{"id":2538,"date":"2014-01-20T15:23:08","date_gmt":"2014-01-20T20:23:08","guid":{"rendered":"http:\/\/www.khpi.org\/blog\/?p=2538"},"modified":"2014-02-25T11:00:59","modified_gmt":"2014-02-25T16:00:59","slug":"kentucky-childrens-hospital-in-lexington-restarts-its-pediatric-heart-surgery-program","status":"publish","type":"post","link":"http:\/\/www.khpi.org\/blog\/kentucky-childrens-hospital-in-lexington-restarts-its-pediatric-heart-surgery-program\/","title":{"rendered":"Kentucky Children’s Hospital in Lexington Restarts its Pediatric Heart Surgery Program."},"content":{"rendered":"

Implications for Louisville’s Kosair Children’s Hospital and the University of Louisville.<\/strong><\/p>\n

The pediatric cardiac surgery program at the University of Kentucky has seen a steady stream of negative national publicity over the last year.\u00a0 Following the death of several babies with congenital heart defects, the University suspended its pediatric cardiac surgery program in 2012.\u00a0 The institution announced a desire to improve its outcomes and established an internal review process.\u00a0 Its pediatric cardiac surgeon left for elsewhere. Few details were available.<\/p>\n

CNN reported last Friday that Kentucky Children’s Hospital had resumed its pediatric heart<\/a> surgery program as of the New Year.\u00a0 Much of the news report centered on parents\u2019 dissatisfaction that the internal report released last September “doesn’t explain why the babies died,” and with the hospital’s apparent reluctance to provide more specific mortality rates.\u00a0 In an article \u00a0charged with emotional comments, Executive Vice President For Health Affairs at UK, Dr. Michael Karpf, was not cast in a particularly favorable light. \u00a0In responding to concerns that there seemed to be no medical governing body needed to sign off on the decision to reopen the unit, Dr. Karpf is heard saying, “The only person I need permission from is me.”\u00a0 I believe this arrogant-sounding statement was unfairly taken out of context.<\/p>\n

The Report Was Not Glowing.<\/strong>
\nActually, the 102 page report released last September provides a considerable amount of information about the hospital’s pediatric cardiology services. The report addresses recommendations regarding the future, and was not intended to be a review of past clinical outcomes. Nonetheless, in my opinion, it supports concerns that the hospital may not have been fully prepared to offer the most complicated cardiac procedures to children.\u00a0 In fact, given that the report was prepared with “extensive input and guidance from legal counsel,” the document is refreshingly and commendably frank.<\/p>\n

Most of the issues of concern to the reviewers derive from the fact that Kentucky Children’s Hospital is not a dedicated freestanding institution.\u00a0 It has to share its operating rooms, cardiac catheterization laboratories, other facilities, and personnel with the adult services of UK Hospital.\u00a0 There are predictable problems with scheduling, equipment, and staffing with personnel who have extensive current experience with pediatric patients.\u00a0 There was no dedicated pediatric cardiac intensive care unit.\u00a0 The existing general intensive care unit was staffed overnight by residents and nurses, with attending-level physicians “available” by telephone.\u00a0 It was recognized that increasing case volumes are necessary to develop a quality program that is sustainable, but this was thought to be a challenge because the institution is \u201csurrounded by four well-established pediatric cardiovascular centers in the region.”<\/p>\n

The review committee ultimately recommended creating a new “Pediatric Cardiac Service Line” implying that a more coordinated effort was needed.\u00a0 A four bed dedicated pediatric cardiac intensive care unit was to be created and staffed 24\/7 at a higher professional level.\u00a0 As many as eight additional faculty with pediatric expertise were thought needed.\u00a0 With these and many other specific program enhancements thought necessary, it was recommended that the hospital might reopen its surgery program as early as January 1, 2014, but then only for less complex Level I diagnoses.\u00a0 The review committee contemplated a gradual increase in the difficulty of cases over time, but did not contemplate taking on the most complex Level V patients.\u00a0 An aggressive statewide marketing program to increase the number of patients from Kentucky was outlined. I have no knowledge whether the specific recommended prerequisites for restarting have been met.<\/p>\n

There is obviously much more that can be said about a 102 page analysis of multi-service capabilities.\u00a0 I would however like to address the prominent focus on mortality rates as the measure of quality and outcome. There is no question that the University of Kentucky does collect data about disease severity and mortality using a national reporting system.\u00a0 It has been reluctant however to release anything other than a global mortality rate of 7.1% following heart surgeries. [Pediatric heart surgery mortality rates reflect the number of patients who die within 30 days of the surgery or before they are discharged, whichever period is longer.]\u00a0 There is some disagreement on how UK’s average compares to national mortality rates, but frankly, without a more detailed disclosure of mortality rates by severity of disease, the numbers disclosed up to now are meaningless to me.\u00a0 By its own admission, the majority of the patients in Lexington had less severe congenital abnormalities.\u00a0 What we really need to know is how Level I severity cases compared to national Level I averages, and so on up the scale of difficulty.\u00a0 A 7.1% mortality rate for Level I or even Level III cases would be disastrous, but a 7.1% rate for level IV or V would be acceptable. (In fact the national mortality rate for \u00a0Level IV surgery is 7.3% and for Level V is 17.1%.) \u00a0It may be that the numbers were too painful for the University to release. This is a problem all healthcare providers face in the new world of outcome disclosure.<\/p>\n

Why is all this relevant to our pediatric battleground in Louisville?<\/h1>\n

One of my (probably na\u00efve) assumptions behind the University of Kentucky’s desire to associate with Norton Kosair Children\u2019s Hospital <\/a>was to facilitate a pediatric cardiac program that could provide care to the full spectrum of disease.\u00a0 This is still probably partially correct.\u00a0 In its review document, UK in several places recognizes that collaborations and mentorships with the larger programs that surround it would be mutually beneficial.\u00a0 The committee even went so far as to specifically comment that a relationship with Norton Kosair Children’s Hospital would be desirable, “but logistically difficult.”\u00a0 [I wonder why?]<\/p>\n

It is clear however that UK is not contemplating giving up much of its pediatric cardiology program. Indeed it is ramping up to be a more formidable competitor to Norton Kosair, but might be willing to send its more difficult cases to Louisville.\u00a0 [With a truly world-class pediatric Children’s Hospital just across the river in Cincinnati, our Kentucky institutions should reevaluate where the sickest of the sick could best be served.]<\/p>\n

In truth, given the small amount of information given to the public about the justification for a presence of the University of Kentucky in Children’s Hospital and the virtual absence of any specifics, I can only speculate as to their reasons.\u00a0 My instinct is that many academic and clinical benefits are possible, but for that to happen, both Vice Presidents For Health Affairs [or Presidents for that matter] would have to cooperate and interact with the full confidence of their institutions and communities behind them.\u00a0 In my opinion, this will be a challenge.\u00a0 I urge all our institutional leaders to rise above territorial urges and petty academic rivalries to think first about what is best for people with illness. In my mind, “What is best for Kentuckians will be best for the Universities of Kentucky and Louisville.”\u00a0 Get over the rest!<\/p>\n

Anybody think differently? Even one person?<\/p>\n

Peter Hasselbacher, MD
\nPresident, KHPI
\nEmeritus Professor of Medicine, UofL
\nJanuary 20, 2014<\/p>\n

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