A Pilot Project: Improving the Transition Care Process for Neurosurgical Adolescent Patients with Indwelling Shunts to Adult Care

  • Amanda Johnson
    Corresponding author at: University of Chicago, Section of Neurosurgery, 5841 S. Maryland Ave., MC 3026, Chicago, IL 60637, United States of America.
    University of Chicago Medicine, Section of Neurosurgery, IL, United States of America

    Rush University, Department of Women, Children, and Family Nursing, Rush University College of Nursing, IL, United States of America
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  • Jill Marks
    Rush University, Department of Women, Children, and Family Nursing, Rush University College of Nursing, IL, United States of America
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  • Jeanne Little
    Rush University, Department of Women, Children, and Family Nursing, Rush University College of Nursing, IL, United States of America
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      A formal transition program has not been described for neurosurgical adolescent patients with an indwelling shunt device. Transitioning from pediatric neurosurgical care to adult care without transition guidance has caused abrupt transfer of care at this institution. The goal of this pilot transition program was to help patients and caregivers feel informed and prepared for transition.


      The Got Transition®, Six Core Elements of Transition, were used to create this program. Both a policy and a registry to track and monitor patients were created. A validated questionnaire for transition readiness was measured. Education was provided based on the results of the questionnaire to prepare the adolescent for transfer of care. A smartphone application was used to promote health care independence. Transfer to adult neurosurgical care included hand-off between the pediatric and adult teams, child life and social work involvement, and scheduled follow up with an adult neurosurgical provider.


      All patients 14 to 18 years with indwelling shunts were enrolled in the pilot program. Eight patients completed a baseline transition readiness assessment, received education and anticipatory guidance, and downloaded the smartphone application. At the end of the six month pilot, three patients were successfully transferred to adult care.


      The integration of a transition readiness questionnaire and smart phone application during this pilot program was feasible and continues to be used at this institution. Adolescent patients with shunts require gradual and carefully planned transition services.


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