax (03) 364 1486. Use the Red Book as a source of information and contact patient’s primary haematologist for advice.

Fortnightly transplant committee meetings are an opportunity to discuss follow up care.

Post-Transplant Follow-Up

After discharge from Christchurch Hospital, patients should be followed up initially at weekly intervals for one month (autologous) or until immunosuppressive therapy is stable (allogeneic). The interval can be extended to fortnightly for two months (autologous) or until immunosuppressive therapy is withdrawn (allogeneic).

Vital obs (pulse, BP, oxygen sats, RR, temp) and weight should be measured weekly initially and then at each visit.

Allogeneic transplant patients should be monitored for development of GVHD. Helpful tips can be obtained from the Red Book and Be The Match website.

In the first month after discharge, the patient should have the following laboratory tests measured at least weekly:

• CBC+D
• Blood film
• Renal and liver function
• Drug levels as appropriate (e.g. cyclosporin, tacrolimus, MMF, posaconazole, voriconazole).

Once stable, immunosuppressive drugs (e.g. cyclosporin, tacrolimus) should be measured 2-weekly and more frequently if toxicity is suspected (e.g. cytopenias, abnormal renal function, anaemia, abnormal liver function, peripheral tremor).

CMV and EBV monitoring should be performed as recommended in the Transplant Protocol.

Chimerism testing should be performed as recommended in the Transplant Protocol.

Infection prophylaxis for encapsulated bacteriae, PCP, HSV, VZV, toxoplasma, EBV and CMV should be performed as in the Transplant Protocol. See the Gynaecological Allogeneic Transplant flowchart.

Refer to the Post-Discharge Toolkit (Be The Match) for guidelines on testing requirements at follow-up appointments.

Complete the Transplant Programme forms during the 100 days post transplant assessment, 6 months post-transplant assessment and annually post-transplant. Fax or email a copy of the completed form to the BMT Coordinator; fax (03) 364 1486.

See also Reporting Data to International Registries

Re-referral Criteria

We request that you contact us to notify us of any significant event including the following:

• Death of a patient.
• Diagnosis or change in therapy for GVHD.
• Diagnosis of a transplant-related adverse event.
• Diagnosis of relapse.
• Diagnosis of post-transplant infectious complication.
• Change of patient contact details.
• Change of patient family doctor or general physician.

Contact Us

Advice is available to any physician caring for a patient transplanted at Christchurch Hospital. Written advice can be obtained by e-mailing the primary specialist (named on the Transplant Protocol; email address is firstname.surname@cdhb.health.nz) or faxing a referral to 03 364 1067.

For urgent questions in normal working hours, call the hospital switchboard and ask for the primary specialist. Out of hours, the on-call haematologist can be contacted via the hospital switchboard on 03 364 0640.

Topic Code: 92275