Document Type

DNP Project


School of Nursing

Date of Degree

Spring 2022


Doctor of Nursing Practice (DNP)

Primary Advisor

Karen J. Whitt, PhD, FNP-C, AGN-BC, FAANP; Rohit Satoskar, MD, FAASLD


adult liver transplant patients; transfer of care


Background: The transfer of care of the adult liver transplant patient from the inpatient to the outpatient setting has increased in complexity and has the potential to lead to errors and adverse events.

Objective: This pre-post design quality improvement project implemented a hand-off communication tool to improve adult liver transplant patient outcomes when transitioning from the inpatient to outpatient setting.

Methods: The hand-off tool was based on Illness severity, Patient summary, Action list, Situation awareness, and Synthesis (I-PASS). An EMR chart review was completed on discharged liver transplant patients 3 months (N=28) prior and 4 months (N=36) after I-PASS implementation. Data gathered included 30-day readmission rates, incidence of patient calling with questions prior to first outpatient follow-up appointment, medication errors, time needed for advanced practice providers (APPs) to prepare for visit and total time of clinic visit after discharge. APPs (N= 10) were given a survey including the System Usability Score (SUS) before and after I-PASS implementation.

Results: Improvements in all five patient outcome measures were noted post-implementation of I-PASS, yet not statistically significant. There was an overall, statistically significant, improvement in APP satisfaction ratings with the hand-off process after implementation of the I- PASS tool (p<.05). The I-PASS tool achieved a SUS score of 84.7 which is considered excellent.

Conclusions: Positive trends for improved outcomes were observed in this sample of adult liver transplant patients. Significant improvements in measures of APP satisfaction support continued implementation of the I-PASS model and expansion to other organ groups within our organization.

Open Access


Included in

Nursing Commons



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