Bill - 60-year-old male status post lung transplant for idiopathic pulmonary fibrosis.

What do you think is going on with this patient?
(everyone to answer)

Initial Assessment ( ~3 min)

Post op for lung transplant. In bathroom, waiting for nurse to return and help, decide to return to bed by himself.

Falls and hits his head on bed.

Patient placed in traction and on bed rest.

Share what you are most concerned about.
(everyone to answer)

Review Assessment ( ~3 min)

57 hours since fall, still not seen by any physician, and in traction ...

Patient contracts Pneumonia and Clostridium Difficile and transferred to ICU

Share what you are most concerned about.
(everyone to answer)

Response Discussion ( ~3 min)

Patient’s family concerned about infection and the lack of physician visits. Requests meeting with physician to discuss concerns – seven people on the medical team attend meeting in ICU room. Family ask to know how they can help and what they can anticipate. The medical team stood with arms folded and stated there was “nothing”.
Summary:

Bill Aydt died in 2005.

Bill had a successful lung transplant, fell trying to get from bathroom to bed, then battled for the next 7 months in the hospital with pneumonia, deep vein thrombosis (DVT), a pulmonary emboli (PE), multiple episodes of clostridium difficile (C.Diff) multiple cases of methicillin-resistant staphylococcus aureus (MRSA), and a stage 4 bedsore.
What can our team learn from this case to improve the care in a similar situation?
Team Discussion (~5 min)
What systems do we have in place to prevent this?
(every team member to answer)
What system issues might have contributed to this outcome?
(every team member to answer)
Systems Discussion (~5 min)
Issues:
- patient centered care
- patient assessment by medical team
- fall prevention
- pulmonary care while immobile
- infection control - pneumonia, C.diff, MRSA
- Decubiti prevention
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