Transplant patient care in general practice: Actions taken following a significant event

Summary

A young person with a heart transplant and steroid-induced diabetes came into our surgery. This was at a time of high circulating levels of influenza, Covid and strep A.

They presented with chest infection symptoms and were given antibiotics for chest infection by an advanced care practitioner. Advice was given to monitor blood glucose levels and temperature.

A few days later the patient's mum rang as the patient was still coughing. The doctor spoke to the patient who sounded well. They were given an extended antibiotic course.

The patient sadly passed away the following day.

Following our significant event meeting following the event, we had a number of clinical meetings to learn more about the care of transplant patients.

Despite being a full-time GP for 30 years, much of the information was unknown to me and probably unknown to the majority of GPs so we feel it is really important that transplant teams and primary care awareness is raised around this.

We would like to use the hub to do this and promote safety netting that can easily be put in place to mitigate the risk.

Content

Our action points following the event:

• For all patients, when any third party information is passed from a professional this should be recorded exactly as reported with name and contact details of the professional (the information given to the on-call doctor resulted in a speedy response thinking a face to face would be needed, the subsequent telephone conversation left the impression of an improving condition hence no face to face).
• We should strive to improve communication with transplant units, providing our professionals a bypass number direct to reception to avoid answer phone messages and queues, and also seeking their number to break down any logistical barriers to communication.
• We have added all potential significant drugs that could interact with transplant patient medications, such as ibuprofen, clarithromycin, erythromycin, allopurinol as sensitivities so they are not prescribed in error (no prescribing issues in this case, but would be very easy for this to occur and cause severe renal failure on account of interaction with tacrolimus).
• We are adding the adrenal suppression code to alert us to the long-term steroid consequence and have highlighted significant increase risk of steroid-induced diabetes.
• We have added pop-ups that advise of the above that appear when we enter a transplant patient's notes (as long as transplant is coded).
• There is also a pop-up to advise that the normal presentation for unwellness may not apply, such as tachycardia or high temperature, raised CRP or white blood count, and to highlight that vomiting is a big concern as could impact on suppression medication and could also ppt adrenal crisis, thus low threshold for admission for IV treatment should be considered.