"Inadequate Care - State cites hospital's treatment of liver donor who died -
Calling his care "shocking" and "fragmented at best," State Health Commissioner Antonia Novello yesterday cited 18 deficiencies in The Mount Sinai Hospital's post-operative care of a patient who died in January, three days after donating a section of his liver to save his brother's life.
While she stopped short of saying the death of Michael Hurewitz, 57, could have been prevented, Novello painted a picture of a transplant unit that was understaffed and too slow to notice or react to his worsening condition. An autopsy showed that Hurewitz had a bacterial infection that had spread throughout his stomach, small intestine, portal vein, esophagus and into his lungs. The infection caused him to aspirate blood into his lungs, killing him.
"The care of the patient was inadequate, and for that we hold Mount Sinai responsible," Novello said in a news conference in Manhattan yesterday.
Hurewitz's widow, Vicky Hurewitz, said in a statement released yesterday that his death was "entirely preventable had proper and timely treatment been instituted by adequately trained, experienced and supervised personnel."
His brother, Adam, 54, of Setauket, chief of pulmonary and critical care medicine at Winthrop-University Hospital in Mineola, has not returned to work since the transplant and is not commenting on the report, said Winthrop spokesman John Broder. The brothers grew up in Rockville Centre; at the time of his death Michael Hurewitz worked as a reporter for the Albany Times-Union. He lived in upstate Schuylerville.
Among the key findings in the report Novello issued yesterday:
The surgeon who operated on Hurewitz at the Manhattan hospital, Dr. Charles Miller, never visited him after the surgery, which is contrary to standard practice and in violation of state regulations.
One surgical resident with only 12 days' experience on the unit was assigned to care for all 34 transplant donors and recipients, a task that left her feeling "totally overwhelmed," Novello said.
The ratio of nurses to patients was 1 to 7, the health commissioner said, compared with a 1 to 1 ratio at University of Rochester Medical Center, which performed the most liver transplants from living donors in the state last year. Novello said there is no required ratio for health care staff to patients.
The transplant fellow - a doctor who is training in a subspecialty - who was on duty failed to respond to the resident's pleas for help when Hurewitz was clearly ill. When the fellow returned to the hospital from a nearby bookstore, he did not examine Hurewitz and instead began a pre-operative workup on another patient.
There was a lack of communication among staff about the patient's diet. Though his chart specified a clear liquid diet, the transplant fellow let the family bring in a full lobster dinner the day after surgery.
The hospital, which performed 35 adult-to-adult living liver donor transplants last year, is being fined $48,000, the maximum possible. Novello said the state had forbidden Mount Sinai from performing such liver transplants for the next six months to ensure that "corrective actions" are taken. Transplants using organs from cadavers or using parts of livers from living adults for children needing transplants will continue, she said.
"I don't believe that, until proven otherwise, we should stop" the hospital's other transplant programs, Novello said.
She said it was "probably customary" that some of the doctors involved would also be reviewed by the health department's Office of Professional Medical Conduct, which can fine a doctor or revoke a medical license. Letters are being sent to the state's three other hospitals that do living liver transplants - New York University Hospitals Center, New York-Presbyterian Hospital, both in Manhattan, and the University of Rochester Medical Center - to ensure they have adequate post-operative care and staffing.
Mount Sinai said in a statement yesterday that correcting problems "is our highest priority. We are deeply distressed that these problems contributed to the death of Mr. Hurewitz and the loss to his family." Barry Freedman, the hospital president, disagreed with the finding that post-operative supervision was inadequate.
Novello said no problems occurred during the operation on Jan. 10, which involved taking about 60 percent of Hurewitz's healthy liver and transplanting it into his brother, who has a liver disease.
But, she said, two days later the otherwise healthy donor developed a rapid heartbeat, which was apparently overlooked by the attending transplant fellow. Around 1 a.m. on Jan. 13, Hurewitz developed hiccups and nausea and was given a medication for the symptoms, which may have masked the underlying problem, the health department report said.
It goes on to say that a surgical resident, unaware of those symptoms, examined Hurewitz at 8:45 a.m. and said his vital signs were stable. Early in the afternoon, Hurewitz began vomiting "brownish materials," generally a sign of blood, Novello said. The surgical resident, who had five months' surgical experience and had been on the unit 12 days, was the only doctor on the unit for three hours, Novello said. The resident called the transplant fellow on duty, who was at a bookstore outside the hospital. He advised against treatment and "despite the patient's distress," the health department said, did not examine Hurewitz upon his return. Hurewitz continued to vomit blood and three hours later was dead.
An autopsy found that Hurewitz was infected with Clostridium perfringens, a bacterium present in the intestines of humans and animals as well as in the soil and sewage. Novello said the health department was still trying to determine the source of the infection.
She added that it was "possible but we just don't know" if Hurewitz's ingestion of a lobster dinner was somehow related to the infection."
I still cant believe this hospital just announced LAY-OFFS of personnel - had the audacity to already eliminated 15 vacant RN positions and is planning to reduce even more, as well as other services. Just amazing how they think that even less staffing will solve their problems of already-poor staffing.
see "...Stuck In The Twlight Zone" http://allnurses.com/forums/showthre...2&pagenumber=1