Background: Children with spina bifida (SB) involves multiple organs and systems leading to permanent disability which requires specific and uninterrupted health care. Preparation for the SB transition must include a program focused on family self-management and an available health network with access in each region. Thus it is necessary to implement multidisciplinary transition practices using guides and algorithms adapted to specific regional environments. The objective is to present a strategic planning and recommendations for specialists working closely with urology to help patient access to adult centers and its implementation in young people with SB.Material and method: A search was carried out for a systematic review on each specialty that treats patients with SB. The experience was examined ‘’for each related specialty’’, guidelines for transition care and recommendations from experts in each area were given to continue treatment in adult centers through an algorithmic approach. To evaluate the preparation of adolescents and young people with chronic health conditions and parents, the instrument Transition Readiness Assessment Questionnaire (TRAQ) 5.0, Spanish version (Argentina), was used.Results:Every year 270 patients with SB are treated in a multidisciplinary department and about 5.5% transition to adult centers. According to the algorithm: Neurosurgery: with swallowing disorders, headache and visual alterations: suspicion of valve dysfunction: connection with ophthalmology. Furthermore, if there are changes in MMII muscle tone and urodynamic worsening with difficulty in CIC: suspicion of tethered spinal cord: connection with Urology: if renovesical ultrasound shows hydronephrosis and this is accompanied by UTI, video urodynamics is indicated, which, if positive with reflux vesicoureteral, Nephrological aspect should be investigated: with proteinuria and GFR calculation. In addition, discussion with Gastroenterologists about dietary guidelines (nutrition) and intestinal guidelines (such as leaks and constipation) in order to achieve healthier habits, correct postures with Kinesiology in the pelvic floor and with Nursing: who will triangulate again with Urology for adjustment with autoCIC, sexuality in disability and adherence to treatments, which leads us to the intervention of the Psi sphere. The latter will provide us with the possibility to achieve independence. Psychopedagogists evaluated 15 patients between 2022 and 2023 with average Traq 5.0 scores of 3.52. At the same time, Kinesiology will optimize the indications of Orthopedics and spinal pathology with a close relationship again with the Neurosurgery department. Pediatricians in adolescence will make interactions possible with Clinicians from adult centers as feedback for a year.Conclusions:
This “Integrated Transition” algorithm could help patient access with chronic conditions to the adult health care system, reducing the time at risk without medical care.
