Transition Team

CNSs are also key in the transition process for young patients who are growing into adulthood. They provide support, advice, education for hospital staff and colleagues in the community, with whom they work closely. A transition nurse works collaboratively with the children’s team to facilitate the transition process.

The transition nurses work with children and their families from the age of 12+ to develop a care pathway with them and start the preparation for transfer to adult services, with the aim of minimising emotional distress.
The service is nurse-led and the young person can either come on their own, or with their parents or carers. The care pathway is extensive and addresses issues specific to the teenager/young adult, such as independence. We try to get them to think about their independence by addressing social and psychological issues, and providing information on their heart condition and medication.
Confidentiality and consent are also discussed with patients and their families. This is a good way to inform and prepare them for the adult service.
The young patients should ideally be seen three times before they transfer to the adult congenital heart disease team. The model of a ‘ready, steady, go’ approach is in place within the care plan. A checklist is completed, before the medical transfer, to help analyse the patient’s knowledge and capacity for self-care and consent. The transition service will support adolescents and young adults until their 25th birthday, when the ACHD CNSs take over their care.

Clinical nurse specialists – CHD transition
• Loredana Haidu
• Danielle Horler
• Michelle Lambell