“Raw” Curated Contemporaneous Case Study Methodology by Jonathan M. Metsch, DR.P.H.

I taught full time in the Baruch MBA in Health Care Administration program from 1972 to 1975, then was a health care administrator for over thirty years, finishing for seventeen years as President & CEO of LibertyHealth/ Jersey City Medical Center, where we built a replacement safety-net hospital (it took 15 years), played a key role on September 11th, 2001, and once again became a medical school affiliated teaching hospital (having been free-standing for decades).
After retiring from LibertyHealth, I returned to the Baruch program for four years as Adjunct Professor and started writing case studies. I developed case studies based on my CEO experiences. Interestingly case studies on failures provided better Lessons Learned than cases on successes. I also used Harvard Case Studies, and invited “Visiting” Professors to present cases typically related to the new realities of Obamacare, mostly C-Level executives I was still in touch with from my first stint at Baruch. I was very proud of what they had accomplished and shared.
In retirement I have watched health care disruption become so complex that there are few, if any, up-to-date case studies. So I developed a method of “raw” contemporaneous cases studies each developed by curating news articles into a coherent thread, after a topic has called out to me. Topics come from navigating the system (think out-of-network physicians, for example), news feeds, and friends and family.
Now, my Career Capstone Project is to bring “raw” cases to AUPHA that can be used in real-time, meaning they can start a discussion for immediate use in class.

For example if I was teaching now I would be doing contemporaneous cases on Medicare for ALL v. “TrumpCare”, surprise medical bills/ out of network, Candida auris, Ebola, WalmartCare, conflict of interest, migrant children holding facilities..

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Here’s my way of developing a case:

A. Spend some time looking at the case format at http://doctordidyouwashyourhands.com/

B. To identify CCCS topics sign-up for daily automatic health care news feeds. For example:
1. STAT https://www.statnews.com/
2. MedPageToday https://www.medpagetoday.com/
3. Becker’s Hospital Review https://www.beckershospitalreview.com/
4. Healthcare Dive https://www.healthcaredive.com/
5. FierceHealthcare https://www.fiercehealthcare.com/
6. New York Times
7. Hospital Association Daily News Clips

C. Set up Google Alerts https://www.google.com/alerts https://support.google.com/websearch/answer/4815696?hl=en (for example: Amazon. health care; medical/ recreational marijuana; cost of prescription/ generic drugs; Ebola; Emerging viruses; flu; health care disruption; health care innovation; health insurance; hospital innovation;.; ObamaCare; opioid crisis; Trump Care; Zika)

D. Select topics to follow and make a folder for each (for example: Amazon+, precision medicine, Zika, marijuana, antibiotics; insurance; flu, hospitals; Obamacare/ TrumpCare; opioid crisis; prescription and generic drugs, right-to-try)

E. Then every day from News Feeds select articles on your topics and move them to the appropriate folder.

F. When you are inspired to write a “case” start a Word document, then go to the case folder and select key points from the articles, and cut and paste them to the Word document. As well capture article title, author and hyperlink.

G. Move the key points around until you have created a story.

H. Then label each point A,B.C…and move article title, author and hyperlink to footnotes at the end of the case.

I. Then write an introduction to the case.

J. Questions to jonathanmetsch@gmail.com

Jonathan M. Metsch, Dr.P.H.
http://www.mountsinai.org/profiles/jonathan-m-metsch

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PART 5. What are the Lessons Learned (or not!) from the Johns Hopkins All Children’s Hospital and North Carolina Children’s Hospital pediatric cardiac surgery program failures?

“Repairing a heart is a risky business, especially when the organ fails to develop properly in the womb. Any number of abnormalities can arise, from major arteries that grow in the wrong place to pumping chambers that fail to form.

Now, a 2017 U.S. News analysis underscores a crucial factor that can tip the balance between life and death: where the surgery is performed.

The analysis of four years of data from hospitals across the country indicates that 26 percent of deaths – more than 1 out of every 4 – that occur following surgery for the most severe heart defects could be prevented by having the operation performed at hospitals where surgical teams do the greatest numbers of procedures.” (A)

Little has changed, however, since the first research linked volume to outcomes in the 1970s. Smaller surgical programs continue to perform procedures best left to surgeons at more experienced institutions, even when there’s a high-volume hospital nearby.

The reasons for the health care industry’s reluctance to act include the same forces that shape so much else in medicine: prestige and money. Hospitals mindful of their reputation and bottom line encourage doctors to keep patients in-house, rather than referring them to rivals with the experience and resources to care for them. Surgeons also oppose efforts to limit the scope of their practice.

Community leaders, too, may rebel at the notion of closing low-volume services, because lost revenue could threaten a local hospital’s survival. Plus, some smaller hospitals provide high-quality care and get excellent results.

In 2015, U.S. News demonstrated that thousands of lives could be saved each year if patients with certain conditions, including those needing joint-replacement operations, were treated in high-volume settings. Overall, knee-replacement patients who had their surgery in the lowest-volume centers were nearly 70 percent more likely to die than patients treated at the busiest centers. For hip-replacement patients, the risk was nearly 50 percent higher…

Children who need complex congenital heart procedures face a 1 in 5 chance of dying before going home, while the risk for those needing simple repairs is less than 1 percent, says Dr. Jeffrey Jacobs, chief of cardiovascular surgery at Johns Hopkins All Children’s Hospital in St. Petersburg, Florida. Jacobs also leads The Society of Thoracic Surgeons Workforce on National Databases.” (A)

ASSIGNMENT: What are the Lessons Learned from the Johns Hopkins All Children’s Hospital and North Carolina Children’s Hospital pediatric open cardiac surgery program failures? What are the regulatory implications?

First scan Parts 1-4 by clicking on:

 “The U.S. has more than double the number of congenital heart surgery centers that it needs, researchers said here.

Currently, the nation boasts more than 150 such centers: 116 participating in the Society of Thoracic Surgeons (STS) National Database as of 2018, and probably another 30-40 not reporting to it, said Carl Backer, MD, of Ann & Robert H. Lurie Children’s Hospital of Chicago, and former president of the Congenital Heart Surgeons’ Society (CHSS).

Among them are “problem institutions,” outliers with unexpectedly high mortality rates, Backer told a standing-room-only crowd at the American Heart Association (AHA) annual meeting…

The idea is that higher case volume is tied to lower patient mortality in pediatric cardiac surgery, 300 cases per year being the inflection point in one study cited by Backer.

This 300-case threshold held up in a separate analysis by his group, which mined STS data and found that mortality rates adjusted for case complexity came out to 1.7% for centers doing at least 300 cases annually and 5.4% for others with 100 each year (P<0.01).

Regionalizing congenital heart surgery therefore should have the goal of keeping case volumes above 300 per hospital while minimizing travel distance. In addition, policies should allow for at least one program per state that has over 2 million inhabitants, according to Backer.

His magic number: 71 sites scattered across the country.

Currently, Florida and Texas each already have 10 pediatric heart surgery centers — and California 11. In Backer’s plan, this would be reduced to six programs in Texas, four in Florida, and nine in California.” (B)

“A decision on the future of the Sydney Children’s Hospital Network has been delayed four months after an independent review called for urgent action amid protracted conflict over the state’s paediatric heart surgeries.

In July, Health Minister Brad Hazzard held a roundtable of doctors and other healthcare workers from across the state after reviewers said governance issues and tensions between the Randwick and Westmead hospitals needed to be settled “as a matter of urgency”…

A NSW Health spokesman said Professor Henry’s review will make recommendations on the governance and planning of healthcare services for children for the next five years.

“These recommendations will obviously relate to considerations of the governance of the Children’s Hospitals Network and the configuration of paediatric cardiac surgery at the Sydney Children’s Hospital, Randwick and Children’s Hospital at Westmead,” the spokesman said…

Westmead cardiologists believe patients will have better outcomes if cardiac services are focused at one hospital, while doctors from Randwick believe losing cardiac surgery would compromise other services.

“Our message has always been very clear, we believe that cardiac surgery is a vital component of any children’s tertiary referral hospital,” Chair of the Sydney Children’s Hospital Randwick medical staff council Dr Susan Russell said after July’s roundtable.

Most clinicians at that roundtable – including paediatric healthcare workers from rural and regional NSW – agreed the state would be best served with one major children’s hospital providing cardiac surgery services. But medical staff from the Randwick hospital disagreed.” (C)

“Johns Hopkins All Children’s Hospital has hired a familiar face to help it restart its troubled heart surgery unit.

Dr. James Quintessenza will return as the department’s chief surgeon and co-director, hospital leaders announced Tuesday.

Quintessenza, 62, oversaw the pediatric heart surgery department at All Children’s for almost two decades. But he was pushed out after the hospital became part of the Johns Hopkins system…

 “We will spend the next year recruiting additional doctors and staff, including for cardiac intensive care, interventional and fetal cardiology,” Kmetz wrote. “We will take whatever time is necessary to do this right.”..

The announcement comes after a tumultuous 11 months for the hospital and its heart surgery unit.

The Times investigation, published last November, found that the department’s 2017 death rate was higher than any other children’s heart surgery program in Florida had seen in the past decade. Complication rates also spiked, the Times found.

The problems began after Johns Hopkins took over All Children’s in 2011 and started making changes to the heart department. Quintessenza had performed the most difficult surgeries. But the hospital’s new leaders wanted the cases evenly divided among its three heart surgeons.

Frontline workers noticed problems with surgeries performed by the other two surgeons as early as 2015 and raised concerns to their supervisors, the Times reported. But procedures continued as the hospital’s leaders pushed to grow the Heart Institute.

Hospital leaders also made changes to the cardiologists and critical care doctors who worked in the department.

Quintessenza disagreed with the hospital’s leaders, the Times reported. The spike in deaths and complications happened after he left.

After the Times’ investigation, six top administrators resigned, including the hospital’s CEO and the chief heart surgeon who had replaced Quintessenza. Federal and state inspectors identified widespread safety problems throughout the hospital and mandated sweeping changes…

 “We made a mistake, and we need to make sure we help support these families and make it right,” Johns Hopkins Health System president Kevin Sowers told the Times in June.

Quintessenza, who graduated from the University of Florida School of Medicine, was instrumental in growing the All Children’s heart surgery program.

He performed the first pediatric heart transplant there in 1995. Two years later he became the chief of pediatric heart surgery. The heart transplant program was ranked one of the nation’s best in a 1999 federal government review.

After Quintessenza left in 2016, he was quickly hired by Kentucky Children’s Hospital to help restart its pediatric heart surgery program. The hospital had halted surgeries after its death rate increased in 2012.” (D)

“In just three years, Johns Hopkins All Children’s Hospital has tripled the number of babies it treats born with congenital diaphragmatic hernia – a hole in their diaphragm, a life-threatening birth defect.

The St. Petersburg pediatric hospital treated 50 children with congenital diaphragmatic hernia in the third year of its CDH program, up from 16 to 18 patients treated in the first year, said Dr. David Kays, medical director of the program.

About half the patients are from families in Florida, and about half travel from around the United States to St. Petersburg for treatment.

Now, the hospital has a dedicated Center for Congenital Diaphragmatic Hernia, a 15-bed unit that is believed to be the nation’s first inpatient unit dedicated to the treatment of infants and children with condition, said Thomas Kmetz, president of Johns Hopkins All Children’s Hospital.

The center is staffed by an interdisciplinary team and led by Kays, who was recruited to All Children’s in early 2016 from University of Florida. At UF, he treated 321 children over 23 years – about 15 children a year, Kays said at a dedication ceremony Thursday for the new center at All Children’s.

“I came here to build what I thought would be the world’s best program in congenital diaphragmatic hernia,” Kays said. “There was a trajectory to this children’s hospital that was perfect for this program. I couldn’t take this program to Boston Children’s or Children’s Hospital in Philadelphia. There were too many egos to accept me to come in and change the paradigm. But this place was just right. It had the same vision to be a great children’s hospital the way I wanted to build a great program.”..

Kays has a reputation in the pediatric surgical world as a bit of a renegade, “a hard-driving guy with outcomes so great that some people don’t even believe it,” said Dr. Paul Danielson, interim chair of the hospital’s department of surgery.

Danielson describes Kays as a revolutionary, and the CDH unit as truly interdisciplinary.

“It’s not multi-disciplinary, where different specialties come and work together. It’s where different disciplines come together and create their own new discipline,” Danielson said. (E)

“Johns Hopkins All Children’s Hospital in St. Petersburg and Golisano Children’s Hospital of Southwest Florida have entered into an agreement to expand care for kids across Florida’s west coast. The agreement gives providers at both locations access to medical privileges to admit and treat patients. Golisano Children’s Hospital will also be able to take part in pediatric research studies and protocols through Johns Hopkins All Children’s Hospital.

This relationship provides a process for collaboration between the two hospitals, with a focus on increasing access to specialized pediatric care. Through this agreement, Johns Hopkins All Children’s Hospital and Golisano Children’s Hospital will work together to deliver the highest quality care, leverage resources and create better value for families.” (F)

“Three cardiologists from outside the state have reviewed the North Carolina Children’s Hospital pediatric heart surgery program and concluded the program can resume complex pediatric heart surgeries there.

The six-page advisory report released this week by UNC Health Care officials acknowledged that new leadership and investment in the program has helped resolve some of the thornier issues exposed several months ago in a New York Times investigative piece.

The external review panel also highlighted the program’s precarious perch as a smaller-volume pediatric cardiology program aspiring to grow in the shadow of a larger program only miles away at Duke University.

“The current pediatric cardiac surgical volume presents challenges in a number of areas,” according to the report compiled by Catherine Krawczeski, division chief of pediatric cardiology at Nationwide Children’s Hospital Heart Center, Victor Morell, surgeon-in-chief and division chief of the UPMC Children’s Hospital of Pittsburgh’s pediatric cardiothoracic surgery, and Edward Bove, chairman of the University of Michigan medical school’s cardiac surgery department.

The external panel suggests having two pediatric cardiac surgeons at a minimum, able to provide coverage 24 hours a day throughout the year.

UNC averaged slightly fewer than 120 “index pediatric surgeries” in the last year, putting it in a “medium” category in terms of volume. The panel found this “borderline for optimally supporting and maintaining” two full-time pediatric cardiac surgeons…

Meanwhile, the panel noted UNC “must balance” its role as a state hospital and being an important resource for patients with complex needs while also considering whether a referral to another institution might produce a better outcome.

“Complex patients with additional comorbidities that place the patient at higher risk of poor outcome (either surgically or postoperatively) should continue to be carefully evaluated by the medical and surgical teams with referral to another center if deemed appropriate,” the panel stated…

The panel suggested also considering programs that might differentiate UNC from regional competitors, suggesting perhaps a comprehensive multi-disciplinary single care unit that includes cardiac, liver, kidney and neurodevelopment specialists, or an adult congenital heart program, a pulmonary hypertension program or cardio genetics program.” (G)

“Wesley Burks, chief executive of UNC Health Care, reportedly said Tuesday that North Carolina Children’s would be making “further enhancements” to its program, “because we recognize the importance of caring for very sick children with incredibly complex medical problems.”

The health system hasn’t announced a date for resuming surgeries.” (H)

“The federal agency that oversees transplant programs said it would investigate Newark Beth Israel Medical Center after ProPublica reported that the hospital was keeping a vegetative patient on life support for the sake of boosting its survival rate…

The team appeared to tailor medical decisions for at least four patients because of these concerns. In the case of Darryl Young, a heart transplant recipient, members of the medical staff didn’t offer options like hospice care to his family because they wanted to make sure Young lived at least a year after his surgery, according to current and former employees familiar with his care. In an audio recording obtained by ProPublica, Dr. Mark Zucker, the director of the heart and lung transplant programs, told the team at an April meeting, “I’m not sure that this is ethical, moral or right,” but it’s “for the global good of the future transplant recipients.”

In response to the concerns raised by the article, Newark Beth Israel said that it would conduct an “evaluation and review of the program, its processes and its leadership.” It later added that it had hired an outside consultant to perform the review…

Dr. Herb Conaway, a New Jersey assemblyman and chair of the Legislature’s Health and Senior Services Committee, called for the transplant team’s actions to be reviewed. “The implicated doctors must face consequences if the allegations are indeed accurate,” he said in a statement on Friday. “Their actions are a stain on the entire medical community, and they must be held accountable for what they have done to both this patient and his family.”

The editorial board of The Star-Ledger in Newark, which co-published the ProPublica investigation, urged prompt scrutiny of the hospital. “This is astoundingly unethical, and if true, should prompt firings of those involved and a federal and state review,” the board wrote. “The Attorney General’s Office should look into it, too, in case there’s something criminal here.” (I)

“The heart transplant program at Oregon Health & Science University Hospital will resume operations after a yearlong suspension, the hospital announced Aug. 26.

Portland, Ore.-based OHSU voluntarily suspended its transplant program last August after all four of the program’s cardiologists resigned for unspecified reasons.

Since then, OHSU has hired three advanced heart failure cardiologists to join the program. On Aug. 26, the United Network for Organ Sharing approved the program’s new primary physician for heart transplantation, which will allow the transplant program to resume operations.” (J)

“There was a life-threatening mistake at one of the largest hospitals in the Delaware Valley, involving two patients waiting for a kidney transplant. Last week, CBS3 received a tip that a patient at the Lourdes Hospital Transplant Center received a kidney transplant meant for another patient on the waiting list.

The hospital system confirmed that the surgery mix-up did, in fact, take place last week. The two patients have the same name and are around the same age.

After several follow-up conversations with Virtua Health, which took over Lourdes Health System earlier this year, the hospital system admits they gave the wrong person a kidney transplant last Monday.

Officials tell us the organ recipient was in need of a kidney and the surgery was successful. But, they say, the next day a staff member discovered the kidney recipient was out of priority order based on the matching organ donor list.” (K)

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MEDICARE FOR ALL. “Midway through July’s interminable Democratic debate, Senator Elizabeth Warren asked a simple question. “I don’t understand why anybody goes to all the trouble of running for president of the United States just to talk about what we really can’t do and shouldn’t fight for,”..“I don’t get it.” (A)

ASSIGNMENT: After scanning From REPEAL & REPLACE to WRECK & REJOICE (from Obamacare to Trumpcare) http://doctordidyouwashyourhands.com/2018/04/from-repeal-replace-to-wreck-rejoice-from-obamacare-to-trumpcare/ , start tracking Medicare for All.

“On March 24th, 2017. “Speaker Paul Ryan (R-Wis.) on Friday said his party “came up short” in a news conference minutes after pulling the GOP healthcare bill off the House floor, acknowledging that ObamaCare will stay in place “for the foreseeable future.””

Yet on December 20th, 2017 the INDIVIDUAL MANDARE was repealed. ““When the individual mandate is being repealed that means ObamaCare is being repealed,” Trump said…“We have essentially repealed ObamaCare, and we will come up with something much better…””

At the end of this post there are links to a series of over 60 posts tracking the activity between March 24th and December 20th. Laws are like sausages,” goes the famous quote often attributed to the Prussian Chancellor Otto von Bismarck, “it is better not to see them being made.”

_______________________

“Senator Elizabeth Warren on Friday revealed her plan to pay for an expansive transformation of the nation’s health care system, proposing huge tax increases on businesses and wealthy Americans to help cover $20.5 trillion in new federal spending…

Under Ms. Warren’s plan, private health insurance — which now covers most of the population — would be eliminated and replaced by free government health coverage for all Americans. That is a fundamental shift from a market-driven system that has defined health care in the United States for decades but produced vast inequities in quality, service and cost…

Like Mr. Sanders, Ms. Warren would essentially eliminate medical costs for individuals, including premiums, deductibles and other out-of-pocket expenses. But it is not clear if her plan would cover the costs of free health care for everyone. It relies on ambitious assumptions about how much it can lower payments to hospitals, doctors and pharmaceutical companies, and how cheaply such a large system could be run.” (B)

“Warren’s plan estimates that total health costs could be held to $52 trillion and that $20.5 trillion in new federal spending would be necessary…

Where the $20.5 trillion comes from:

Employers are one of the main sources of revenue in this proposal. Warren says she would raise nearly $9 trillion here, a figure that comes from the roughly $9 trillion private employers are projected to spend over the next decade on health insurance. The idea here is that instead of contributing to employees’ health insurance, employers would pay virtually all of that money to the government.

In addition, she will boost her proposed 3% wealth tax on people with over a billion dollars to 6% and also boost taxes on large corporations. Altogether, she believes, taxes on the rich and on corporations would raise an estimated $6 trillion. An additional $2.3 trillion would come from improving tax enforcement.

But there are lingering questions about how much revenue some of these taxes would bring in or how easy it would be to impose a wealth tax in particular.

“Something like half of the wealth of the wealthiest people in America are held in privately held corporations, privately held businesses,” said Howard Gleckman, senior fellow at the Urban-Brookings Tax Policy Center. “And it’s really hard to value those assets for tax purposes.”

Warren also includes comprehensive immigration reform as part of her plan. Giving more people a path to citizenship would mean more taxpayers, which would mean more tax revenue.

While Medicare for All is Sanders’ plan, his bill does not include set methods to pay for the plan. Rather, Sanders has included “options” to pay for his health care plan. In a recent interview with CNBC, he said “we’ll have that debate” over how exactly to finance the plan.” (C)

“Here’s a summary of what Ms. Warren has proposed on either side of the ledger.

To reduce the plan’s costs:

Change the way Medicare pays for certain types of hospital stays, such as paying a package rate rather than different fees for surgical services, and paying doctors in hospital-owned practices the lower prices paid to those in private practices. ($2.3 trillion)

Assume that the Medicare for all program itself can operate very leanly. The Urban Institute estimated that Medicare would devote about 6 percent of its health budget on administrators to decide what and how Medicare would pay for things, and to prevent fraud. In Ms. Warren’s plan, that rate is 2.3 percent. ($1.8 trillion)

Assume very aggressive drug discounts. Ms. Warren believes a government system will be able to reduce spending on drugs substantially, including lowering the prices of branded prescription drugs by 70 percent. ($1.7 trillion)

Assume slower growth in health spending over time. The federal government now thinks health spending will increase by 5.5 percent a year; the Warren campaign assumes 3.9 percent growth under Medicare for all, closer to the rate of growth in gross domestic product. ($1.1 trillion)

Assume lower payments to hospitals. The campaign believes hospitals can be paid around 110 percent of what they are currently paid by Medicare, a number that would cause some hospitals to operate at a loss. Currently, private health insurers often pay a lot more to hospitals than Medicare for similar procedures. ($600 billion)

What Warren Proposes

“Medicare for all” would shift a huge amount of health care money to the federal budget, increasing federal spending by $34 trillion over a decade, according to the Urban Institute. Here’s how Elizabeth Warren would make the math work.

To pay for the plan:

Employers would be required to pay fees to the federal government, equivalent to 98 percent of what they now spend on their employees’ health care. Some companies would be exempt, and companies with unionized work forces would be able to lower this payment if they increased workers’ wages. Currently, companies vary greatly in the cost and generosity of their health benefits, so this fee would vary substantially by firm. ($8.8 trillion)

States and local governments would be required to make payments to the federal government, similar to what they currently spend on government employee benefits and their share of Medicaid expenses. ($6.1 trillion)

Corporate taxation would be increased. ($2.9 trillion)

Tax collections would increase through improvements to I.R.S. enforcement, which Ms. Warren believes could raise a lot of money. ($2.3 trillion)

The top 1 percent of individual earners would pay new taxes on their capital gains; they would pay taxes on increases in investment value annually, instead of waiting until assets are sold. ($2 trillion)

Income tax collections would increase, since workers would no longer pay part of their salaries for insurance premiums, which are not taxed now. ($1.4 trillion)

Billionaires would pay a higher wealth tax than the rate Ms. Warren has previously proposed: 6 percent, up from 3 percent. ($1 trillion)

A new financial transactions tax would be imposed on stock trades. ($800 billion)

Pentagon spending from an overseas contingency fund, often criticized as a slush fund, would be eliminated. ($800 billion)

Income earned by immigrants, following the passage of her immigration overhaul plan, would provide new tax revenues. ($400 billion)

A risk fee on the liabilities of banks with more than $50 billion in assets would be introduced. ($100 billion)” (D)

“Displaying a new assertiveness toward her Democratic opponents, Elizabeth Warren laced into her chief political rivals, warning on Friday night that the country was in a “time of crisis” and arguing that Democrats would lose in 2020 if they nominated “anyone who comes on this stage and tells you they can make change without a fight.”

Speaking to thunderous applause during the party’s biggest Iowa political event of the year, Ms. Warren denounced candidates in the presidential race who opposed bold ideas in favor of more moderate solutions, in veiled attacks on Joseph R. Biden Jr. and Pete Buttigieg.

“Fear and complacency does not win elections,” she said at the Iowa Democratic Party’s fund-raising dinner. “Hope and courage wins elections. I’m not running some consultant-driven campaign with some vague ideas that are designed not to offend anyone.”..

 “We need big ideas, and here’s the critical part: We need to be willing to fight for them,” Ms. Warren said. “It’s easy to give up on a big idea, but when we give up on big ideas, we give up on the people whose lives would be touched by those ideas.”” (E)

“How does the Warren plan expand Medicare to cover everyone without raising taxes on the middle class? There are four main components.

First, the Warren team argues that a single-payer system would provide significant savings in overall medical costs — more than other studies are assuming. Some of these would come from bargaining down prices, especially on drugs. Others would come from a reduction in administrative costs.

Are these savings plausible? Well, America does pay incredibly high prices for drugs compared with other countries, and the complexity of our system imposes a huge administrative burden — not just the overhead of insurance companies, but the sheer number of people doctors and hospitals have to employ to deal with multiple insurers. I’ve been puzzled at the reluctance of other studies to credit Medicare for all with big savings on these fronts.

And we should note that even with these assumed cost savings, U.S. health spending per capita would remain far above that of other advanced countries. So there’s a case — not an open-and-shut case, but a reasonable one — for optimism here.

Second — and the cleverest item in the plan — the Warren team would basically require employers who are now offering health insurance to their employees to pay the cost of that insurance to the government instead. Bear in mind that large employers are already required by law (specifically, the Affordable Care Act) to provide insurance. So this would just redirect those funds.

Third, state and local governments currently spend a lot on health care, mainly but not only through their share of Medicaid spending. The Warren plan would require “maintenance of effort,” basically requiring that states continue to spend that money, but on supporting a national plan.

Finally, even with all this there’s a significant budget hole. Warren’s team argues that this can be closed in two ways: some further taxes on corporations and large fortunes, and — an important point — strengthening the I.R.S., which we know fails to collect large amounts of legally owed taxes, principally from people with high incomes, because Republicans have starved the agency of resources.” (F)

“Whatever their many flaws, Medicare for All advocates used to have a decent answer to the question of how they’d pay for it. Taxes would go up, they’d admit, but these taxes would be de facto premiums, because they’d replace the money Americans already spend on premiums and other health costs. On top of that, the taxes would be progressive, increasing with income, unlike normal premiums — and aggressive price controls would reduce costs overall.

I mean, good luck with that, both politically and practically. But you can’t deny that there’s a logic to it.

For whatever reason, though, Elizabeth Warren today opted for a different approach: one where premiums go away, middle-class taxes don’t go up (not even a penny!), and taxes on the rich make up the difference. In other words, it’s a system where everyone else gets their health care at the expense of the wealthy. Even if that sounds appealing, her plan for doing this shows how silly it is.

First, the plan doesn’t keep its promise. Nearly half the funds come from redirecting the money that employers spend on health benefits to the government. Sorry, but your health benefits are part of your compensation. Sending that money to the state instead is a tax on you, not your employer.

And second, in trying to force rich people to pay for (much of the other half of) everyone’s health care, the plan basically blows every dollar the government could hope to collect from the wealthy in the coming years. The corporate tax goes back up to the uncompetitive 35 percent rate it was before the tax reform, and would be collected far more aggressively too. (Part of the burden of the corporate tax is borne by workers, by the way.) Warren’s wealth tax for “ultra-millionaires” gets a new 6 percent annual rate for those with more than $1 billion.

We already have a ton of debt and frightening obligations to provide old-age entitlements to hordes of retiring Baby Boomers, and yet this plan would eat up trillions in new revenue sticking the rich with the health-care bills of middle-class Americans who say they like their current insurance…

The easy solution is just to go back to the old argument, where taxes do go up but they’re more progressive than premiums and lower on average. But maybe middle-class Americans won’t want to give up their health insurance unless you bribe them with buckets of rich-people money.” (G)

“Senator Elizabeth Warren vowed on Friday to pass major health care legislation in her first 100 days as president, unveiling a new, detailed plan to significantly expand public health insurance coverage as a first step, and promising to pass a “Medicare for all” system by the end of her third year in office that would cover all Americans.

The initial bill she would seek to pass if elected would be a step short of the broader Medicare for all plan she has championed. But it would substantially expand the reach and generosity of public health insurance, creating a government plan that would offer free coverage to all American children and people earning less than double the federal poverty rate, or about $50,000 for a family of four, and that could be purchased by other Americans who want it…

But under the plan she presented on Friday, she would not seek passage of a single-payer system early in her presidency. The proposal would instead move people into that system gradually — in a way she hopes would build public support for full-fledged Medicare for all — while temporarily preserving the employer-based insurance system that covers most working-age adults today.

“I believe the next president must do everything she can within one presidential term to complete the transition to Medicare for all,” Ms. Warren, of Massachusetts, wrote in her plan. “My plan will reduce the financial and political power of the insurance companies — as well as their ability to frighten the American people — by implementing reforms immediately and demonstrating at each phase that true Medicare for all coverage is better than their private options. I believe this approach gives us our best chance to succeed.”..

With her interim plan, Ms. Warren is attempting to offer something attractive to both sides of the Democratic health care debate: preserving her commitment to the single-payer vision that energizes voters on the left, while offering a less disruptive set of proposals in the short term to those who may be reluctant to give up their existing coverage…

Ms. Warren’s agenda would cost more than $30 trillion. She plans to offset much of that cost through new taxes on the richest Americans and on businesses.

But she would still rely on Democrats winning control of the Senate, where Republicans currently hold a slim majority. And she is laying out ambitious details for getting to a single-payer system even as voter support for the idea is narrowing; polls suggest substantially more Americans prefer the “public option” type of plans that Mr. Biden and Mr. Buttigieg have proposed…”  (H)

“Allowing more time underscores Warren’s — or any candidate’s — difficulty in delivering on government-run universal health coverage. Winning congressional approval would be a heavy lift, no matter which party holds majorities in the House and Senate.

 “Every serious proposal for Medicare for All contemplates a significant transition period,” Warren wrote in an online post. “My plan will be completed in my first term. It includes dramatic actions to lower drug prices, a Medicare for All option available to everyone that is more generous than any plan proposed by any other presidential candidate, critical health system reforms to save money and save lives, and a full transition to Medicare for All.”

Even as she continued to praise Medicare for All, though, Friday’s announcement represented a move toward the political middle on an issue that has been one of the most important to voters in the Democratic primary — which begins Feb. 3 in Iowa…

Taking years to get to Medicare for All would give Warren time to convince people happy with their current, private insurance to accept a fully government-funded system. But Friday’s announcement seems sure to raise more tough questions about health care for a candidate who has been struggling with it lately — following her riding improved polling throughout the summer to become one of the front runners in the crowded Democratic primary field…

She is also recognizing that incremental measures that progressives often dismiss as not going far enough could have a real impact on people’s lives. That view was reinforced by a recent study by the Urban Institute and Commonwealth Fund policy centers, which concluded that Democrats have more than one way to get to coverage for all.

“Warren’s proposals to shore up the Affordable Care Act, lower drug prices, and create a public option would still provide substantial health care cost relief for people,” said the Kaiser Foundation’s Levitt.” (I)

Back in 2010, as Obamacare was about to squeak through Congress, Nancy Pelosi famously declared, “We have to pass the bill so that you can find out what is in it.” This line was willfully misrepresented by Republicans (and some reporters who should have known better) as an admission that there was something underhanded about the way the legislation was enacted. What she meant, however, was that voters wouldn’t fully appreciate the A.C.A. until they experienced its benefits in real life.

It took years to get there, but in the end Pelosi was proved right, as health care became a winning issue for Democrats. In the 2018 midterms and in subsequent state elections, voters punished politicians whom they suspected of wanting to undermine key achievements like protection for pre-existing conditions and, yes, Medicaid expansion…

The lesson I take from the politics of Obamacare, however, is that successful health reform, even if incomplete, creates the preconditions for further reform. What looks impossible now might look very different once tens of millions of additional people have actual experience with expanded Medicare, and can compare it with private insurance.

Although I’ve long argued against making Medicare for All a purity test, there is a good case for eventually going single-payer. But the only way that’s going to happen is via something like Warren’s approach: initial reforms that deliver concrete benefits, and maybe provide a steppingstone to something even bigger.” (J)

“Last week, President Donald Trump signed an executive order titled “Protecting and Improving Medicare for Our Nation’s Seniors.” The order is the latest example of how Trump says one thing while doing another. Rather than strengthening Medicare, Trump envisions turning large swaths of the 54-year-old program for the elderly over to the private sector while directing the federal government to dismantle safeguards on seniors’ health care access, shift costs onto beneficiaries, and limit seniors’ choice of providers.

Among other things, the executive order lays out a path to:

Shift the Medicare program toward private plans

Expand private contracting between beneficiaries and providers, putting seniors at risk for higher costs and surprise medical bills

Further restrict seniors’ choice of providers in Medicare Advantage

Expand Medicare Medical Savings Accounts as a tax shelter for the wealthy.. (K)

  1. A.Why Run For President If You Don’t Want to Fight?, by Sarah Jones, https://www.thecut.com/2019/07/elizabeth-warren-best-question-democratic-debate.html
  2. B.Elizabeth Warren Proposes $20.5 Trillion Health Care Plan, by Thomas Kaplan, Abby Goodnough and Margot Sanger-Katz, https://www.nytimes.com/2019/11/01/us/politics/elizabeth-warren-medicare-for-all.html?smid=nytcore-ios-share
  3. C.Here’s How Warren Finds $20.5 Trillion To Pay For ‘Medicare For All’, by Danielle Kurtzleben, https://www.npr.org/2019/11/01/775339519/heres-how-warren-finds-20-5-trillion-to-pay-for-medicare-for-all
  4. D.Elizabeth Warren’s ‘Medicare for All’ Math, by Margot Sanger-Katz and Sarah Kliff, https://www.nytimes.com/2019/11/01/upshot/elizabeth-warrens-medicare-for-all-math.html?smid=nytcore-ios-share
  5. E.Warren Laces Into Rivals as Iowa Campaign Grows Combative, by Sydney Ember and Reid J. Epstein, https://www.nytimes.com/2019/11/01/us/politics/iowa-democrats.html?smid=nytcore-ios-share
  6. F.Did Warren Pass the Medicare Test? I Think So, by Paul Krugman, https://www.nytimes.com/2019/11/01/opinion/did-warren-pass-the-medicare-test-i-think-so.html?smid=nytcore-ios-share
  7. G.Just Admit There Will Be Premiums in Medicare for All and Get It Over With, by ROBERT VERBRUGGEN, https://www.nationalreview.com/corner/elizabeth-warren-medicare-for-all-plan-there-will-be-premiums/
  8. H.Elizabeth Warren Vows to Expand Health Coverage in First 100 Days, by Abby Goodnough, Thomas Kaplan and Margot Sanger-Katz, https://www.nytimes.com/2019/11/15/us/politics/elizabeth-warren-medicare-for-all-100-days.html?smid=nytcore-ios-share
  9. I.Elizabeth Warren Says ‘Medicare for All’ Rollout Process Will Take 3 Years, by WILL WEISSERT, https://time.com/5730682/elizabeth-warren-medicare-for-all/
  10. J.Doing the Health Care Two-Step, by Paul Krugman, https://www.nytimes.com/2019/11/18/opinion/medicare-for-all.html?smid=nytcore-ios-share
  11. K.Trump’s Plan To Privatize Medicare, by By Emily Gee, Maura Calsyn, and Nicole Rapfogel, https://www.americanprogress.org/issues/healthcare/news/2019/10/11/475646/trumps-plan-privatize-medicare/

SUPPLEMENTARY MATERIAL

S.1129 – Medicare for All Act of 2019

Sponsor: Sen. Sanders, Bernard [I-VT] (Introduced 04/10/2019)

https://www.congress.gov/bill/116th-congress/senate-bill/1129/text

Compare Medicare-for-all and Public Plan Proposals

Where 2020 Democrats stand on Medicare-for-all https://www.washingtonpost.com/graphics/politics/policy-2020/medicare-for-all/

Where the top Democratic U.S. presidential candidates stand on ‘Medicare for All’

https://www.reuters.com/article/us-usa-election-healthcare-factbox/where-the-top-democratic-us-presidential-candidates-stand-on-medicare-for-all-idUSKCN1VV13A

MEDICARE FOR ALL. Use this calculator to find out what Elizabeth’s plan for Medicare for All will mean for you. https://elizabethwarren.com/calculator/medicare-for-all

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“The soldier, above all other people, prays for peace, for he must suffer and bear the deepest wounds and scars of war.” Douglas MacArthur

From 1967 to 1970, during the Vietnam War, my first assignment as a junior Air Force 2nd Lieutenant, was as Administrative Officer of the 4th Casualty Staging Flight attached to Wilford Hall USAF Medical Center, Lackland AFB in San Antonio, Texas. We received combat casualties still in battlefield bandages, often within 24 hours of injury, and either admitted them to Wilford Hall or further transported them to hospitals near home.

Recently it occurred to me to look back at how battlefield casualties were handled going back to the Revolutionary War and forward to Iraq/ Afghanistan. BATTLEFIELD MEDICINE is now a medical discipline! (But battlefield surgeon readiness may be at risk.)

BATTLEFIELD MEDICINE. “A war benefits medicine more than it benefits anybody else. It’s terrible, of course, but it does.” *

Introduction

SURGEONS IN EVERY branch of service in military hospitals worldwide perform complex, high-risk operations on active-duty personnel, their family members and some retirees in such small numbers that they may put patients at risk, a U.S. News & World Report investigation has found.

Three decades of research has shown doctors and hospitals with the highest volumes of certain complex surgical procedures achieve the best results. But military surgeons serve a population that’s relatively young and healthy. They lack the steady stream of older patients requiring surgery that would allow the doctors to sharpen their skills and sustain their readiness to help troops on the battlefield.

“You want to do more. In some cases, you’re begging to do more,” says Dr. Scott Steele, chair of colorectal surgery at the Cleveland Clinic, a West Point Graduate, former Army surgeon and Bronze Star recipient with more than two decades of service, including deployments in Iraq and Afghanistan…

The U.S. News analysis suggests that the surgical case shortage, coupled with the remoteness of some base hospitals from larger military or civilian medical centers, prompts some surgeons to tackle cases that may exceed their surgical skills…”  (A)

THE REVOLUTIONARY WAR

“When the Revolutionary War began its actual skirmishes in 1776, early attempts to prepare for the medical needs related to War were made in the City of New York. During the spring and summer of 1776, Samuel Loudon was publishing his newspaper the New York Packet, in which he included numerous articles and announcements regarding the Continental Army. On July 29, for example, came the following announcement written by Thomas Carnes, Stewart and Quartermaster to the General Hospital of King’s College, New York. Anticipating an increase demand for medically trained staff, he filed the following request for volunteers:

“GENERAL HOSPITAL New-York, July 29, 1776 Wanted immediately in the General Hospital, a number of women who can be recommended for their honesty, to act in the capacity of nurses: and a number of faithful men for the same purpose…King’s College, New York” (A)

“One of the most famous surgeons, and the first, was Cornelius Osborn. He was recruited in the Spring of 1776 and had little training even as a physician. The Continental Congress was even concerned about the well-being of the troops and the militia. They passed several ordinances and helped establish the order for the several field Hospitals during the War. The hospitals served about 20,000 men in the fight. Each hospital was required for each surgery to have at least one physician or surgeon, and one assistant, which was usually and apprentice of some sort. Each hospital’s staff numbers varied on how many wounded it served and the severity of the wounds….

Most of the deaths in the Revolutionary War were from infection and illness rather than actual combat. The common practice if a limb was badly infected of fractured was to amputate it, where most amputees died of gangrene a result of not properly cleaning instruments after surgeries. Only 35% of amputees actually survived surgery. There were no pain killers quite developed back then. So at most the patient were given alcohol and a stick to bite down on while the surgeon worked. Two assistants would hold him down, a good surgeon could perform the entire process in a mere 45 seconds, after which the patient usually went into shock and fainted. This allowed the surgeon to stich up the wound and prepare for the next amputation. Another way they decided to clean wounds, disease, or infection was by applying mercury directly to the cut of injured space, and letting it run through the blood stream which usually resulted in death.” (B)

“To seek treatment for any serious ailment, a soldier would have had to go to a hospital of sorts. Military regiments had a surgeon on staff to care for the men, so the soldier’s first stop would be with the surgeon. During battles, the surgeon could be found in a makeshift or “flying” hospital that consisted of a tent, an operating table, and some medical equipment. If the surgeon could not treat the soldier, he might be sent to a hospital. Many regimental hospitals were in nearby houses, while general hospitals for more in-depth treatment were sometimes set up in barns, churches, or other public buildings. The conditions were often cramped, which resulted in the rapid spread of contagious illnesses and infections….

Woe to the soldier who required surgery after being wounded on the battlefield! The conditions in “flying” hospitals were deplorable. Not only was the operating room simply a table in a tent, but there was little thought given to keeping the table and tools clean. In fact, wounds were sometimes cleaned using plain water from a bucket, and the used water would be saved to clean out the next soldier’s wounds as well.” (C)

“Hospitalization was a serious problem during the American Revolutionary War. Plans were made quite early to care for the wounded and sick, but at the best they were meager and inadequate. However on April 11, 1777 Dr. William Shippen Jr., of Philadelphia was chosen Director General of all the military hospitals for the army. Consequently the reorganization of hospital conditions took place…

After the battle of Brandywine, September 11, 1777, hospitals were established at Bethlehem, Allentown, Easton and Ephrata. After the battle of Germantown, October 4, 1777, emergency hospitals were organized at Evansburg, Trappe, Falkner Swamp and Skippack. Hospitals at Litiz and Reading were also continued. By December 1777, new hospitals were opened at Rheimstown, Warwick and Shaeferstown. Yellow Springs (now Chester Springs) an important hospital was organized under the direction of Dr. Samuel Kennedy. At Lionville, Uwchlan Quaker Meeting House was also made a hospital for a time. Apothecary General Craigie’s shop, Carlisle, was the source of hospital drugs….” (D)

WAR of 1812

“The big advances in military medicine were decades away.  William Morton would develop ether anesthesia for surgery, but not before 1846.  Florence Nightingale would create the professional nurse and reform the British hospital, but not until 1857.  Robert Koch would put forth his germ theory in 1890.  Although the War of 1812 took place well before these advances, there were many skilled military surgeons, most of them aware of the salutary effects of cleanliness.

At one Army hospital in Burlington, Vermont for example, the ward master had a long list of rules: chamber pots were to be cleaned at least three times a day and lined with water or charcoal.  Beds and bedclothes were to be aired daily and exposed to sunlight when possible. Once a month the straw in each bed sack was to be changed. If a patient died, the straw was to be burned…

Skilled as some practitioners were, the war took place in a period when some medical attention could kill you.  Army doctors used emetics to cause vomiting and cathartics to cause diarrhea, both as stomach cleansers.  Patients were sometime bled intentionally.  These cures often left the patients weak, dehydrated and unlikely to survive.

Battle injuries, of course, just compounded the misery.  A bullet in the head, chest or abdomen meant almost certain death.  A bullet in the limbs meant a twenty percent chance of death if the wound was cleaned and in most cases the limb amputated…

Stoicism seemed to be the watchword of the day.  There are accounts of soldiers singing, joking, and even smoking during an amputation.  People at this time were familiar with pain, and soldiers were expected to rise to the occasion. Recovery took place in the hospital, where, in some units, a soldier received half-rations and half-pay as an incentive to get well quickly.” (A)

“Military surgeons often resorted to so-called “heroic” treatments. Those treatments often seem crude and sometime barbaric to modern eyes. Bleeding, the deliberate opening of vein to remove blood from a patient, was thought to reduce blood volume and reduce fever and infection. Blistering, the practice of creating a skin infection on the patient, was thought to lead to pus that would carry away infection. Other physicians deliberately induced vomiting in an attempt to combat disease. Such practices were seldom helpful and often made the patient’s condition worse.

Among the items found in a surgeon’s medicine chest were opium and alcohol, useful for pain management, and quinine, found to be effective in treating malaria. But many drugs were either unhelpful or, in the case of the mercury used to treat syphilis, quite toxic.

Army medicine also suffered from some basic organizational shortcomings. The War Department was ill prepared when the conflict broke out in 1812. Officials had no standardized system of accounting for or replenishing its medical supplies, or for evaluating the competency and training of its medical staff.

But as the conflict wore on, army medicine improved noticeably. Congress created the post of surgeon general and outlined professional qualifications for selecting surgeons. In addition, the Congress attempted to improve cleanliness among soldiers through better camp sanitation, and tried to alleviate hospital overcrowding. Over time, the contents of the surgeon’s medicine chest became standardized, and a better system of hospitals emerged. Permanent hospitals were located well to the rear, away from the fighting, and linked to more mobile, “flying hospitals” closer to the front lines.

But in many ways, the most intractable problem remained the scientific unknowns. Solutions to the fundamental puzzles—the nature of disease, how it was transmitted, and how to prevent infection—remained several decades away. More often than not, army doctors found themselves groping in the dark for answers.” (B)

MEXICAN WAR

“Disease posed far greater threat than the battlefield. In addition to ubiquitous camp diseases like dysentery that had hounded Taylor’s army before it ever crossed the Rio Grande, the rainy season and its mosquito-borne malaria came directly on the heels of the city’s occupation and further compounded public health woes for all of Matamoros’ residents.[6] Smallpox, too, carried off its share of victims. Although all American soldiers were supposed to have been vaccinated against the disease upon entering the army, volunteers sometimes fell through the cracks in the rush to deploy troops, and one army surgeon complained his supply of the vaccine had been ruined by the Mexican heat.[7] Most to be feared was the deadly yellow fever, and with the help of correspondents on other battlefronts in Mexico and from coastal U.S. cities like New Orleans and Mobile, the bluntly titled English language newspaper The American Flag carefully tracked the fever’s progress throughout the Gulf of Mexico.[8]” (A)

To care for the many sick in General Taylor’s command, surgeons set up eight regimental hospitals, each sheltered in two or three large hospital tents, and a general hospital, housed in a large frame building in Corpus Christi. In the latter facility, those whose illness was likely to be prolonged joined the overflow of patients from the regimental hospitals. The medical staff manning these hospitals included the medical director for Taylor’s force, Presley H. Craig, Jarvis as director of the general hospital, a purveyor, and thirteen more department physicians. Three civilian doctors were hired until more Regular Army surgeons could be assigned to Taylor’s command..” (B)

“From the founding of the nation and throughout the first half of the 19th century, drugs were not regulated by the federal government. Problems with drug impurity were episodic, and when occurring, they were usually contained within a state or a region. The usual reaction to a case involving impure or bogus medicine was a call for reform at state houses with individual states instituting laws governing aspects of drug manufacture and trade, but these regulations were spotty at best. The situation changed during the MexicanAmerican War, which began in 1846 and ended in 1848…

Although the high death rate had many contributing factors from compromised food provision and poor living conditions to infectious diseases, public outrage focused on the medical care given to soldiers. It was concluded that adulterated drugs supplied to the Army had caused the large numbers of deaths among soldiers.

This enraged the public, and the outcry led Congress to pass the Drug Importation Act of 1848, the first federal drug law. It was very limited in scope and addressed only the purity of drugs imported into the United States. Congress charged Customs with enforcing the law. Special examiners were appointed at six major ports of entry—New York, Boston, Philadelphia, Baltimore, Charleston, and New Orleans. They checked the “quality, purity, and fitness for medical purposes” of imported drugs using the major  pharmacopoeias (publications describing drugs) and dispensatories for standards.” (C)

THE CIVIL WAR

 “Many of America’s modern medical accomplishments have their roots in the legacy of America’s defining war.”

“During the 1860s, doctors had yet to develop bacteriology and were generally ignorant of the causes of disease. Generally, Civil War doctors underwent two years of medical school, though some pursued more education. Medicine in the United States was woefully behind Europe. Harvard Medical School did not even own a single stethoscope or microscope until after the war. Most Civil War surgeons had never treated a gunshot wound and many had never performed surgery. Medical boards admitted many “quacks,” with little to no qualification. Yet, for the most part, the Civil War doctor (as understaffed, underqualified, and under-supplied as he was) did the best he could, muddling through the so-called “medical middle ages.” Some 10,000 surgeons served in the Union army and about 4,000 served in the Confederate. Medicine made significant gains during the course of the war. However, it was the tragedy of the era that medical knowledge of the 1860s had not yet encompassed the use of sterile dressings, antiseptic surgery, and the recognition of the importance of sanitation and hygiene. As a result, thousands died from diseases such as typhoid or dysentery…

Battlefield surgery…was also at best archaic. Doctors often took over houses, churches, schools, even barns for hospitals. The field hospital was located near the front lines — sometimes only a mile behind the lines — and was marked with (in the Federal Army from 1862 on) with a yellow flag with a green “H”. Anesthesia’s first recorded use was in 1846 and was commonly in use during the Civil War. In fact, there are 800,000 recorded cases of its use. Chloroform was the most common anesthetic, used in 75% of operations. ..A capable surgeon could amputate a limb in 10 minutes. Surgeons worked all night, with piles of limbs reaching four or five feet. Lack of water and time meant they did not wash off hands or instruments

Bloody fingers often were used as probes. Bloody knives were used as scalpels. Doctors operated in pus stained coats. Everything about Civil War surgery was septic. The antiseptic era and Lister’s pioneering works in medicine were in the future. Blood poisoning, sepsis or Pyemia (Pyemia meaning literally pus in the blood) was common and often very deadly…” (A)

“Early on, stretcher bearers were members of the regimental band, and many fled when the battle started. Soldiers acting as stretcher bearers rarely returned to the front lines. As the war evolved, stretcher bearers became part of the medical corps. At the battle of Antietam, there were 71 Union field hospitals. As the war went on, these were consolidated. There were ambulances here that were used to bring the wounded to temporary battlefield hospitals, which were larger, often under tents, and out of artillery range. Later in the war, patients were transported to large general hospitals by train or ship in urban centers. These did not exist when the war began. There was no military ambulance corps in the Union Army until August of 1862. Until that time, civilians drove the ambulances. Initially the ambulance corps was under the Quartermaster corps, which meant that ambulances were often commandeered to deliver supplies and ammunition to the front…

Large general hospitals were established by September of 1862 (11). These were in large cities, and soldiers were transported there by train or ship. At the end of the war, there were about 400 hospitals with about 400,000 beds. There were 2 million admissions to these hospitals with an overall mortality of 8%. In the South, the largest general hospital, Chimborazo, was in Richmond, Virginia. It was built out of tobacco crates on 40 acres. It contained five separate hospitals, each made up of 30 buildings. There were 150 wards with 40 to 60 patients per ward. The census was as high as 4000. They treated about 76,000 patients with a 9% mortality (12)…”  (B)

Most of the major medical advances of the Civil War were in organization and technique, rather than medical breakthroughs. In August of 1862, Jonathan Letterman, the Medical Director of the Army of the Potomac, created a highly-organized system of ambulances and trained stretcher bearers designed to evacuate the wounded as quickly as possible…

A system of triage was established that is still used today. The sheer number of wounded at some of the battles made triage necessary. In general, the wounded soldiers were divided into three groups: the slightly wounded, those “beyond hope”, and surgical cases. The surgical cases were dealt with first since they would be the most likely to benefit from immediate care. These included many of the men wounded in the extremities and some with head wounds that were considered treatable. The slightly wounded would be tended to next, their wounds were not considered life-threatening so they could wait until the first group was treated. Those beyond hope included most wounds to the trunk of the body and serious head wounds. The men would have been given morphine for pain and made as comfortable as possible…

Due to the sheer number of wounded patients the surgeons had to care for, surgical techniques and the management of traumatic wounds improved dramatically. Specialization became more commonplace during the war, and great strides were made in orthopedic medicine, plastic surgery, neurosurgery and prosthetics. Specialized hospitals were established, the most famous of which was set up in Atlanta, Georgia, by Dr. James Baxter Bean for treating maxillofacial injuries. General anesthesia was widely used in the war, helping it become acceptable to the public. Embalming the dead also became commonplace.

Medical technology and scientific knowledge have changed dramatically since the Civil War, but the basic principles of military health care remain the same. Location of medical personnel near the action, rapid evacuation of the wounded, and providing adequate supplies of medicines and equipment continue to be crucial in the goal of saving soldiers’ lives.” (C)

“Many misconceptions exist regarding medicine during the Civil War era, and this period is commonly referred to as the Middle Ages of American medicine. Medical care was heavily criticized in the press throughout the war. It was stated that surgery was often done without anesthesia, many unnecessary amputations were done, and that care was not state of the art for the times. None of these assertions is true. Actually, during the Civil War, there were many medical advances and discoveries..

Medical Use of quinine for the prevention of malaria

Use of quarantine, which virtually eliminated yellow fever

Successful treatment of hospital gangrene with bromine and isolation

Development of an ambulance system for evacuation of the wounded

Use of trains and boats to transport patients

Establishment of large general hospitals

Creation of specialty hospitals

Surgical Safe use of anesthetics

Performance of rudimentary neurosurgery

Development of techniques for arterial ligation

Performance of the first plastic surgery..”  (D)

SPANISH-AMERICAN WAR

“In the three decades between the Civil War and the Spanish-American War, virtually all practical experience of trauma medicine evaporated. Yet in those years, medicine advanced. The 1893 appointment of George Sternberg to Surgeon General allowed the rise of bacteriology and many other vogue advancements to be incorporated into trauma medicine. Additionally, the opening of 200 nursing schools across the United States kept attendant medical practitioners well-versed on germ theory and sterilization…

The Spanish-American War of 1898 was brief, with relatively few battle casualties, but epidemic disease, especially typhoid fever, devastated the volunteer troops. Post-war investigations and commissions generated better understanding of the problem of asymptomatic carriers and a series of recommendations that greatly improved military medicine. The new practices, including the development of a typhoid vaccine, saved thousands of lives during World War I. Studies that established the role of the mosquito in yellow fever spawned preventive measures that ended the huge epidemics of that disease in the Western Hemisphere; this in turn made possible successful construction of the Panama Canal…

New forms of surgical dressings especially designed for field use, composed of sterilized, sublimated, and iodoform gauze; sterilized gauze bandages, absorbent cotton, catgut, and silk, sterilized and packed in convenient envelopes; tow, compressed cotton sponges, and plaster of paris bandages were also prepared under the immediate supervision of this office…”  (A)

“Despite the lessons learned in the Civil War, the government had taken no concerted steps toward establishing a skilled nursing service to care for the sick and wounded during wartime…

The war with Spain was quickly demonstrating the important need for trained nurses as hastily constructed army camps for more than twenty-eight thousand members of the regular army were devastated by diarrhea, dysentery, typhoid fever, and malaria— all of which took a much greater toll than did enemy gunfire.

As a result of their work in the Civil War, religious sisters were recognized for providing skilled nursing services. In view of the urgent need for medical assistance in the summer of 1898, it was no surprise when the government called for every nursing sister who could be spared. Official government records indicated that the various orders furnished around 250 sister nurses, with the Daughters of Charity (originally referred to in the United States as Sisters of Charity), providing the majority of nurses.8 Although members of other orders were represented, their numbers were considerably less” (B)

World War I

Medicine, in World War I, made major advances in several directions. The war is better known as the first mass killing of the 20th century—with an estimated 10 million military deaths alone—but for the injured, doctors learned enough to vastly improve a soldier’s chances of survival. They went from amputation as the only solution, to being able to transport soldiers to hospital, to disinfect their wounds and to operate on them to repair the damage wrought by artillery. Ambulances, antiseptic, and anesthesia, three elements of medicine taken entirely for granted today, emerged from the depths of suffering in the First World War…

Antiseptics and anesthesia saved lives once they arrived at the hospital, but without motor ambulances and hospital trains to get them there, wounded soldiers stood little chance. From the impromptu rescue of soldiers from Meaux in September 1914, the American Ambulance Field Service grew to number more than 100 ambulances by the end of the first year of the war. Philanthropists such as Anne Harriman Vanderbilt bought cars, as did civic groups from cities around the United States. The Ford Motor Company donated 10 Model-T chassis to be converted into ambulances…

What inspired these major advances in medicine? There was a deep need, and people stepped up to find solutions. The new technology of war—heavy artillery, long-range cannons, barrage shelling, and machine guns—rained devastation at unprecedented levels. Medicine had to try to keep up. One good example of this evolution is in facial reconstruction surgery. Soldiers survived having jaws and noses shattered by artillery fragments, so surgeons at the American Hospital and Val-de-Grace Hospital pioneered maxillofacial techniques, and at the same time, brought dentistry into the medical sciences in France.”  (A)

“On the battlefields, physicians employed recently invented medical technology in addressing their patients’ injuries. The X-ray machine, which had been invented a couple decades before the war, was invaluable for doctors searching for bullets and shrapnel in their patients’ bodies. Marie Curie installed X-ray machines in cars and trucks, creating mobile imaging in the field. And a French radiologist named E.J. Hirtz, who worked with Curie, invented a compass that could be used in conjunction with X-ray photographs to pinpoint the location of foreign objects in the body. The advent of specialization within the medical profession in this era, and the advancement of technology helped to define those specialized roles.” (B)

WORLD WAR II

“Battlefield medicine evolved considerably between World War I and World War II. In the former, approximately 4 out of every 100 wounded men could expect to survive; in the latter, the rate improved to 50 out of 100…

A number of new drugs and medical techniques developed in the years between the world wars dramatically improved the survival rate among the sick and injured. For example, combat medics (and even men in the field) carried packets of sulfanilamide and sulfathiazole to coat wounds as a first line of defense against infection. Antibiotics such as streptomycin and penicillin also helped save the lives of countless soldiers…

American servicemen were also inoculated for a wide variety of diseases before being shipped overseas. The most common vaccinations were for smallpox, typhoid, and tetanus, though soldiers assigned totropical or extremely rural areas were also vaccinated for cholera, typhus, yellow fever, and, in somecases, bubonic plague.” (A)

“World War Two was a time where medicine began catching up with evolving technology.  In World War One infection took the lives of many soldiers along with disease.  The number of deaths from injury complications motivated scientists and doctors to determine cures for infection…  

One development was the creation of Penicillin.  It was created pre-war but was not used in large quantities till World War Two.  The first batches in 1939 were weak, but through determination a new version, 20 times more strong, came out in 1945 ().  On D-Day penicillin was used en masse, saving thousands of lives and strengthening America’s cause.  It saved many lives, but still left many to die because the time lapse between injury and treatment still remained very broad.  However, the number of people being infected was vastly decreased and survival chances were greatly increased…

The mediocre blood transfusion process was also greatly improved upon in World War Two.  Primitive techniques became more advanced, and the system of storing and distributing blood became more efficient.  With a better system of storing blood, blood was usually available when a soldier needed it.  The blood was also most likely fresher and less contaminated since the containers were better constructed.  However, blood was often in short supply.”  (B) 

“A major contribution of the 20th century was the widespread recognition and treatment of what we now call post-traumatic stress disorder, or PTSD. It has probably existed back into history. There are case reports from the Civil War, for example. During World War I, it was sometimes called “shell shock,” which probably included cases of actual brain damage. More often soldiers suffering from PTSD were diagnosed as “cowardice.” Soldiers were shot for it in the British, French, German, Austrian, and Russian armies. As the war dragged on, it became better recognized, but its treatment varied widely. The Russians tried to treat near the front lines, sending the soldiers back to their units as early as feasible. We adopted that practice, and in fact, armies today still treat psychiatric casualties this way. What may seem heartless, actually proved to be the most effective way to treat PTSD and to prevent long term sequelae. The recognition of PTSD as a psychiatric disease of war was not firmly established until World War II. They called it “combat fatigue.” But whatever they called it, they recognized it and treated it.” (C)

KOREAN WAR

“Though the Korean War came to be regarded as a failure by many because of its unsettled conclusion, in one area it was an unreserved success: the care and treatment of wounded soldiers. In World War II, the fatality rate for seriously wounded soldiers was 4.5 percent. In the Korean War, that number was cut almost in half, to 2.5 percent. That success is attributed to the combination of the Mobile Army Surgical Hospital, or MASH unit, and the aeromedical evacuation system – the casualty evacuation (casevac) and medical evacuation (medevac) helicopter. Both had been developed and used to a limited extent prior to 1950, but it was in the Korean War that both – particularly the helicopter – came into their own, and as Army Maj. William G. Howard wrote, “fundamentally changed the Army’s medical-evacuation doctrine.” Helicopter medevacs transported more than 20,000 casualties during the war. One pilot, 1st Lt. Joseph L. Bowler, set a record of 824 medical evacuations over a 10-month period. Another example tellingly highlights the impact of the helicopter. The Eighth Army surgeon estimated that of the 750 critically wounded soldiers evacuated on Feb. 20, 1951, half would have died if only ground transportation had been used…

The Korean War also provided an opportunity to study and test new equipment and procedures, many of which would go on to become standards of care in both the military and civilian medical communities. These included vascular reconstruction, the use of artificial kidneys, development of lightweight body armor, and research on the effects of extreme cold on the body, which led to development of better cold weather clothing and improved cold weather medical advice and treatment. The newest antibiotics were used widely, and other drugs that advanced medical care included the anticoagulant heparin, the sedative Nembutal, and the use of serum albumin and whole blood to treat shock cases. In addition, computerized data collection (in the form of computer punch cards) of the type of battle and non-battle casualties was used for the first time. The extensive detail and accessibility of this data allowed for the most thorough and comprehensive analysis of military medical information yet…” (A)

Medical professionals made significant changes to the way they treated injured troops during the Korean War, which led to fewer casualties as well as medical advancements for civilians. The war set the stage for how medical professionals treat trauma patients today.” (B)

VIETNAM

Both the Korean and Vietnam wars proved to be severe challenges to the medical system, the former for cold weather operations, and the latter for tropical and jungle warfare. The medical services gradually adapted to these challenges. By the time of the Vietnam war, for example, operations could be done in contained, air-conditioned operating theaters that were containerized so as to be moved close to the battlefield. (See Figure 6.) Helicopter evacuation supplemented ground ambulances, and air transport replaced hospital trains. The system of progressive levels of casualty care has turned into doctrine, and remains the guiding principle for casualty care. Operation during the 40 years since Vietnam have produced far fewer casualties, yet have challenged the military medical services in different ways. Small unit operations at greater and greater distances have increased reliance on medical corpsmen, who are now trained to at least the level of civilian Emergency Medical Technicians, and often higher. Casualty care and evacuation in a hostile civilian environment, always a problem in warfare, has been made more complex by opponents who refuse to respect the non-combatant status of medical facilities and personnel.” (A)

IRAQ and AFGHANISTAN

“In the Vietnam War, with its close quarters and heavy use of helicopters, the time between hurt and help averaged two hours but could be as little as 30 minutes. With the improved speed came a reduction in deaths among the wounded, from 8.5 percent in World War I to 1.7 percent in Vietnam.

In the Persian Gulf, “many of the wounded may have to be carried first by litter from the field, then by truck back to a station where helicopters may evacuate them to a surgical hospital,” General Blanck said. “It could take hours in some situations.” The Platoon Lifesaver

Because of potential delays, the military now gives all soldiers training in a few emergency medical techniques like clearing respiratory blockage. “A wounded soldier’s survival may depend on his buddy’s ability to initiate lifesaving care on the battlefield,” wrote Lieut. Col. James A. Martin, commander of the Army Medical Research Unit. “Each soldier should possess the skill to clear an airway, control bleeding and start an intravenous fluid line to control shock.”

Foot soldiers do not have that full training, but in many platoons, General Blanck said, one soldier has been trained and designated the lifesaver.

“We did not have this in Vietnam,” he said, “and it may really be needed in the kind of warfare we may have in the gulf.”

Other changes since the Vietnam War include new vaccines and treatments, including one for Hepatitis A and one to prevent septic shock from a sudden invasion of certain types of bacteria in people who are most seriously wounded. There are vaccines against local diseases, and one against anthrax to protect troops who may be targets of biological warfare.

Once they reach a hospital, soldiers will benefit from improved techniques to repair torn blood vessels and treat burns. CAT scanners will be available in the larger hospitals of each corps, General Blanck said. Heat Is a Serious Factor”  (A)

“Injured veterans of the Iraq and Afghanistan Wars can give credit to the medical personnel of earlier wars, including the Vietnam War, for their care and recovery.

Surgeons, anesthesiologists, nurses, and other staff advanced medical practices for soldiers receiving care in the areas of trauma care and blood supply, repair of blood vessels to save limbs, and studying the effects of a range of weapons.

The contributions of medical personnel improved the outcomes of those wounded not only in Vietnam, but also subsequent wars.

A technique in trauma care in the use of topical antimicrobial chemotherapy for the care of burns and other wounds was available for the first time in the theater of operations.

Another practice that evolved during the Vietnam War was the use of universal donor, or Type O, blood banks in various stations throughout Vietnam.

Techniques that were developed during World War II and the Korean War greatly reduced the need for amputations in the field by tying the major artery to the affected limb.

The improvements in emergency responses and trauma care techniques that were developed during the Vietnam War are still relevant now.” (B)

“DRONES”

 “The Navy corpsman was overwhelmed. Dozens of Marines lay injured at the casualty collection point following a devastating artillery bombardment—and the corpsman didn’t have nearly enough to blood at hand to treat them all.

A soldier’s odds of survival increase nearly threefold if they receive a blood transfusion within an hour of being injured. Unfortunately, the Medical Battalion’s field hospital and its copious blood supplies was over a dozen miles away. With the combat zone interdicted by enemy fire, the odds that medical supplies or evacuation would arrive anytime soon looked grim.

Hastily, the corpsman transmits a map coordinate and a brief request.

Fifteen minutes later, a swarm of drones comes swooping down at over a miles per minute. Hatches in their bellies flip open, releasing not bombs but small boxes which come floating down near the collection point using paper parachutes.

Inside each box is some bubble wrap—and three units of blood ready for transfusion.

Overhead, the drones bank around and soar back to the medical battalion and glide towards a large trapeze-like contraption on the ground. Precise maneuvers allow a hook on the drone’s tail to snag onto the trapeze, bringing the unmmaned aircraft to a halt.

As the drones are recovered, staff swap out their spent lithium-ion batteries for recharging, replacing them with fresh batteries—and new cargo boxes in their bellies.

In a few minutes, the drones are ready to deliver even more life-preserving blood products.

The above battle may never have happened—but it was simulated in a series of exercise in Australia involving a U.S. Marine Corps Air-Ground Taskforce, the Australian Defense Force…and a gaggle of forward-deployed commercial drones.” (A)

(A).Will Blood-Bearing Delivery Drones Transform Disaster Relief and Battlefield Medicine?, by Sebastien Roblin,  https://www.forbes.com/sites/sebastienroblin/2019/10/22/will-blood-bearing-delivery-drones–transform-disaster-relief-and-battlefield-medicine/#4e4ddb506252

ROBOTIC SURGERY“U.S. Army physicians, located far from a field hospital, could soon be performing delicate, highly specialized surgery on wounded soldiers using robotics and other forms of telemedicine.

Army Surgeon General Lt. Gen. Nadja West said recently that the demands of future battlefields will force the military medical community to prepare for operational environments that are vastly different.

“We might not have the life-saving ‘golden hour’ evacuation system we have been accustomed to for the past 17 years,” West told an audience recently at an Association of the United States Army function.

“Our soldiers may be isolated for 72 hours or more, requiring prolonged field care if injured in an austere environment,” she said.

Enemy air superiority may not allow the U.S. military to fly critically wounded soldiers to well-equipped hospitals in far-off countries, so field hospitals may have to rely on new, robotic technology to save patients, West added.

Robotic surgery, which is currently used in non-invasive procedures, could be adapted to meet the Army’s battlefield needs, she said.

“There is robotic surgery that’s going on right now,” West said, adding that the challenge will be “how quickly we can scale it all throughout our enterprise.” (A)

** https://www.brainyquote.com/quotes/douglas_macarthur_125212

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PART 2. “Massachusetts Surgeons will have to document each time they enter and leave the operating room, and who took over in their absence… amid controversies over doctors who perform more than one surgery at a time…

Over twenty years ago a general surgeon at one of our community hospitals left the OR to operate at a competing hospital and told a nurse to close the incision. He claimed OR nurses could train and be certified as “closers”. Problem was the nurse hadn’t been certified and we did not have hospital privileges for this competency. The nurse was fired and the surgeon fought disciplinary action although up to the Board of Trustees. Recollection is that he had been suspended from the medical staff, by me for over six months and that became his penalty as well as a long period of probation.

There are many areas in the hospital where it may be hard for a patient to discern who is actually providing care: an attending or a resident? An anesthesiologist or a nurse anesthetist? an orthopedic (foot) surgeon or a podiatrist for ankle surgery?; a primary care physician or a nurse practitioner?

PART 1 before new Part 2.

ASSIGNMENT: You are the CMO of your local teaching and the CEO wants to know if you should prohibit double-booking? And you are instructed to make sure patients know who is treating them, so what do you do?

PART 1. December 5, 2017. Should surgeons be allowed to operate in more than one OR at a time?

“Dr. Kirkham Wood arrived in the operating room at Massachusetts General Hospital before 7 one August morning with a schedule for the day that would give many surgeons pause.

Wood, chief of MGH’s orthopedic spine service at the time and a nationally renowned practitioner in his specialty, is a confident, veteran surgeon. He would need all of his talent and confidence this day, and then some, as he planned to tackle two complicated spinal surgeries over the next many hours — two patients, two operating rooms, moving back and forth from one to the other, focusing on the challenging tasks that demanded his special skills, leaving the other work to a general surgeon, who assisted briefly, and two surgeons in training.

In medicine it is called concurrent surgery, and the practice is hardly unique to Wood or MGH. It is allowed in some form at many prestigious hospitals, limited or banned at many others. Hospitals that permit double-booking consider it an efficient way to deploy the talents of their most in-demand specialists while reducing wasted operating room time.” (A)

‘Known as “running two rooms” – or double-booked, simultaneous or concurrent surgery – the practice occurs in teaching hospitals where senior attending surgeons delegate trainees – usually residents or fellows – to perform parts of one surgery while the attending surgeon works on a second patient in another operating room. Sometimes senior surgeons aren’t even in the OR, but are seeing patients elsewhere.

The decision about whether to allow the practice is left to hospitals, which are primarily responsible for policing it. Medicare billing rules permit it as long as the attending surgeon is present during the critical portion of each operation – and that portion is defined by the surgeon. And while it occurs in many specialties, double-booking is believed to be most common in orthopedics, cardiac surgery and neurosurgery.”  (B)

American College of Surgeons – Overlapping Operations- Statements on Principles (C)

“Overlap of two distinct operations by the primary attending surgeon occurs in two general circumstances.

The first and most common scenario is when the key or critical elements of the first operation have been completed, and there is no reasonable expectation that the primary attending surgeon will need to return to that operation. In this circumstance, a second operation is started in another operating room while a qualified practitioner performs noncritical components of the first operation—for example, wound closure—allowing the primary surgeon to initiate the second operation. In this situation, a qualified practitioner must be physically present in the operating room of the first operation.

The second and less common scenario is when the key or critical elements of the first operation have been completed and the primary attending surgeon is performing key or critical portions of a second operation in another room. In this scenario, the primary attending surgeon must assign immediate availability in the first operating room to another attending surgeon.

The patient needs to be informed in either of these circumstances. The performance of overlapping procedures should not negatively affect the seamless and timely flow of either procedure.””

“The Centers for Medicare and Medicaid Services does allow surgeons to bill for concurrent surgeries under certain circumstances but requires that the attending physician is “present during all critical and key portions of both operations.”

Surgeon Matthew Indeck, president of the American College of Surgeons’ central Pennsylvania chapter, said he “certainly would not support

[concurrent]

cases being done in distant hospitals” or keeping a patient under anesthesia longer than necessary.

But he acknowledged that a line delineating what’s appropriate and what isn’t “is very fuzzy.”” (D)

“……transparency and patient consent. Wrong is the only way to describe the fact that secretaries, nurses, anesthesiologists, residents, and fellows knew but the patient did not. If you defend double-booking, tell the patient. Sometimes I wonder why doctors don’t see themselves as patients. To us, the experienced professional, medical, and surgical practice is rote. It’s hardly so to the person being wheeled onto a narrow table on which they will be cut open. Would any surgeon-patient consent to this practice?” (E)

“Swedish Health has decided to largely prohibit its doctors from conducting overlapping surgeries, responding to the concerns of patients who were troubled by the practice…

Under the new policy, implemented Monday, surgeons must be present for the “substantial majority” of each surgical procedure. They are not required to be present for the very end of the case — closing the surgical incision once the planned procedure is completed — as that can be delegated to a qualified fellow assisting on the case.

Some smaller aspects at the beginning of a surgery, such as the harvesting of healthy blood vessels that would later be used in a coronary-artery bypass surgery, can also be delegated while the attending surgeon is out of the room, according to the policy. There is also flexibility for unexpected emergencies.

Staff will document the times surgeons enter and exit the operating room — something that didn’t previously appear in the records of many surgical patients.” (F)

“Patients whose hip surgeries were performed by surgeons overseeing two operations at once were nearly twice as likely to suffer serious complications as those whose doctors focused on one patient at a time, according to a large Canadian study, the first research to show that overlapping surgery can pose health risks.

The study of more than 90,000 hip operations at some 75 hospitals in Ontario also found that the longer the duration of overlap between surgeries, the more likely patients were to suffer a serious complication within a year, including infections and a need for follow-up surgery.

“If your surgeon is in multiple places, there’s an increased risk of having a complication,” Dr. Bheeshma Ravi, a hip surgeon at Sunnybrook Health Sciences Centre in Toronto and lead author of the study to be published Monday in JAMA Internal Medicine, told the Globe. “I think that just makes sense.”” (G)

PART 2. July 29, 2019

“Surgeons will have to document each time they enter and leave the operating room, and who took over in their absence, under a rule approved Wednesday by the (Massachusettes) state medical board amid controversies over doctors who perform more than one surgery at a time…

Massachusetts is the first state to approve such requirements, according to board members. A spokesman for the Federation of State Medical Boards, which represents the nation’s 70 state medical and osteopathic regulatory boards, said it was unaware of any other states with similar regulations… (A)

“Beginning next month, all surgeons in Massachusetts will be required to document every time they enter or leave the operating room, and for how long, for any reason. That’s according to a new rule passed Wednesday by the Massachusetts Board of Registration in Medicine. Along with documenting their entry or exit, surgeons will also be required to identify the names of any participating “physician extenders” including residents, fellows, and physicians assistants…

Candace Lapidus Sloane, chairwoman of the medical board, told The Globe, “As a doctor and as a patient, I know that when you undergo a serious surgery, or your loved one undergoes a serious surgery, you find the best doctor you can. You’re going there for that surgeon’s skill. And if it’s not going to be that surgeon [who actually does the operation], the patient has a right to know.” Basically, it comes down to getting what you’re paying for, right?

The only opposition to the rule, as stated by The Globe, was from the Massachusetts Medical Society which deemed it too hard to identify all “physician extenders” because, especially at teaching hospitals, things can switch in an instant. But at that point, the patient should be informed and it should be their prerogative to move forward with the procedure or not.” (B)

“The issue was catapulted into public consciousness in October 2015 by an exhaustive investigation of concurrent surgery at Harvard’s famed Massachusetts General Hospital by The Boston Globe. The validity of the story has been vehemently disputed by hospital officials who defend their care as safe and appropriate…

Patients who signed standard consent forms said they were not told their surgeries were double-booked; some said they would never have agreed had they known…

Critics of the practice, who include some surgeons and patient-safety advocates, say that double-booking adds unnecessary risk, erodes trust and primarily enriches specialists. Surgery, they say, is not piecework and cannot be scheduled like trains: Unexpected complications are not uncommon.

All patients “deserve the sole and undivided attention of the surgeon, and that trumps all other considerations,” said Michael Mulholland, chair of surgery at the University of Michigan Health System, which halted ­double-booking a decade ago. Surgeons might leave the room when a patient’s incision is being closed, Mulholland said. A computerized system records the doctor’s entry and exit…

Some surgeons say they are troubled by the resemblance of double-booking to a practice known as “ghost surgery,” in which patients learn, usually after something goes wrong, that someone other than the surgeon they hired performed their operation…

Rickert and others advise patients who want to avoid overlap to ask detailed questions well in advance and to put their request in writing and on the consent form.

“If you say, ‘I want only you to do the surgery,’ doctors will typically do it,’” Rickert said. “They want the business.”

He also recommends asking, “Are you going to be in the room the entire time during my surgery?” and then repeating that statement in front of the OR nurses the day of surgery. “If the doctor’s not willing to say yes, vote with your feet.”

If a surgeon says he or she will be “present” or “immediately available,” a patient should ask what that means. It may mean that the surgeon is somewhere on a sprawling hospital campus but not in — or even near — your operating room. (C)

“I certainly knew that for many procedures, residents might be involved,” said Arthur Caplan, a professor of bioethics at NYU School of Medicine. (NYU Langone Medical Center does not permit concurrent surgery.) “But I was a little taken aback that the attending surgeon was not in the room.” (D)

“A recent trial resulting in a $2 million malpractice verdict pulled back the curtain on a Syracuse orthopedic surgeon’s routine of doing 14 operations in a single day.

A state Supreme Court jury in Syracuse unanimously found Dr. Brett Greenky and his practice, Syracuse Orthopedic Specialists, negligent July 2 for his handling of a hip replacement surgery performed six years ago. The lawsuit says the operation permanently injured Dorothy G. Murphy, 63, who is still limping, using a cane and in pain. She is a former Camillus resident who now lives in Florida.

The trial shined a light on a controversial hospital practice in which a doctor leaves the operating room after completing the most critical part of an operation to start surgery on another patient in a second room.

Murphy was the sixth of Greenky’s 14 patients on Sept. 9, 2013 at St. Joseph’s Hospital Health Center…

During the trial Robert Lahm, Murphy’s attorney, likened Greenky’s surgical approach to an “assembly line.” A copy of Greenky’s schedule for that day shows most of the operations were total knee and hip replacements.

Patients were staggered across two operating rooms. Greenky would cut open a patient, put in an implant, close up part of the incision, then leave before the operation was over to start surgery on another anesthetized patient in a second room. Meanwhile, a resident physician in training or physician assistant closed the previous patient’s wound and applied a dressing.

Sometimes Greenky does overlapping surgery in three operating rooms. In a deposition, he said he performs about 600 knee and hip replacements annually and each operation takes, on average, 45 minutes…

Murphy said she cannot understand why surgeons performing complex operations are allowed to work more than 14 hours a day when bus drivers are prohibited by federal regulations from driving more than 10 hours.” (E)

“A judge has ordered Massachusetts General Hospital to release a secret 2011 report written by a lawyer whom the hospital hired to investigate its practice of letting some surgeons oversee more than one operation at a time.

Suffolk Superior Court Judge Rosemary Connolly said that — pending a possible appeal — the hospital must share an unredacted copy of the report with an orthopedic surgeon fired by Mass. General in 2015 after he complained about concurrent surgeries…

Burke, who now practices at Beth Israel Deaconess Hospital in Milton, worked for Mass. General for 35 years until he was dismissed in August 2015. The hospital said he was fired for improperly releasing patient records, with names redacted, to the Globe. Burke contends he was sacked because he blew the whistle on what he considered a serious patient-safety issue.

In 2011, the hospital hired a former US attorney, Donald Stern, to investigate Burke’s complaints to Mass. General officials about concurrent surgeries, also known as double-booking. The hospital never made the report public, but Dr. Peter Slavin, the hospital’s president, told the Globe in 2015 that Stern “found no basis to support Dr. Burke’s concerns.”

Burke’s attorneys have repeatedly requested the report. But Mass. General’s lawyers have insisted it contains legal advice from Stern to the hospital and is protected by attorney-client privilege.

The judge rejected that argument. She said Mass. General hired Stern to conduct an internal review, not to provide legal advice. She also noted that the hospital shared the report with a public relations firm, Rasky Baerlein Strategic Communications, which it hired to respond to the Globe’s inquiries.

And, the judge wrote, the hospital allowed the report to be stored on a computer server at Simmons College, which employed a dean who headed Mass. General’s Board of Trustees.

“MGH has used the report as both sword and shield,” Connolly wrote.

“The mounting evidence all leads to the conclusion that even if sections of the Stern report were once privileged, they no longer are,” she continued.

In addition to ordering the hospital to turn over the report, the judge directed it to provide all drafts of the document and backup materials.

Ellen J. Zucker, Burke’s lead counsel, was pleased. “In the end, based on MGH’s own words and conduct, this is not a close call,” Zucker said.

A hospital spokeswoman declined to comment.” (F)

Prequels

Every clinician with a doctoral degree has earned the respect to be called doctor.

Do you want to be treated by a stranger when you are admitted to the hospital? Every practicing physician should have hospital privileges.

Have you met your interventional pathologist or interventional neurologist or interventional oncologist?

It’s like the Wild, Wild West, the (physician specialty) turf wars….

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“A SEVERE FLU PANDEMIC… could kill more than 33 million people worldwide in just 250 days.” – “Boy, do we not have our act together.” — Bill Gates”. (J)

“It’s never an easy business to predict which flu viruses will make people sick the following winter. And there’s reason to believe two of the four choices made last winter for this upcoming season’s vaccine could be off the mark.”

“Flu circulation “remains difficult to predict and flu viruses are constantly breaking rules that we try to establish for them,”..”

 “No battle plan survives contact with the enemy” * 

Worth reading:

The Next Plague Is Coming. Is America Ready?, by Ed Yong

https://www.theatlantic.com/magazine/archive/2018/07/when-the-next-plague-hits/561734/

ASSIGNMENT: Does your community have a seasonal flu EMERGENCY RESPONSE PLAN? Do your community’s hospitals have SURGE CAPACITY  and RAPID RESPONSE TEAMS? If not, develop a plan!

HOBOKEN CASE STUDY

In July of 2009 the Mayor of Hoboken asked me to organize a H1N1 “Swine Flu” Task Force. We started with a set of questions based on reports from communities that had already experienced a Swine Flu surge:

Health Officer: Where vaccination sites should be established? Is there a special plan to monitor restaurants and food shops where flu-related safety guidelines need to be strictly enforced? Who will start preparing a Community Education plan?

Hospital: What is the back-up plan if hospital becomes “contaminated” and is closed to admissions, or if nursing staff is depleted by flu-related absenteeism, etc.? ICU triage? Availability of respirators?

OEM:  off-site screening centers if hospital ER is on overload

Hoboken Volunteer Ambulance Corps:  “mutual assist” plan

Hoboken Police Department & Hoboken Fire Department: back-up plan if the ranks get depleted by the flu

BOE: criteria in deciding whether or not to close schools

Stevens Institute of Technology: surveillance and plan for (college) students

“Field Manual” for the Mayor outlining all variabilities and options

Why was there no swine flu surge in NJ/ NYC metro area? maybe “herd” immunity” from prior year’s flu?

“Australia had an unusually early and fairly severe flu season this year. Since that may foretell a serious outbreak on its way in the United States, public health experts now are urging Americans to get their flu shots as soon as possible.

“It’s too early to tell for sure, because sometimes Australia is predictive and sometimes it’s not,” said Dr. Daniel B. Jernigan, director of the influenza division of the Centers for Disease Control and Prevention. “But the best move is to get the vaccine right now.”..

In 2017, Australia suffered its worst outbreak in the 20 years since modern surveillance techniques were adopted. The 2017-2018 flu season in the United States, which followed six months later as winter came to the Northern Hemisphere, was one of the worst in modern American memory, with an estimated 79,000 dead.” (A)

“Maryland health officials on Tuesday confirmed the first 11 influenza cases of the flu season. Officials urge Marylanders to get vaccinated.

“We don’t know yet whether flu activity this early indicates a particularly bad season on the horizon,” Maryland Department of Health Secretary Robert R. Neall said in a statement. “Still, we can’t emphasize strongly enough – get your flu shot now. Don’t put it off. The vaccine is widely available at grocery stores, pharmacies and local health clinics, in addition to your doctor’s office.”

Most of the 11 cases recorded since Sept. 1 have been subtyped as influenza A, with a few classified as influenza B. Though most influenza cases are mild, the virus can pose a serious risk for young children, seniors, pregnant women and people with compromised immune systems.

During last year’s flu season, 3,274 people were hospitalized and 82 died as a result of the flu in Maryland, according to state health officials.” (B)

“The first pediatric influenza-associated death of the 2019-20 flu season has been reported in California. According to a statement issued by Riverside University Health System a 4-year-old child who tested positive for the flu and had underlying health issues passed away from his illness.

According to the US Centers for Disease Control and Prevention (CDC) a total of 130 influenza-associated pediatric deaths were reported during the 2018-19 flu season. This number was a decrease from the 187 pediatric deaths reported during the 2017-18 season.

CDC investigators hypothesize that the real-world impact of the flu is being underreported. “Using mathematical modeling to account for under-detection, CDC estimates that the actual number of flu-related deaths in children during [the 2017-18] season was closer to 600—nearly 3 times what was reported through existing mechanisms,” the authors of a recent report wrote in a flu spotlight.

Cameron Kaiser, MD, public health officer of Riverside County, says that this early season death could be predictive of a severe flu season.” (C)

“The overall effectiveness of last flu season’s vaccine was only 29% because it didn’t protect against a flu virus that appeared later in the season, according to the U.S. Centers for Disease Control and Prevention.

It said the vaccine was 47% effective into February, but that dropped to just 9% after the late strain showed up, the Associated Press reported.

Flu vaccines are created each year to protect against flu strains predicted to be circulating in the upcoming season.

The effectiveness of last season’s vaccine was the second lowest since 2011. The vaccine for the 2014-15 flu season was only 19% effective, the AP reported.” (D)

It’s never an easy business to predict which flu viruses will make people sick the following winter. And there’s reason to believe two of the four choices made last winter for this upcoming season’s vaccine could be off the mark.

Twice a year influenza experts meet at the World Health Organization to pore over surveillance data provided by countries around the world to try to predict which strains are becoming the most dominant. The Northern Hemisphere strain selection meeting is held in late February; the Southern Hemisphere meeting occurs in late September.

The selections that officials made…for the next Southern Hemisphere vaccine suggest that two of four viruses in the Northern Hemisphere vaccine that doctors and pharmacies are now pressing people to get may not be optimally protective this winter. Those two are influenza A/H3N2 and the influenza B/Victoria virus…

Flu vaccine is a four-in-one or a three-in-one shot that protects against both influenza A viruses — H3N2 and H1N1 — and either both or one of the influenza B viruses, B/Victoria and B/Yamagata. Most flu vaccine is made with killed viruses, and most vaccine used in the United States is quadrivalent — four-in-one…

Flu circulation “remains difficult to predict and flu viruses are constantly breaking rules that we try to establish for them,” Hensley said, adding that flu vaccines “often protect against severe disease even when … mismatched.” (E)

“A shortage of high dose flu shots is concerning some older adults.

The Vanderburgh County Health Department says people older than 65 are recommended to take a high dose flu shot.

Director of Clinical Outreach, Lynn Herr, says there is an option rather than not getting the shot at all.

“Then we need to have a conversation with our primary caregiver saying go ahead and get the regular or go ahead and wait for the higher dose flu shot.”

According to the CDC, the high dose vaccine helps people 65 years or older have a better fight against the flu.

This shot contains four times the antigen than a regular flu shot.” (F)

“DEFINITION OF EMERGENCY RESPONSE

 What Are “Emergencies”? Emergencies are incidents that threaten public safety, health and welfare.  If severe or prolonged, they can exceed the capacity of first responders, local fire fighters or law enforcement officials.  Such incidents range widely in size, location, cause, and effect, but nearly all have an environmental component.” (G) 

Medical surge capacity refers to the ability to evaluate and care for a markedly increased volume of patients—one that challenges or exceeds normal operating capacity. The surge requirements may extend beyond direct patient care to include such tasks as extensive laboratory studies or epidemiological investigations.

Because of its relation to patient volume, most current initiatives to address surge capacity focus on identifying adequate numbers of hospital beds, personnel, pharmaceuticals, supplies, and equipment. The problem with this approach is that the necessary standby quantity of each critical asset depends on the systems and processes that:

Identify the medical need

Identify the resources to address the need in a timely manner

Move the resources expeditiously to locations of patient need (as applicable)

Manage and support the resources to their absolute maximum capacity.

In other words, fewer standby resources are necessary if systems are in place to maximize the abilities of existing operational resources. Moreover, the integration of additional resources (whether standby, mutual aid, State or Federal aid) is difficult without adequate management systems. Thus, medical surge capacity is primarily about the systems and processes that influence specific asset quantity.

Basic example: If a hospital wishes to have the capacity to medically manage 10 additional patients on respirators, it could buy, store, and maintain 10 respirators. This would provide an important component of that capacity (other critical care equipment and staff would also be needed), but it would also be very expensive for the facility. If the hospital establishes a mutual aid and/or cooperative agreement with regional hospitals, it might be able to rely on neighboring hospitals to loan respirators and credentialed staff and, therefore, might need to invest in only a few standby items (e.g., extra critical care beds), minimizing purchase and maintenance of expensive equipment that generate no income except during rare emergency situations.”  (H)

Today, Rapid Response Teams (RRTs) are a crucial component of many hospitals.  Implementing a RRT was one of the six strategies that defined the Institute for Healthcare Improvement (IHI) 100,000 Lives campaign.  Most RRTs consist of critical care nurses, but they can also include respiratory therapists, pharmacists, and physicians.

Research consistently shows that patients exhibit signs and symptoms of deterioration for several hours prior to a code.  These symptoms include changes in vital signs, mental status, and lab markers. The goal of a RRT is to intervene upstream from a potential code.  They reach the patient before deterioration turns into crisis.  This is different than a code blue team that typically responds to a patient that has already decompensated to cardiac arrest.

Historically, most hospitals relied on busy bedside nurses to identify crashing patients and call for rapid response.  With 49 states having no limits on the number of patients assigned per nurse, many medical-surgical ward nurses are caring for 6 or more patients per shift.  Placing this additional responsibility on their already over-flowing plate is challenging at best.  Providing a RRT empowers bedside nurses to trigger an escalation of care earlier and faster. (I)

“… even the U.S. is disturbingly vulnerable—and in some respects is becoming quickly more so. It depends on a just-in-time medical economy, in which stockpiles are limited and even key items are made to order. Most of the intravenous bags used in the country are manufactured in Puerto Rico, so when Hurricane Maria devastated the island last September, the bags fell in short supply. Some hospitals were forced to inject saline with syringes—and so syringe supplies started running low too. The most common lifesaving drugs all depend on long supply chains that include India and China—chains that would likely break in a severe pandemic. “Each year, the system gets leaner and leaner,” says Michael Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota. “It doesn’t take much of a hiccup anymore to challenge it.”” (J)

“One hundred years ago, in 1918, a strain of H1N1 flu swept the world. It might have originated in Haskell County, Kansas, or in France or China—but soon it was everywhere. In two years, it killed as many as 100 million people—5 percent of the world’s population, and far more than the number who died in World War I. It killed not just the very young, old, and sick, but also the strong and fit, bringing them down through their own violent immune responses. It killed so quickly that hospitals ran out of beds, cities ran out of coffins, and coroners could not meet the demand for death certificates. It lowered Americans’ life expectancy by more than a decade. “The flu resculpted human populations more radically than anything since the Black Death,” Laura Spinney wrote in Pale Rider, her 2017 book about the pandemic. It was one of the deadliest natural disasters in history—a potent reminder of the threat posed by disease.” (K)

To receive email updates about Seasonal Flu, enter your email address at:

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PREQUELS

PANDEMIC PREPAREDNESS. “It’s like a chain—one weak link and the whole thing falls apart. You need no weak links.”

Tomorrow morning’s Emergency Preparedness meeting (just scheduled for 8AM)

“We are arguably as vulnerable—or more vulnerable—to another (flu) pandemic as we were in 1918.”

“..in a severe (flu) pandemic, the U.S. healthcare system could be overwhelmed in just weeks.

“Think hospitals are under a strain now, from a slightly bad flu season? Wait until a really bad one hits.”

In the ICU at Massachusetts General Hospital, nurses use Gatorade to combat flu-related dehydration (due to shortages of intravenous fluids)

The CDC postponed its briefing on preparation for nuclear war and will focus on responding to severe influenza

______________________

* Helmuth von Moltke the Elder.

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PART 4. New Jersey. “..heart transplant center, inflated survival rates to keep its funding — keeping a brain-dead patient on life support until he hit a one-year survival benchmark..”

When I started as President & CEO of Jersey City Medical Center in 1989, New Jersey had a comprehensive Certificate of Need process. When the state awarded a “CN” funding followed through the all payor reimbursement system then in place.

Over time JCMC was designated as: a Regional Perinatal Center; Level II Trauma Center; Teaching Hospital Cancer Program; a Children’s Hospital; and approved to start cardiac surgery/ interventional cardiology. With these programs JCMC became a major teaching affiliate of Mount Sinai School of Medicine and a total replacement hospital was opened on a new site in 2004.

The pediatric cardiac surgery problems at Johns Hopkins All Children’s Hospital and North Carolina Children’s Hospital are due, in part, to the disappearance of most state CON regulations resulting in hospitals opening “trophy” services that lead to low volume programs. Funding becomes a challenge.

ASSIGNMENT: What are the Lessons Learned from the Johns Hopkins All Children’s Hospital and North Carolina Children’s Hospital pediatric open cardiac surgery program failures? What are the regulatory implications?

After New PART 4 are excerpts from Parts 1-3, as well as an unabridged chronology.

PART 4. Johns Hopkins All Children’s Hospital and North Carolina Children’s Hospital pediatric cardiac surgery programs at “crossroads.”

“The hospital that calls itself New Jersey’s premier heart transplant center, Newark Beth Israel, inflated survival rates to keep its funding — in at least one instance by keeping a brain-dead patient on life support until he hit a one-year survival benchmark, startling new reporting revealed.

Family members were never told that Navy veteran Darryl Young was in an irreversible vegetative state after his heart transplant last year, and staff never offered hospice, other palliative care services or a Do Not Resuscitate directive, ProPublica revealed.

Meanwhile, behind the scenes, doctors were secretly recorded discussing how Young needed to be aggressively cared for despite their belief that he would never wake up or recover function, the ProPublica report said.” (H)

 “The North Carolina Children’s Hospital got a bit of good news last week from a state agency that sent a team of investigators on-site for 11 days of questioning and review of the pediatric heart surgery program.

The state Department of Health and Human Services says the program currently is in compliance with U.S. Centers for Medicare and Medicaid Services requirements…

An external review board was tapped to evaluate the program and new Quality and Safety reporting procedures were put in place.

The external review board has had one telephone conference meeting, according to Alan Wolf, a spokesman for the health care system, and has plans to meet in person soon.

Despite the state health department’s findings, the UNC Health Care system has no plans to schedule those types of surgeries before the external review is complete, according to Wolf.” (A)

“The families of two children who were paralyzed after heart surgeries at Johns Hopkins All Children’s Hospital will receive $26 million and $12.75 million in settlements with the hospital, state records show.

Although the identities of the children are not public, the records describing their cases match two of the patients featured in a Tampa Bay Times investigation into the hospital’s troubled heart unit. Both families were struggling with the costs of caring for a permanently disabled child with no relief in sight.

A third family that lost a child after heart surgery will receive $750,000…

In June, Johns Hopkins Health System CEO Kevin Sowers told the Times that he and hospital leaders had reached out to the families of children who died or were injured in the hospital’s heart surgery unit.

“We made a mistake, and we need to make sure we help support these families and make it right,” he said…  (B)

“UNC Hospitals in Chapel Hill is on probation after the system received preliminary denial of its accreditation.

Preliminary Denial of Accreditation is recommended when there’s an immediate threat to health and safety, a submission of falsified documents or misrepresented information, a lack of a required license, or significant noncompliance with Joint Commission standards, according to the Joint Commission..

“To be clear: There was no finding of any immediate threats to patient health and safety,” UNC Health Care spokesman Alan Wolf said in an email.

The Joint Commission recently conducted the triennial accreditation survey, when surveyors examined the main hospital in Chapel Hill.

UNC Health Care credited the slide in accreditation to new standards by the Joint Commission. The hospital will remain on preliminary denial of accreditation status until the hospital undergoes a new survey and satisfies the requirements.

The hospital network says it has already put plans in place to fix each problematic area…

UNC Health Care said the Joint Commission accepted its plans of correction, and expects the validation survey to take place next week.” (C)

UNC Hospitals is one step closer to regaining its clean reputation, but concerns remain.

After completing follow-up inspections, the Joint Commission lifted its preliminary denial of UNC Hospitals’ accreditation and upgraded the hospital to “accreditation with a follow-up survey.”

UNC Hospitals was originally placed on probation because it failed to meet the suicide prevention standards of the Joint Commission…

Most of the serious problems revolved around the treatment of mental health patients, particularly those at risk for suicide attempts or for being abused and exploited. The Joint Commission demanded better management of ligature risks — places where a patient could hang or choke themselves — and better identification of potential victims of abuse.

The Joint Commission only recommends Preliminary Denial of Accreditation when there’s an immediate threat to health and safety, a submission of falsified documents or misrepresented information, a lack of a required license, or significant noncompliance with Joint Commission standards…

The clean bill of accreditation means the Joint Commission is satisfied with UNC Hospitals’ response to its performance issues. But the hospitals will probably face added scrutiny.”  (D)

A North Carolina children’s hospital that stopped performing complex heart surgeries in recent months after high death rates were disclosed may now resume the procedures, according to an advisory board that was examining the hospital’s practices.

The board noted “significant investment and progress” had been made at North Carolina Children’s Hospital while suggesting areas for improvement, including increasing the number of surgeries performed, a factor associated with better outcomes.

The external board made its recommendations in a six-page report released on Tuesday by UNC Health Care, which runs the hospital and is affiliated with the University of North Carolina…..

The advisory board did not seem to address conditions at the hospital when doctors voiced concerns several years ago, but noted that “team dynamics and interactions appear to be strong.” Recommendations it made to the hospital’s board of directors included continuing to publicly report mortality data; hiring a second full-time pediatric heart surgeon; and considering a joint venture with another hospital to increase the volume of surgeries.

Concerns about the quality of pediatric heart surgery programs have been disclosed at hospitals across the country, especially at institutions with a smaller number of surgeries. Several programs have been suspended or shut down; other hospitals have merged their programs with larger ones to achieve more consistent results.

The advisory board was composed of three doctors from outside institutions: Nationwide Children’s Hospital in Columbus, Ohio; the University of Michigan School of Medicine; and Children’s Hospital of Pittsburgh.

Two doctors leading UNC’s pediatric heart program previously worked at two of those institutions: Dr. Timothy Hoffman, chief of pediatric cardiology, came to UNC from Nationwide Children’s Hospital. Dr. Mahesh Sharma, chief pediatric cardiac surgeon, joined UNC from Children’s Hospital of Pittsburgh.” (E)

“The News & Observer reports the outside review board’s report was announced Tuesday. It noted ongoing improvements in the unit, though it advised the hospital to consider if patients with complex heart problems along with additional illnesses should be referred to other hospitals.” (F)

“Rumors floated around a children’s heart surgery unit in a major hospital of a major city. Babies operated on for complex heart problems were dying, and dying at rates far higher than those of comparable hospitals. Doctors and cardiologists feared, even avoided, referring young babies for surgery at the unit — a culture of silence surrounding it all…

But this is not UNC. And this is not 2019. This was thirty years ago at Bristol Royal Infirmary, the flagship hospital of Bristol, a city of about 500,000, in the United Kingdom.

“It would be reassuring to believe that it could not happen again,” wrote Sir Ian Kennedy, chair of the public inquiry into the tragedy that claimed the lives of dozens of babies at Bristol. But he didn’t sound particularly reassured, and sadly his doubt has been borne out. It has happened again.

The parallels between the two scandals are uncanny. At both hospitals, the cardiac surgery for very young babies was malfunctioning, and babies were dying at appalling rates. At both hospitals a culture of silence surrounded a growing sense among staff that something was going catastrophically wrong.

And at both hospitals it took outsiders to blow the whistle: at UNC someone leaked recordings of the conversations held by a group of concerned cardiologists (doctors who refer patients to cardiac surgery) in June 2016 to the New York Times. Dr Kevin Kelly, leader of the children’s hospital at UNC, had convened the meeting to discuss the “crisis.” “When you walk out of here,” he says in the recordings, “stop talking about it outside of this room.”

At Bristol thirty years ago, a young new anesthetist named Stephen Bolsin grew concerned about eight-hour operations instead taking twelve. He began to collect data on the outcomes of babies at the unit. When he sensed the numbers didn’t look good, he took his concerns to the head of the unit, surgeon James Wisheart, who shut him down.

When Bolsin went over his head to the hospital manager, Wisheart got wind of this breach in the strict medical hierarchy and said this amazing – and terrifyingly similar – thing: “If you wish to remain in Bristol you should not disclose the results of pediatric cardiac surgery to people outside the unit ever again.”” (G)

PART 1. Brand names don’t always signify the highest quality of care

 “Sandra Vázquez paced the heart unit at Johns Hopkins All Children’s Hospital.

Her 5-month-old son, Sebastián Vixtha, lay unconscious in his hospital crib, breathing faintly through a tube. Two surgeries to fix his heart had failed, even the one that was supposed to be straightforward.

Vázquez saw another mom in the room next door crying. Her baby was also in bad shape.

Down the hall, 4-month-old Leslie Lugo had developed a serious infection in the surgical incision that snaked down her chest. Her parents argued with the doctors. They didn’t believe the hospital room had been kept sterile.

By the end of the week, all three babies would die…

The internationally renowned Johns Hopkins had taken over the St. Petersburg All Children’s Hospital six years earlier and vowed to transform its pediatric heart surgery unit into one of the nation’s best.

Instead, the program got worse and worse until children were dying at a stunning rate, a Tampa Bay Times investigation has found.

Nearly one in 10 patients died last year. The mortality rate, suddenly the highest in Florida, had tripled since 2015…

Times reporters spent a year examining the All Children’s Heart Institute – a small, but important division of the larger hospital devoted to caring for children born with heart defects…

They discovered a program beset with problems that were whispered about in heart surgery circles but hidden from the public.

Among the findings:

All Children’s surgeons made serious mistakes, and their procedures went wrong in unusual ways. They lost needles in at least two infants’ chests. Sutures burst. Infections mounted. Patches designed to cover holes in tiny hearts failed.

Johns Hopkins’ handpicked administrators disregarded safety concerns the program’s staff had raised as early as 2015. It wasn’t until early 2017 that All Children’s stopped performing the most complex procedures. And it wasn’t until late that year that it pulled one of its main surgeons from the operating room.

Even after the hospital stopped the most complex procedures, children continued to suffer. A doctor told Cash Beni-King’s parents his operation would be easy. His mother and father imagined him growing up, playing football. Instead multiple surgeries failed, and he died.

In just a year and a half, at least 11 patients died after operations by the hospital’s two principal heart surgeons. The 2017 death rate was the highest any Florida pediatric heart program had seen in the last decade.

Parents were kept in the dark about the institute’s troubles, including some that affected their children’s care. Leslie Lugo’s family didn’t know she caught pneumonia in the hospital until they read her autopsy report. The parents of another child didn’t learn a surgical needle was left inside their baby until after she was sent home.

The Times presented its findings to hospital leaders in a series of memos early this month. They declined interview requests and did not make the institute’s doctors available to comment.

In a statement, All Children’s did not dispute the Times’ reporting. The hospital said it halted all pediatric heart surgeries in October and is conducting a review of the program.

“Johns Hopkins All Children’s Hospital is defined by our commitment to patient safety and providing the highest quality care possible to the children and families we serve,” the hospital wrote. “An important part of that commitment is a willingness to learn.” (G)

The top three leaders of Johns Hopkins All Children’s Hospital in Florida resigned Tuesday following a Tampa Bay Times investigation that revealed increasing mortality rates among heart surgery patients.

The resignations from the 259-bed teaching hospital in St. Petersburg included CEO Jonathan Ellen, M.D., and Vice President Jackie Crain, as well as Jeffrey Jacobs, M.D., who is the heart institute’s deputy director, the Tampa Bay Times reported. Paul Colombani, M.D., stepped down as chairman of the department of surgery but will continue working in a clinical capacity, a statement from the health system said…

Johns Hopkins, which owns and operates the hospital, said it would install Kevin Sowers, who is president of the Johns Hopkins Health System and executive vice president of Johns Hopkins Medicine, to lead the hospital in a temporary capacity while a plan for interim leadership is put into place.

Johns Hopkins’ board also said it commissioned an external review to examine the heart surgery program and said it would share its lessons from the review to help hospitals around the country avoid the same mistakes.

The moves come following the Tampa Bay Times investigation that highlighted a growing number of heart surgery deaths at the hospital amid warnings about safety from staffers that went unheeded. (H)

“Three additional senior administrators have left Johns Hopkins All Children’s Hospital in the wake of a Tampa Bay Times investigation into high mortality rates at the hospital’s Heart Institute, the hospital announced Wednesday.

A total of six senior officials have left since the Times report, including the hospital’s CEO, three vice presidents and two surgeons who held leadership roles at the Heart Institute. A seventh official stepped down as chairman of the surgery department but remained employed at the hospital as a doctor.

The resignations announced Wednesday included vice presidents Dr. Brigitta Mueller, the hospital’s chief patient safety officer, and Sylvia Ameen, who oversaw culture and employee engagement and served as the hospital’s chief spokeswoman.

The hospital also said Dr. Gerhard Ziemer, who started as the Heart Institute’s new director and chief of cardiovascular surgery in October, would leave the hospital. The hospital never publicly announced Ziemer had been hired, and he had not yet obtained his Florida medical license when the Times investigation was published at the end of November. At that point, the hospital said the Heart Institute   had already stopped performing surgeries.

Sowers also announced that Johns Hopkins had hired external experts to develop a plan to restart heart surgeries at All Children’s.

That is a separate effort from an external review of the problems in the Heart Institute, which Johns Hopkins announced its board had commissioned last month, spokeswoman Kim Hoppe said…

Johns Hopkins is one of the most prestigious brands in medicine and is internationally renowned for developing innovative patient safety protocols that are used at hospitals across the world. But last weekend, the Times published a story detailing a series of safety problems at hospitals across its network. In response, the health system pledged to “do better.” (I)

“The Johns Hopkins Medicine Board of Trustees has appointed a former federal prosecutor to lead its investigation into the Johns Hopkins All Children’s Hospital’s heart surgery unit, the health system announced late Tuesday.

F. Joseph Warin, of the global law firm Gibson Dunn, and his team will review the high mortality rates and other problems at the hospital’s Heart Institute and report back to a special committee of the board of trustees by May, the health system said.

Once the review is complete, the health system said it would also name an independent monitor at All Children’s to “make sure that the hospital is being held accountable for taking corrective action where necessary.”

The announcement was accompanied by a video of Johns Hopkins Health System president Kevin Sowers, who acknowledged for the first time that the hospital had been warned about problems by frontline workers.

“I know personally that many of you courageously spoke out when you had concerns but were ignored or turned away,” he said. “That behavior is unacceptable and will not be tolerated going forward.”

Sowers, who is also interim president at All Children’s, said he hoped to meet with the families of patients affected by problems in the Heart Institute in the coming days to share his “profound sadness for the failures of care they experienced.” (J)

 “State and federal inspectors descended on Johns Hopkins All Children’s Hospital this week, following sharp calls for an investigation into problems in the hospital’s heart surgery unit, the Tampa Bay Times has learned.

The scope of the inspection is unclear. But hospital regulators had been criticized in recent weeks for their lax response to early signs of an increase in mortality at the hospital’s Heart Institute…

State and federal regulators knew the institute was having problems months earlier. In April, the hospital’s CEO told the Times that the institute had “challenges” that led to an uptick in mortality, and acknowledged the hospital had left surgical needles inside two children.

In May, state regulators cited the hospital for not properly reporting two medical mistakes, which is required by state law. Days later, a spokeswoman for the federal agency told the Times that it would perform its own investigation.

But state regulators didn’t fine the hospital, and overlooked several subsequent warnings that its surgical results had been poor.

And federal inspectors later changed course and decided not to undertake a comprehensive review of the heart surgery program, the Times reported last month. One reason was that state inspectors hadn’t found any violations of federal rules, a spokeswoman said. Another was that a nonprofit hospital accreditor was due to perform a scheduled review.” (L)

 “.. experience showcases the promise of a much-touted but little understood collaboration in health care: alliances between community hospitals and some of the nation’s biggest and most respected institutions.

For prospective patients, it can be hard to assess what these relationships actually mean – and whether they matter.

Leah Binder, president and chief executive of the Leapfrog Group, a Washington-based patient safety organization that grades hospitals based on data involving medical errors and best practices, cautions that affiliation with a famous name is not a guarantee of quality.

Brand names don’t always signify the highest quality of care,” she said. “And hospitals are really complicated places.”..

To expand their reach, flagship hospitals including Mayo, the Cleveland Clinic and Houston’s MD Anderson Cancer Center have signed affiliation agreements with smaller hospitals around the country. These agreements, which can involve different levels of clinical integration, typically grant community hospitals access to experts and specialized services at the larger hospitals while allowing them to remain independently owned and operated. For community hospitals, a primary goal of the brand-name affiliation is stemming the loss of patients to local competitors…

In some cases, large hospital systems opt for a different approach, largely involving acquisition. Johns Hopkins acquired Sibley Memorial and Suburban hospitals in the Washington, D.C., area, along with All Children’s Hospital in St. Petersburg, Fla. The latter was re-christened Johns Hopkins All Children’s Hospital in 2016…

Although affiliation agreements differ, many involve payment of an annual fee by smaller hospitals. Officials at Mayo and MD Anderson declined to reveal the amount, as did executives at several affiliates. Contracts with Mayo must be renewed annually, while some with MD Anderson exceed five years…

“It is not the Mayo Clinic,” said Dr. David Hayes, medical director of the Mayo Clinic Care Network, which was launched in 2011. “It is a Mayo clinic affiliate.”

Of the 250 U.S. hospitals or health systems that have expressed serious interest in joining Mayo’s network, 34 have become members.

For patients considering a hospital that has such an affiliation, Binder advises checking ratings from a variety of sources, among them Leapfrog, Medicare and Consumer Reports, and not just relying on reputation.

“In theory, it can be very helpful,” Binder said of such alliances. “The problem is that theory and reality don’t always come together in health care.”

Case in point: Hopkins’ All Children’s has been besieged by recent reports of catastrophic surgical injuries and errors and a spike in deaths among pediatric heart patients since Hopkins took over. Hopkins’ chief executive has apologized, more than a half-dozen top executives resigned and Hopkins recently hired a former federal prosecutor to conduct a review of what went wrong.

“For me and my family, I always look at the data,” Binder said. “Nothing else matters if you’re not taken care of in a hospital, or you have the best surgeon in the world and die from an infection.” ” (Q)

PART 2. June 1, 2019. “The situation that the New York Times described in North Carolina parallels that at Johns Hopkins All Children’s Hospital in St. Petersburg, which stopped performing heart surgeries after the Tampa Bay Times reported on problems in the unit

 “Tasha and Thomas Jones sat beside their 2-year-old daughter as she lay in intensive care at North Carolina Children’s Hospital. Skylar had just come out of heart surgery and should recover well, her parents were told. But that night, she flatlined. Doctors and nurses swarmed around her, performing chest compressions for nearly an hour before putting the little girl on life support.

Five days later, in June 2016, the hospital’s pediatric cardiologists gathered one floor below for what became a wrenching discussion. Patients with complex conditions had been dying at higher-than-expected rates in past years, some of the doctors suspected. Now, even children like Skylar, undergoing less risky surgeries, seemed to fare poorly.

The cardiologists pressed their division chief about what was happening at the hospital, part of the respected University of North Carolina medical center in Chapel Hill, while struggling to decide if they should continue to send patients to UNC for heart surgery…

That March, a newborn had died after muscles supporting a valve in his heart appeared to have been damaged during surgery. At least two patients undergoing low-risk surgeries had recently experienced complications. In May, a baby girl with a complex heart condition died two weeks after her operation. Two days later, Skylar went in for surgery.

In the doctors’ meeting, the chief of pediatric cardiology, Dr. Timothy Hoffman, was blunt. “It’s a nightmare right now,” he said. “We are in crisis, and everyone is aware of that.”

That comment and others – captured in secret audio recordings provided to The New York Times – offer a rare, unfiltered look inside a medical institution as physicians weighed their ethical obligations to patients while their bosses also worried about harming the surgical program.

In meetings in 2016 and 2017, all nine cardiologists expressed concerns about the program’s performance. The head of the hospital and other leaders there were alarmed as well, according to the recordings. The cardiologists – who diagnose and treat heart conditions but don’t perform surgeries – could not pinpoint what might be going wrong in an intertwined system involving surgeons, anesthesiologists, intensive care doctors and support staff. But they discussed everything from inadequate resources to misgivings about the chief pediatric cardiac surgeon to whether the hospital was taking on patients it wasn’t equipped to handle. Several doctors began referring more children elsewhere for surgery.

The heart specialists had been asking to review the institution’s mortality statistics for cardiac surgery – information that most other hospitals make public – but said they had not been able to get it for several years. Last month, after repeated requests from The Times, UNC released limited data showing that for four years through June 2017, it had a higher death rate than nearly all of the 82 institutions nationwide that do publicly report…

The best option, Dr. Kelly said, was to combine UNC’s surgery program with Duke’s. For years, physicians at both children’s hospitals talked informally about joining forces, but nothing came of it. They were “basically destroying each other’s capacity to be great,” Dr. Kelly said, by running competing programs less than 15 miles apart. But even combining the programs wasn’t an instant fix: It would take at least a year and a half, he said… (D)

“The situation that the New York Times described in North Carolina parallels that at Johns Hopkins All Children’s Hospital in St. Petersburg, which stopped performing heart surgeries after the Tampa Bay Times reported on problems in the unit…

UNC Health Care only made some of its death rate data public to the New York Times after numerous requests from the newsroom. The statistics showed that UNC’s children’s heart surgery program had one of the highest four-year death rates in the country…

UNC Health Care told the New York Times that the physicians’ concerns had been handled appropriately.

After the New York Times started reporting, the hospital ramped up efforts to find a temporary pediatric heart surgeon and reached out to families whose children had died or had unusual complications to discuss their cases…

The turmoil at UNC underscores concerns about the quality and consistency of care provided by dozens of pediatric heart surgery programs across the country. Each year in the United States about 40,000 babies are born with heart defects; about 10,000 are likely to need surgery or other procedures before their first birthday.

The best outcomes for patients with complex heart problems correlate with hospitals that perform a high volume of surgeries – several hundred a year – studies show. But a proliferation of the surgery programs has made it difficult for many institutions, including UNC, to reach those numbers: The North Carolina hospital does about 100 to 150 a year. Lower numbers can leave surgeons and staff at some hospitals with insufficient experience and resources to achieve better results, researchers have found.

“We can do better. And it’s not that hard to do better,” said Dr. Carl Backer, former president of the Congenital Heart Surgeons’ Society, who practices at Lurie Children’s Hospital of Chicago. “We don’t have to build new hospitals. We don’t have to build new ICUs. We just need to move patients to more appropriate centers.”

Studies show that the best outcomes for patients with complex heart problems correlate with hospitals that do a higher volume of surgeries – several hundred a year.

At least five pediatric heart surgery programs across the country were suspended or shut down in the last decade after questions were raised about their performance; a Florida institution run by the prestigious Johns Hopkins medical system stopped operations after reporting by The Tampa Bay Times in 2018. At least a half-dozen hospitals have merged their programs with larger ones to achieve more consistent results. And more institutions are considering such partnerships.” (E)

“North Carolina’s secretary of health on Friday called for an investigation into a hospital where doctors had suspected children with complex heart conditions had been dying at higher than expected rates after undergoing heart surgery.

Dr. Mandy Cohen, the secretary, said in a statement that a team from the state’s division of health service regulation would work with federal regulators to conduct a “thorough investigation” into events that occurred in 2016 and 2017 at North Carolina Children’s Hospital, part of the University of North Carolina medical center in Chapel Hill…

The investigation is in response to an article published by The New York Times on Thursday, which gave a detailed look inside the medical institution as cardiologists grappled with whether to keep sending their young patients there for surgery.” (H)

PART 3. Hopkins All Children’s Hospital/ North Carolina Children’s – pediatric cardiac surgery debacles.

“Johns Hopkins All Children’s Hospital has begun implementing some of the dozens of recommendations from a law firm hired to identify deficiencies at the hospital and its parent organization, Johns Hopkins Medicine, in the wake of high death rates in the St. Petersburg hospital’s pediatric cardiology program…

The recommendations focus on four key areas, said Dr. Kevin Sowers, president of Johns Hopkins Health System and executive vice president of Johns Hopkins Medicine.

He outlined those four areas in a video posted online. They are: strengthen the management and culture at Johns Hopkins All Children’s Hospital; improve processes for evaluating patient clinical quality and safety; clarify and streamline the reporting structure between the six Johns Hopkins Hospitals and the Johns Hopkins Health System; and review the ways in which the boards of Johns Hopkins All Children’s Hospital and Johns Hopkins Medicine should advance their governance responsibilities…

…In the coming weeks, the board of Johns Hopkins Medicine will appoint a monitor to track and report regularly back to them on the hospital’s progress.” (A)

“The recommendations for improvement include:

Prioritize a culture of absolute commitment to patient safety and of raising and addressing problems and concerns, including throughout the process of hiring and evaluating senior executives

Give physician leaders a stronger voice, create a more robust check-and-balance on the president

Better educate staff and faculty about JHM’s commitment to transparency and a culture of “see something, say something” and to improve channels to submit complaints and provide for independent review

Separate the medical staff office responsibilities from the patient safety and quality department responsibilities, which previously were overseen by a single vice president of medical affairs…

In the coming weeks, the board of Johns Hopkins medicine will appoint an external monitor to track and report back regularly to them on the hospital’s progress,” he said.

The initial focus will be on the St. Petersburg hospital, a team will go to the other five hospitals in the network to ensure the changes are taking place.” (B)

“The review recommended a commitment to patient safety and said the “see something, say something” culture is a vital part of that.

The hospital published the report on its website along with a video of Sowers talking about the results.

“Above all, we must work each and every day to support a culture in which each of us is supported and empowered to speak up and speak out,” Sowers said in the video.

He provided a toll free number where employees can anonymously report any issues: 1-844-SPEAK2US.” (C)

 “Children’s heart surgery departments across Florida will soon be subject to more oversight.

Gov. Ron DeSantis signed a bill late Tuesday that will let physician experts visit struggling programs and make recommendations for improvement…

The bill signed into law Tuesday makes significant changes.

It lets a committee called the Pediatric Cardiac Technical Advisory Panel appoint physician experts to visit Florida’s 10 children’s heart surgery programs. They will be able to examine surgical results, review death reports, inspect the facilities and interview employees.

Dr. David Nykanen, the chairman of the advisory panel and a pediatric cardiologist at Arnold Palmer Hospital for Children in Orlando, called site visits “crucially important,” especially when departments are having problems.

He said visits could start within the next six months…

The hospital has not yet resumed heart surgeries. The results of a review commissioned by the Johns Hopkins Medicine board are expected soon.” (E)

“A state regulatory process that limited the number of hospitals and some specialty services like transplant programs are going away on July 1.

Despite attempts by two hospitals, Central Florida doesn’t have a pediatric heart transplant program. But that could change in the coming years because a state regulatory process that limited the number of hospitals and some specialty services like transplants is going away on July 1.

For nearly five decades, the program known as certificate of need has required hospitals to get authorization from the state before building new facilities or offering new or expanded services — a complicated process that’s costly, includes reams of paperwork and potential challenges from competitors, and can take months or years…

Starting July 1, general hospitals are no longer required to obtain a certificate of need to build a facility or to start services such as pediatric and adult open heart surgery, organ transplant programs, neonatal intensive care units and rehab programs…

The second part of the bill goes into effect on July 1, 2021, when the certificate of need requirement will be eliminated for certain specialty hospitals such as children’s and women’s hospitals, rehab hospitals, psychiatric and substance abuse hospitals and hospitals that offer intensive residential treatment services for children.” (F)

“Cohen announced late last week that she had assembled a team from the state Division of Health Service Regulation, which licenses and oversees health care facilities, to “conduct a thorough investigation into these events.” They are coordinating with the U.S. Centers for Medicare & Medicaid Services, a federal oversight agency…

Kelly Haight Connor, a spokeswoman for the state health department, said Monday it’s difficult to know how long an investigation will take. In other DHHS investigations, a team often interviews a range of people, from caregivers, staff and those in their care.

Wesley Burks, CEO of UNC Health Care since December 2018 and dean of the UNC School of Medicine, sent a five-paragraph email to staff on May 30 at 10:16 a.m. and attached the Times’ article he described as “critical of UNC Medical Center’s pediatric congenital heart surgery program.”

 “While this program faced culture challenges in the 2016-2017 timeframe, we believe the Times’ criticism is overstated and does not consider the quality improvements we’ve made within this program over many years,” Burks wrote in the email. “As the State’s leading public hospital, UNC Medical Center often gets the most complex and serious cases in its pediatric congenital heart program. For many of these very sick children, we are often parents’ last hope…

On Monday, UNC Health Care spokesman Phil Bridges released a “timeline of Continuous Quality Improvement within the program over the past 10 years.”

The timeline mentions a four-month period from June to September in 2016 in which “concerns and allegations against specific individuals in the Congenital Heart Program” were “independently investigated and reviewed” by the dean’s office and the chief medical officer.

“Allegations of misconduct and concerns determined to be unfounded,” the document states, adding “allegations against specific individuals and results of the investigations constitute personnel records, which may not be disclosed,” citing public records law.

An ongoing initiative, according to the document, calls for a Department of Pediatrics review after every death in the Pediatric Intensive Care Unit, including pediatric cardiac patients, to assess the care provided and evaluate any opportunities for improvement.” (G)

“UNC Health Care officials announced Monday they are halting the most complex pediatric heart surgeries following a report that raised serious safety concerns over a number of child deaths at UNC Children’s Hospital…

Officials from UNC HealthCare said in a statement they plan to create an advisory board of external medical experts and “pause the most complex heart surgeries” until that board and regulatory agencies review the program.

The external advisory board, which is expected to have members from the University of Southern California, the University of Michigan, University of Pittsburgh Medical Center and Nationwide Children’s Hospital, will examine the efficacy of the UNC Children’s Hospital pediatric heart surgery program and make recommendations for improvement. The group will report to the UNC Health Care Board of Directors.

UNC Healthcare officials said they are also developing a new structure to support internal hospital reporting and plan to publicly release Society for Thoracic Surgeons’ (STS) patient outcome data, make a $10 million investment in new technology and bring in new specialists as part of their efforts to “restore confidence” in its pediatric heart program.

“Our pediatric heart program cares for very sick children with incredibly complex medical problems, and our clinical team works tirelessly to help those patients return to normal, healthy and productive lives,” Wesley Burks, M.D., CEO of UNC Health Care said in a statement. “We grieve with families anytime there is a negative outcome and we constantly push to learn from those tragic instances.

UNC Health Care’s board also endorsed the creation of a pediatric heart surgery family advisory council to provide a voice for patients, family members and staff directly to hospital leadership…

Most recently, Johns Hopkins’ All Children’s Hospital came under fire for increasing mortality rates among heart surgery patients at the 259-bed hospital following a Tampa Bay Times investigation. Top leaders of that hospital ultimately resigned and Johns Hopkins’ board also said it commissioned an external review to examine the heart surgery program.

In 2015, St. Mary’s Medical Center in Florida closed it’s pediatric heart surgery program after a CNN investigation revealed it had a mortality rate of more than three times the national average. In 2009, Massachusetts General Hospital suspended its pediatric surgery program in the wake of surgical errors.” (H)

 “UNC Children’s Hospital should merge its pediatric heart surgery program with the same work being done at Duke Health’s Children’s Hospital, just 10 miles away. A common program would greatly enhance the treatment of children and babies in need of complex heart surgery.

As it is, UNC Children’s does 100 to 150 pediatric heart surgeries a year, a rate considered low volume. That makes it harder to recruit and retain surgeons and limits surgeons ability to hone their skills. It also makes it harder to maintain the other parts of the program, cardiologists, anesthesiologists and staff for a pediatric heart intensive care unit.

East Carolina University’s hospital faced similar challenges as it provided pediatric heart surgery at a low-volume level of 50 to 75 surgeries a year. Eighteen months ago, ECU started sending all its pediatric heart surgery patients to Duke. The change helped boost Duke’s volume to where it has done more than 800 surgeries in 18 months. During the same period, Duke has posted a 1 percent mortality rate, despite a caseload in which a third of the operations are high risk.

Unfortunately, UNC Children’s Hospital appears uninterested in combining resources despite overtures from Duke. In a statement Thursday, the hospital said, “While there have been discussions with Duke Health over the years about ways to collaborate across various pediatric specialties, there are no plans to combine our programs. Patients in this region benefit from having two world-class medical institutions located so close together. Our clinicians frequently collaborate with colleagues at Duke. We sometimes transfer patients to them and vice versa.

UNC Children’s would prefer to run its own pediatric heart surgery program as a matter of institutional pride and money — the most complex operations can cost a half-million dollars. But pride and money aren’t — or shouldn’t be — the primary concerns. What matters most is how to get the best care for children in this highly specialized and high-stakes area of medicine. To do that, North Carolina’s best hospitals should combine their resources and expertise.” (J)

Typically, with complex medical procedures, outcomes are strongly correlated with volume. That means that if a program does more procedures, it has more expertise, the healthcare team has more experience working together — and as a result, patients have better results. Larger programs often have better equipment and more personnel. Sadly, the pediatric surgery program at North Carolina Children’s Hospital was a low-volume center…

Powerful forces stand in opposition to the closure of low-volume centers. Low-volume centers are attractive because they are geographically convenient; patients do not have to travel long distances for their care. Some insurance coverage is regionally-restricted, and families without resources are unable to access high-volume centers. Low-volume centers are often staffed by entrepreneurial physicians who don’t want restrictions on their right to practice medicine. And their goals are often closely aligned with those of local political officials, who would like to imagine that low-volume programs can replicate the results at large medical centers. Perhaps most importantly, hospital administrators at low-volume centers do not wish to see their revenues slashed — and their leadership positions eliminated.

So the problem of decentralized medicine and low-volume centers is getting worse, not better. To an increasing degree, a larger and larger proportion of specialized procedures in the United States are being done at low-volume centers…” (N)

For an unabridged chronology, click on

PART 3. Hopkins All Children’s Hospital/ North Carolina Children’s – pediatric cardiac surgery http://doctordidyouwashyourhands.com/2019/08/part-3-hopkins-all-childrens-hospital-north-carolina-childrens-pediatric-cardiac-surgery-debacles/

NOTES

PART 1

G.Johns Hopkins promised to elevate All Children’s Heart Institute, by KATHLEEN McGRORY and NEIL BEDI, http://www.tampabay.com/projects/2018/investigations/heartbroken/all-childrens-heart-institute/

H.Top officials at Johns Hopkins All Children’s Hospital resign following reports of heart surgery deaths, by Tina Reed, https://www.fiercehealthcare.com/hospitals-health-systems/top-officials-at-johns-hopkins-all-children-s-hospital-resign

I.Three more All Children’s officials resign following Times investigation, by By Kathleen McGrory and Neil Bedi, https://www.tampabay.com/investigations/2019/01/02/three-more-all-childrens-officials-resign-following-times-investigation/

J.Johns Hopkins hires former prosecutor to investigate All Children’s Heart Institute,by Kathleen McGrory and Neil Bedi , https://www.tampabay.com/investigations/2019/01/09/johns-hopkins-hires-former-prosecutor-to-investigate-all-childrens-heart-institute/

Q.Community Hospitals Link Arms With Prestigious Facilities To Raise Their Profiles, by Sandra G. Boodman, https://khn.org/news/community-hospitals-link-arms-with-prestigious-facilities-to-raise-their-profiles/

PART 2

D.” Horrible complications are happening that you can’t explain.” ” We have to be honest with the patients.” ” It’s a nightmare right now.” Secret recordings captured physicians’ concerns that more children seemed to fare poorly after heart surgery. Their hospital kept doing the operations, by BY ELLEN GABLER, https://www.nytimes.com/interactive/2019/05/30/us/children-heart-surgery-cardiac.html?smid=nytcore-ios-share

E.In North Carolina, the New York Times reveals another heart surgery program in trouble, by Kathleen McGrory and Neil Bedi, https://www.tampabay.com/investigations/2019/05/30/in-north-carolina-the-new-york-times-reveals-another-heart-surgery-program-in-trouble/

H. Secretary Cohen calls for investigation into NC Children’s hospital, https://www.ncspin.com/secretary-cohen-calls-for-investigation-into-nc-childrens-hospital

PART 3

A.Johns Hopkins All Children’s releases ‘lessons learned’ from review, by Margie Manning, https://stpetecatalyst.com/johns-hopkins-all-childrens-releases-lessons-learned-from-review/

B.Law firm recommends Johns Hopkins hospital to make administrative, patient safety changes, by  Veronica Brezina-Smith, https://www.bizjournals.com/tampabay/news/2019/07/01/law-firm-recommends-johns-hopkins-hospital-to.html

C.Johns Hopkins All Children’s Hospital Faces More Changes, by Julio Ochoa, https://wusfnews.wusf.usf.edu/post/johns-hopkins-all-childrens-hospital-faces-more-changes

E.Extra oversight for children’s heart surgery signed into law, by By Kathleen McGrory and Neil Bedi, http://www.tampabay.com/investigations/2019/06/26/extra-oversight-for-childrens-heart-surgery-signed-into-law/

F.Hospitals, transplant programs could multiply in Central Florida with law change, by Naseem S. Miller, https://www.orlandosentinel.com/health/os-ne-health-florida-certificate-of-need-repeal-20190701-tujobp6zofe7dorx7jxhfwc37q-story.html

G.No timeline for state investigation into NC Children’s Hospital, by Anne Blythe, http://www.tampabay.com/investigations/2019/06/26/extra-oversight-for-childrens-heart-surgery-signed-into-law/

H.UNC Children’s suspends complex heart surgeries after report raising safety concerns, by Tina Reed, | https://www.fiercehealthcare.com/hospitals-health-systems/unc-children-s-suspend-complex-heart-surgeries-after-report-raising-safety

J.UNC and Duke should unite on pediatric heart surgery, https://www.newsobserver.com/opinion/article231271418.html

N.Does Medicine Have a Wall of Silence?, by Milton Packer, https://www.medpagetoday.com/blogs/revolutionandrevelation/80256

PART 4

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