CNN: Florida Government repeals safety measures for infant cardiac patients

[tshile]

Pointing out that "why" questions are often difficult to answer with absolute certainty.

Although I will point out that the articles have, in fact, proposed a theory which does actually fit the facts. (You actually mentioned said theory.)

(And so fer, it's the only theory that's been proposed.)

 

Yeah, I'm not trying to be difficult. Really not.

 

I don't know what TimmySmith's motive/agenda/angle might be, but for me it's to bash CNN for being terrible. Which I guess is probably a waste of time because CNN seems to be universally recognized as being awful.

 

But in case there is any confusion, I am absolutely not OK with having children die because well accepted standards are not used for some reason other than medical/scientific reasons (which, given the result being 3x the national average for infant mortality, i have a hard time assuming they have valid medical/scientific reasons)

[Dan T.]

The CNN article was wrong to put the $200,000 Tenet contribution in the lead.  There's no way to prove a quid pro quo between political contributions and unilateral actions by a state government. It's a piece of the story... but they documented plenty of other smoke in this fire. 

 

Just the fact that the Scott-appointed surgeon general decided to scrap the pediatric cardiac care standards, in place for 30 years, just months after media reports of a Tenet-owned hospital failing the standards should set off alarms. 

[TheGoodBits]

The CNN article was wrong to put the $200,000 Tenet contribution in the lead. There's no way to prove a quid pro quo between political contributions and unilateral actions by a state government. It's a piece of the story... but they documented plenty of other smoke in this fire.

Just the fact that the Scott-appointed surgeon general decided to scrap the pediatric cardiac care standards, in place for 30 years, just months after media reports of a Tenet-owned hospital failing the standards should set off alarms.

Expanding on this... The CNN article was written in a way that would make sense to someone who had been following this story for months as it developed. Instead we're left to research background on our own.

This has some good intel: http://miami.cbslocal.com/2015/10/13/state-eyes-repeal-of-standards-for-pediatric-cardiac-surgery/

Bottom line is the donations are certainly very fishy in this whole thing and should absolutely be scrutinized. But it's definitely not the whole story.

[Kilmer17]

Im still trying to understand what exactly the hospital didn't do in the first place that lead to the deaths.  Did they stop sterilizing equipment?  Allow McDs fry cooks to be anesthesiologists?  Specifics would help.

[TheGoodBits]

Im still trying to understand what exactly the hospital didn't do in the first place that lead to the deaths. Did they stop sterilizing equipment? Allow McDs fry cooks to be anesthesiologists? Specifics would help.

I doubt there are specifics available outside of those revealed in potential malpractice lawsuits. But when your fatality rate is well above normal and a board of Doctors is recommending you adopt the standards in question, you're probably doing something wrong.

That, followed by the hospital finally shutting down that program and firing the CEO is pretty much all I need to know to come to the conclusion that there were unsafe practices in place.

[The Evil Genius]

..add you can factor in that the hospital in question was also transferring post surgery kids who were near death to other hospitals (apparently so they didn't have to count them in their death rate stats).

[Larry]

Im still trying to understand what exactly the hospital didn't do in the first place that lead to the deaths.  Did they stop sterilizing equipment?  Allow McDs fry cooks to be anesthesiologists?  Specifics would help.

 

 

Well, the independent review that the hospital allowed, after six kids had died, mentioned some concrete things. 

 

One of the big ones was that they were performing very complicated procedures, with a team that hadn't had sufficient practice at performing more routine procedures.  Their recommendation was that the hospital stop performing cardiac surgery on children less than six months old, and stop performing procedures that were difficulty level 4 or 5.  (The hospital ignored them.) 

 

I'm going to pick out several quotes from the original CNN article on that theme: 

 

But multiple studies show hospitals like St. Mary's tend to give the worst-quality care to children with heart defects, because they get so little practice. The studies show hospitals with fewer surgeries tend to have higher death rates, especially when the surgeries are complex. 

 

While the specific numbers vary slightly according to how they are reported, the numbers at St. Mary's are very low. 

 

According to an independent review of St. Mary's program, the hospital did 23 heart operations in 2013.

 

To put that in perspective, consider that in the United States, 40% of pediatric heart surgery centers in the United States perform more than 250 cases a year, according to data from the Society of Thoracic Surgeons. Eighty percent of centers do more than 100 cases a year. Anything less than 100 cases a year is considered "low volume" by the society. 

 

The volume of open heart surgery cases at St. Mary's keeps getting lower: from 27 cases in 2012 to 18 in 2014, according to documents filed by the hospital with the Florida Agency for Health Care Administration. 

 

"Like anything else, if you use a skill only occasionally, it's hard to develop," says Dr. Roger Mee, the former chief of pediatric heart surgery at the Cleveland Clinic. "With something as complex and dangerous as children's heart surgery, you have to develop a whole team, and it's hard to develop a team around 27 cases." 

 

"With 27 cases a year," he adds, "it would be easy to make a total mess with newborn babies."

 

 

The most scathing review came from Jacobs. 

 

"It is common knowledge that multiple pediatric cardiac surgeons ... have expressed serious concern about babies having complex pediatric cardiac surgery [at] St. Mary's Medical Center," he wrote. 

 

The "extremely low volume" of cases at St. Mary's, he wrote, was evident the day the panel from Children's Medical Services visited. 

 

"This is my fifth CMS site review performed as a reviewer. I have never before gone on a CMS site review where the hospital under review had ZERO pediatric cardiac patients in the [intensive care unit] and ZERO pediatric cardiac patients in the hospital. On our review of April 8, 2014, at St. Mary's Medical Center ... ZERO pediatric cardiac patients were in the ICU and ZERO pediatric cardiac patients were in the hospital," he wrote. 

 

Jacobs, a professor of cardiac surgery at Johns Hopkins University, says St. Mary's was doing too few surgeries to get good at it.

"The number of cardiac surgical procedures performed [at St. Mary's] seems to be too low for the institution and its staff to acquire and maintain proficiency in these types of challenging procedures," he wrote.

 

Now, there's some things in here where I'm not certain about the chronology.  I'm going to present the quotes in the same sequence as they're in, in the article, and then explain what I mean about the chronology. 

 

Jacobs' review wasn't all negative. 

 

He commended St. Mary's for making the "important decision" to limit the complexity of the surgeries it would do on babies' hearts. 

 

Another reviewer, Dr. William Blanchard, the associate statewide pediatric cardiology consultant for Florida's Children's Medical Services, echoed Jacobs' sentiments. 

 

"A phased approach to performance of increasing case complexity is not just desirable, but recommended by safety and quality performance standards," Blanchard wrote, adding that only after making improvements should St. Mary's "advance to the next level of surgical case complexity in a graduated step-wise fashion." 

 

But St. Mary's continued to do open heart surgery on tiny babies. 

 

Nine days after Jacobs and Blanchard visited St. Mary's, the hospital performed open heart surgery on 2-week-old Weston Thermitus. He died about a week later.

 

About a month later, the Department of Health sent St. Mary's a copy of the reviews from the expert panel. 

 

Jacobs, who serves on task forces for the World Health Organization, the American Heart Association, and the Society of Thoracic Surgeons, recommended that St. Mary's not perform any heart surgeries on babies under 6 months of age. For older babies and children, he said the hospital should not perform complex procedures -- those that fall into categories four and five on the scale devised by the Society of Thoracic Surgeons. 

 

Just 11 days after the state sent these recommendations to the hospital, Black operated on Jashnide Desamours, not yet 3 weeks old. The surgery to fix her broken aortic arch was complex, a category four out of five on the Society of Thoracic Surgeons' scale. 

 

"The night of the surgery, she coded," Jashnide's mother, Judelande Damas remembers. Her baby was in cardiac arrest.

 

Black went back into the operating room and put bands on the baby's pulmonary arteries, another complex surgery, again a category four procedure. 

 

"She came out and was bleeding through her nose and everywhere, laying in a pool of blood," remembers Damas, a certified nursing assistant at a rehabilitation center for the elderly. 

 

Jashnide was put on life support, her mother says, and stayed in St. Mary's intensive care unit for more than two months.

Then she says Black wanted to do another operation. 

 

"I said to myself, 'I'm a Christian, so let me pray.' I did, and I said I'm not going to do the surgery. I'm going to transfer her to Joe DiMaggio," she says. 

 

After repair surgery at Joe DiMaggio Children's Hospital, which routinely averages more than 120 heart surgeries a year, Jashnide recovered and today is healthy.

Now, I'm seeing quotes, supposedly from this independent review, advising the hospital to stop performing procedures that are so complex, on patients that are so vulnerable. But I'm also seeing quotes, also supposedly from the same review, complimenting the hospital for supposedly deciding to do just that. So I'm not exactly sure what the actual timeline is, here.

---

And I will again point out. Apparently, one of the standards that the state decided to get rid of, is the one for outside review.

---

..add you can factor in that the hospital in question was also transferring post surgery kids who were near death to other hospitals (apparently so they didn't have to count them in their death rate stats).

 

I'm not sure I'd jump to that conclusion. 

 

Several of the specific cases mentioned in the really long article pulled their kids out of St Mary's over concerns of their kid's care.  (The first one did so after a stranger in an elevator advised them to get their kid out of this hospital.) 

 

I'm not seeing anything that even hints that these transfers were initiated at the hospital's suggestion.

[The Evil Genius]

You're right, I suspect I was making a supposition rather than an informed conclusion, Larry.

 

But the hospital does willingly omit their deaths from their own death stat because they died outside of their hospital (even if the death was likely a result of the surgery).

[Burgold]

Im still trying to understand what exactly the hospital didn't do in the first place that lead to the deaths.  Did they stop sterilizing equipment?  Allow McDs fry cooks to be anesthesiologists?  Specifics would help.

From one of the articles, I got the sense that their equipment and surgeons just weren't up to snuff for this kind of procedure. They took it on for the prestige and because it's a very useful procedure, but just didn't have the right set-up. I'm slightly inferring that because of one the articles that said a new hospital was trying to open up this program, but was also rated below standards in equipment and personnel.

 

I think  it's akin to taking your car to a mechanic who knows how to fix automotive parts, but has no clue what to do with computerized modern systems, but still takes on a car because a car is a car. A heart surgery is a heart surgery, right?

 

I may be off, but that's what I took from what I read.

[tshile]

this situation scares the hell out of me because i don't know how you can be expected to make decisions about this stuff when you don't have the luxury of planning.

 

i guess you have to prioritize research even when you're sitting in the hospital and a doctor is telling you your child need a serious surgery.

[Burgold]

this situation scares the hell out of me because i don't know how you can be expected to make decisions about this stuff when you don't have the luxury of planning.

 

i guess you have to prioritize research even when you're sitting in the hospital and a doctor is telling you your child need a serious surgery.

That is what's scary. There's always a big layer of trust when it comes to health. If a doctor says you need a medication or a procedure you often figure they know best. Sometimes, you get a second opinion, but often you go with what they say. Add in the emergency layer and you really need to trust the docs.

 

Around the DMV, we're pretty lucky because we have Children's which is a very good hospital and kids can get transported there or aerovaced on occasion if the need is serious enough. Even then though, the doctor and the hospital has to make that ask and that call that this is beyond them and they make the request to Children's. If they don't then chances are you get the level of service the hospital can provide which is hopefully good enough and usually is good, but in an emergency you don't head to the best hospital in the area usually... you go to the closest one.

 

Other areas with fewer options have it even harder.

[twa]

from what I've read they hired a experienced hot-shot surgeon that might have accepted more risks than is wise....of course advancement in medicine does not come w/o risk.

 

comparing rates (which CNN did poorly) is a rather difficult thing when dealing with individual cases.

 

it is usually best to go to centers that do volume ,except when it ain't......or you don't have the option of waiting for a opening

[tshile]

Other areas with fewer options have it even harder.

 

And I feel slightly comfortable because my wife works in the field and has a ton of people she trusts that she can call and run something by.

 

But... god forbid she wasn't available an I had to make the call... or something happened while we were on vacation or otherwise in an unfamiliar place.

 

It actually makes me not want to travel for the next 10 years...

 

*sigh* I could deal with a hospital not being particularly good at something like this, but when they outright lie about their abilities (or the results of their work) it crosses over into scary and makes me angry.

[Larry]

comparing rates (which CNN did poorly) is a rather difficult thing when dealing with individual cases.

Comparing rates, which CNN did CORRECTLY. Despite the hospital's attempts to suppress the facts.

Now, I do think it's valid to point out that the hospital's small volume makes it easier for them to be an outlier. Most NFL kickers make virtually all of their PATs. But if you've only kicked two, it's not hard to have a 50% miss rate.

OTOH, if your kicker has missed 50% of his PATs, then you don't send him in to attempt a 65 yard FG.

[twa]

this situation scares the hell out of me because i don't know how you can be expected to make decisions about this stuff when you don't have the luxury of planning.

 

i guess you have to prioritize research even when you're sitting in the hospital and a doctor is telling you your child need a serious surgery.

 

or your spouse or parents....the advances we have made expand options greatly.

 

it should scare ya

Time and choice are luxuries only some can afford.

[pjfootballer]

I have to tell you guys something.  I worked at St. Mary's Hospital from 2001 until 2005 and with Tenet until 2011.  But I was not on the medical side.  I was on the business side. I was a Patient Advocate.  Meaning, I'd interview patients that would come in without any healthcare coverage and I would try to qualify them for Medicaid, the County Healthcare District or sign them up for charities that would help write their bill off.

 

I transferred up here to Piedmont Medical Center when I moved to South Carolina.  The job was pretty satisfying at first.  Our main goal was to assist the patient with their bills.  We did not collect money or ask for any money.  We tried to qualify them for a program.  But as the years went on, around 2008, while working up here at Piedmont MC, they told us we would have to start collecting co-pays, co-insurances, out of pockets along with qualifying patients for these programs. 

 

They wanted us to ask for money up front and if they couldn't pay, we would then interview them for the programs.  Then, we had to meet collection quotas every month.  If we didn't make them, we would get verbal and written write ups.  I hated worrying about that every month.  My team used to help each other and if one was short while the other was over, we would give the one that was short credit for the collection so they didn't get written up. IT SUCKED having to do that. People were already not feeling well and worred about their health along with the bill they were racking up.

 

The job took it's toll on me.  I had grown men cry in front of me because they couldn't pay their bill. After a while, I hate to say this, but I grew immune and uncaring about the sob stories because I'd heard them all. Towards the end, it seemed like Tenet didn't care about signing people up for programs, they placed more emphasis on collections. I can tell you, I do not have the personality to collect.  You tell me no, I won't press you to pay.

 

It was funny, but October of 2011, I didn't meet the quota.  So my boss (hated her and still do to this day) brought me into her office to give the the verbal warning and to make collections next month.  The next month, I really tried, but fell 1 collection short. I really tried both months but was 2 and 1 short each month.  If I was dogging it, I wouldn't have come so close. So, she brings me into her office and gives me the written warning to sign.  I refused.  I told her I'm under no obligation to sign it and there is nothing in the policy that says I have to (she was a stickler for policy).  So I walked out.  I had the interview with my current job (she didn't know) 4 weeks prior and I had a feeling they would hire me. The called me 2 days later and asked if I wanted to start December 14 or January 14.  Guess which one I picked. So satisfying when I handed her my letter of resignation.

 

Anyway, I don't think it's the hospital I would blame. There are a lot of good people I know that still work there.  I would put the blame on Tenet.  They have a bad reputation here at Piedmont MC.  Most people here in South Carolina, would rather go to a hospital in Charlotte (20+ mile ride) then to go to PMC.  I do know that St. Mary's is in a bad part of town in Riviera Beach, FL, so there are a lot of poor that don't have a choice.

 

Blame Tenet, not the hospital.

[TheGoodBits]

Thanks for the story pj. I assume it's the same with many of these healthcare organizations that own hospital chains. It's a massive business and at the end of the day, the bottom line is what matters the most.

What is sad is when it's the patients that get the short end of the stick.

[twa]

Comparing rates, which CNN did CORRECTLY. Despite the hospital's attempts to suppress the facts.

Now, I do think it's valid to point out that the hospital's small volume makes it easier for them to be an outlier. Most NFL kickers make virtually all of their PATs. But if you've only kicked two, it's not hard to have a 50% miss rate.

OTOH, if your kicker has missed 50% of his PATs, then you don't send him in to attempt a 65 yard FG.

 

correctly according to who?

 

my earlier CNN link with the hospital and govt response differs

[Dan T.]

Im still trying to understand what exactly the hospital didn't do in the first place that lead to the deaths.  Did they stop sterilizing equipment?  Allow McDs fry cooks to be anesthesiologists?  Specifics would help.

 

 

I doubt there are specifics available outside of those revealed in potential malpractice lawsuits. But when your fatality rate is well above normal and a board of Doctors is recommending you adopt the standards in question, you're probably doing something wrong.

That, followed by the hospital finally shutting down that program and firing the CEO is pretty much all I need to know to come to the conclusion that there were unsafe practices in place.

 

 

Re: specifics.  Here's a link to the program review of the St. Mary's pediatric cardiac care program, conducted as part of the 38 year old State pediatric cardiac care standards.  You know, the standards that the State dropped about a year after this report came out and two months after CNN reported on it. 

lt wasn't difficult to find... it was linked right from the CNN article. 

 

https://www.documentcloud.org/documents/2083890-program-evaluation-reviews.html

 

Essentially, it said that many vital tests and services were missing at the hospital regarding pediatric cardiac care, that the hospital was unable to maintain proficiency on pediatric cardiac surgery, and recommended that the hospital stop doing heart surgeries on patients younger than  6 years old.

 

The hospital chose to ignore that recommendation.

[Larry]

correctly according to who?

 

my earlier CNN link with the hospital and govt response differs

Correctly according to mathematics.

They compared apples to apples.

And yes, I read the link you posted, to the hospital saying "well, they should have used this other number, and no, we won't tell you what the other number is, either."

 

[twa]

They compared apples to apples.

 

 

 

McIntosh to Granny Smith?

 

there is no real apple to apple in such matters

[Burgold]

McIntosh to Granny Smith?

 

there is no real apple to apple in such matters

If there's no comparability there can be no accountability and I don't buy that.

[twa]

If there's no comparability there can be no accountability and I don't buy that.

 

there is comparability to a degree IF done right(which CNN did not do)

 

https://www.allkids.org/getmedia/b82476e3-8714-4695-9573-e10b2bf5aa46/VO_RiskStratified.pdf;.aspx

 

it is not simple arithmetic, nor are people just numbers 

[Predicto]

It sounds aweful. But I've read all around it and still can't figure out what "standards" are that were ignored and then scrapped. Or if those standards being ignored is why the child died.

I'm ready to rage. But need some ammo

 

 

Yep.   I ain't saying a word until I know more.

[Jumbo]

Yep.   I ain't saying a word until I know more.

  

 

Not ok. This is ES.