Chapter 3: The Moral Climate of Health Care
State cites hospital's treatment of liver donor who died
By Ridgely Ochs
STAFF WRITER; Staff writer Bryn Nelson and The Associated Press contributed to this story.
March 13, 2002
Calling his care "shocking" and "fragmented at best," State Health Commissioner Antonia Novello yesterday cited 18 deficiencies in The Mount Sinai Hospital's post-operative care of a patient who died in January, three days after donating a section of his liver to save his brother's life.
While she stopped short of saying the death of Michael Hurewitz, 57, could have been prevented, Novello painted a picture of a transplant unit that was understaffed and too slow to notice or react to his worsening condition. An autopsy showed that Hurewitz had a bacterial infection that had spread throughout his stomach, small intestine, portal vein, esophagus and into his lungs. The infection caused him to aspirate blood into his lungs, killing him.
"The care of the patient was inadequate, and for that we hold Mount Sinai responsible," Novello said in a news conference in Manhattan yesterday.
Hurewitz's widow, Vicky Hurewitz, said in a statement released yesterday that his death was "entirely preventable had proper and timely treatment been instituted by adequately trained, experienced and supervised personnel."
His brother, Adam, 54, of Setauket, chief of pulmonary and critical care medicine at Winthrop-University Hospital in Mineola, has not returned to work since the transplant and is not commenting on the report, said Winthrop spokesman John Broder. The brothers grew up in Rockville Centre; at the time of his death Michael Hurewitz worked as a reporter for the Albany Times-Union. He lived in upstate Schuylerville.
Among the key findings in the report Novello issued yesterday:
The surgeon who operated on Hurewitz at the Manhattan hospital, Dr. Charles Miller, never visited him after the surgery, which is contrary to standard practice and in violation of state regulations.
One surgical resident with only 12 days' experience on the unit was assigned to care for all 34 transplant donors and recipients, a task that left her feeling "totally overwhelmed," Novello said.
The ratio of nurses to patients was 1 to 7, the health commissioner said, compared with a 1 to 1 ratio at University of Rochester Medical Center, which performed the most liver transplants from living donors in the state last year. Novello said there is no required ratio for health care staff to patients.
The transplant fellow - a doctor who is training in a subspecialty - who was on duty failed to respond to the resident's pleas for help when Hurewitz was clearly ill. When the fellow returned to the hospital from a nearby bookstore, he did not examine Hurewitz and instead began a pre-operative workup on another patient.
There was a lack of communication among staff about the patient's diet. Though his chart specified a clear liquid diet, the transplant fellow let the family bring in a full lobster dinner the day after surgery.
The hospital, which performed 35 adult-to-adult living liver donor transplants last year, is being fined $48,000, the maximum possible. Novello said the state had forbidden Mount Sinai from performing such liver transplants for the next six months to ensure that "corrective actions" are taken. Transplants using organs from cadavers or using parts of livers from living adults for children needing transplants will continue, she said.
"I don't believe that, until proven otherwise, we should stop" the hospital's other transplant programs, Novello said.
She said it was "probably customary" that some of the doctors involved would also be reviewed by the health department's Office of Professional Medical Conduct, which can fine a doctor or revoke a medical license. Letters are being sent to the state's three other hospitals that do living liver transplants - New York University Hospitals Center, New York-Presbyterian Hospital, both in Manhattan, and the University of Rochester Medical Center - to ensure they have adequate post-operative care and staffing.
Mount Sinai said in a statement yesterday that correcting problems "is our highest priority. We are deeply distressed that these problems contributed to the death of Mr. Hurewitz and the loss to his family." Barry Freedman, the hospital president, disagreed with the finding that post-operative supervision was inadequate.
Novello said no problems occurred during the operation on Jan. 10, which involved taking about 60 percent of Hurewitz's healthy liver and transplanting it into his brother, who has a liver disease.
But, she said, two days later the otherwise healthy donor developed a rapid heartbeat, which was apparently overlooked by the attending transplant fellow. Around 1 a.m. on Jan. 13, Hurewitz developed hiccups and nausea and was given a medication for the symptoms, which may have masked the underlying problem, the health department report said.
It goes on to say that a surgical resident, unaware of those symptoms, examined Hurewitz at 8:45 a.m. and said his vital signs were stable. Early in the afternoon, Hurewitz began vomiting "brownish materials," generally a sign of blood, Novello said. The surgical resident, who had five months' surgical experience and had been on the unit 12 days, was the only doctor on the unit for three hours, Novello said. The resident called the transplant fellow on duty, who was at a bookstore outside the hospital. He advised against treatment and "despite the patient's distress," the health department said, did not examine Hurewitz upon his return. Hurewitz continued to vomit blood and three hours later was dead.
An autopsy found that Hurewitz was infected with Clostridium perfringens, a bacterium present in the intestines of humans and animals as well as in the soil and sewage. Novello said the health department was still trying to determine the source of the infection.
She added that it was "possible but we just don't know" if Hurewitz's ingestion of a lobster dinner was somehow related to the infection.
Staff writer Bryn Nelson and The Associated Press contributed to this story.
Copyright © 2002, Newsday, Inc.
State Health Department Press Release
March 12, 2002
State of New York Department of Health
State Health Department Cites Mt. Sinai Medical Center for Deficient Care in Living Liver Donor Death
$48,000 Fine Levied Following Department Investigation
New York City, March 12, 2002 ó State Health Commissioner Antonia C. Novello M.D., M.P.H., Dr.P.H. today announced fines totaling $48,000 -- the maximum amount permitted by law -- against Mt. Sinai Medical Center following a Department investigation into the January death of a 57 year old Saratoga County man who had undergone surgery to donate a portion of his liver to his ailing brother.
"Unfortunately, our investigation has concluded that the patient did not receive appropriate care following surgery," Dr. Novello said. "I can only describe the patientís post-operative care as fragmented at best, and entrusted to individuals who although qualified were unable to provide the level of attention necessary for his total post-operative care."
The patient died on January 13, 2002, three days after surgery as a living liver donor. The Health Departmentís investigation identified no problems during the operation itself. However, the investigation concluded that the patient was neither carefully monitored nor appropriately examined and evaluated post-surgery. Likewise significant changes in his condition on days following his transplant were not communicated to all those responsible for his care.
Among the investigationís findings:
During the weekend of January 12-13, 2002 the hospitalís Transplantation Institute was inadequately staffed with nurses and physicians in charge of providing the necessary care for 34 transplant recipients and donors.
Post-operative rounds were found to be inadequate for monitoring and management of patients.
A first year surgical resident (PGY 1) was left alone for three hours on January 13 to care for all 34 patients. She described herself as feeling "overwhelmed" by the responsibility of caring for so many patients with only nurses to help her.
A first year Transplant Fellow failed to respond immediately when informed by the PGY 1 of a significant change in the patientís condition.
There was lack of communication among care-givers, both nursing and medical staff, regarding the patientís diet post-op.
Care-givers, including nursing staff and a fourth year surgical resident, also failed to promptly identify abnormal vital signs that would have allowed them to respond appropriately when the patient developed tachycardia (rapid heartbeat) and hiccups 48 hours post-op.
"The hospital allowed this patient to undergo a major, high-risk procedure and then left his postoperative care in the hands of an overburdened, mostly junior staff, without appropriate supervision" Dr. Novello said. "Supervision of medical residents was far too lax, resulting in woefully inadequate post-surgical care."
As a result of the investigation, the Health Department cited a total of 18 deficiencies against Mt. Sinai Medical Center under the categories of Governing Body, Medical Staff, Nursing Services, Patientsí Right, Medical Records, Surgical Services and Critical Care and Special Care Services. State law permits a maximum fine of $2,000 per deficiency for 15 of these deficiencies and $6,000 for each of the deficiencies involving inadequate resident supervison. Regulations require the hospital to propose a specific corrective action for every deficiency cited, explaining in detail how each is to be addressed.
The hospital has cooperated in the investigation and has voluntarily suspended adult living liver donation procedures. The Department will require the suspension to remain in place for at least six months, pending verification that corrective actions have been implemented. The hospital also will be required to hire a consultant acceptable to the Department to look at both the adult and pediatric living liver transplant programs and identify any issues that remain to be resolved.
Approximately 170 living liver transplantation/donation procedures have been performed at Mt. Sinai since the program began in 1993. This is the first death to occur. Although the death was related to post-surgical care and not to the type of surgery, Dr. Novello will ask the New York State Transplant Council to review issues surrounding living liver donations. The Commissioner also is writing to the three other hospitals in New York that currently are performing living liver donation procedures to ensure that patients are receiving appropriate post-operative care and that post-graduate trainees are being appropriately supervised.
Time Line of Events
January 10, 2002
Patient undergoes surgery to remove the right lobe of his liver. No complications occur during procedure. January 11, 2002
Patient is recovering; his condition is stable. January 12, 2002
Patient is "examined" during rounds by first year Transplant Fellow and PGY 4 surgical resident. Transplant Fellow neither looks at, nor asks for patientís vital signs. At 4:00 p.m., patient develops tachycardia. January 13, 2002
Approximately 1:00 a.m., patient develops hiccups and nausea. Patient is given medication to control symptoms, which may have masked the underlying problem.
8:45 a.m., patient is examined by PGY4 surgical resident who is unaware of the patientís continuing tachycardia and nausea and previous hiccups and writes a progress note indicating that vital signs are stable.
1:10 p.m., patient vomits brownish materials; tachycardia persists. PGY 1 surgical resident calls Transplant Fellow who is at a book store outside the hospital. He advises against insertion of a naso-gastric tube. Upon returning to the hospital, and despite the patientís distress, he does not examine him, but instead prepares a pre-operative work-up on another patient scheduled for surgery the next day.
2:00 p.m., patientís oxygen saturation is unacceptably low; 100 percent oxygen is administered by mask.
3:00 p.m., nurse calls PGY 1 resident to inform her that the patient is continuing to vomit and has difficulty breathing.
3:10 p.m., patient becomes unconscious after vomiting more brownish materials and frank blood. Code is called; resuscitation measures are unsuccessful.
3:40 p.m., patient is pronounced dead. An autopsy revealed the presence of Clostridium perfringens infection in the patientís portal vein, esophagus, stomach, small intestine and lung. Clostridium perfringens is a bacteria that is normally present in the intestines of humans and animals, and is also found in soil and sewage. A separate investigation, looking into the source of the infection, is underway.
Copyright © 2002,Newsday, Inc.
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