by Judy Hodgson
There is little doubt that the new Heart Institute at St. Joseph Hospital got off to a rocky start. The opening was delayed several months because its original chief surgeon needed surgery himself and had to be replaced due to a disabling neck injury .
The facility finally opened at the end of April. But on July 29 -- just three months and 40 operations into the program -- heart procedures were suspended pending a review by the hospital, the state and, at the request of the hospital, the American Society of Thoracic Surgeons.
The reviews are expected to take four to six weeks.
"It's a temporary suspension," said Paul Chodkowski, chief executive officer of St. Joseph. "There is a total commitment to reinstate the program."
The heart program -- including coronary bypass, valve replacement and angioplasty -- was halted just one day after a 56-year-old Eureka woman died following bypass surgery.
The action was voluntary, Chodkowski said, and it was taken prior to a complaint being filed with the state Department of Health Services.
The Journal has learned from public records that four deaths have occurred which may be considered program-related. On May 25 a 54-year old man with severe coronary disease died of a massive pulmonary embolism. He had undergone a successful bypass operation 11 days earlier and had been discharged from the hospital. Then on May 30 a 70-year-old woman died following a complicated surgery that involved valve replacement, ventricle enlargement and double bypass.
Two months later there were two more deaths, one on July 21 (a 58-year-old woman following angioplasty) and the bypass patient on July 28.
It appears that only one death -- the last one -- could be classified as a heart bypass mortality but the hospital officials and others were concerned enough to temporarily suspend operations.
"The experience of my patients overall was good," said Dr. Robert Lock, a Eureka cardiologist. "I referred 20 patients to the program. All but one did famously.
"(The last death) was my patient," he said. "People are looking for answers, but it was an unexplained death ... when someone can't come off the pump.... The patient died." (During heart surgery, patients are put on a pump that bypasses the heart and lungs and the heart is stopped.)
Lock performs procedures such as angioplasty on patients but bypass and valve surgeries at the Heart Institute were performed by the cardiac surgeon, Dr. Charles Dietl.
Cardiac catheterization and pacemaker implants have been performed at St. Joseph for 10 years and those procedures will continue. But angioplasty had to be suspended because it requires a backup surgeon to perform more extensive surgery if angioplasty fails.
"We've done a lot of successful angioplasties" since the Heart Institute started up, Lock said. "One was a heart attack in the hospital. A clot burst. We bailed that patient out in the middle of the night."
With four deaths out of 40 heart patients, the program's "overall death rate was not what I would have wanted," Lock said.
But Lock and other physicians are quick to point out that after three months it is too early in the program at St. Joseph to determine a mortality rate.
Chodkowski agreed. "We really don't know whether it's high or low. What we really need to do is to look at each of those cases individually."
St. Joseph may also have treated a larger percentage of high-risk patients than is typical for a start-up cardiac surgery program. Usually new programs choose lower-risk patients and send high-risk patients to larger and more experienced facilities.
Chodkowski declined to comment on individual cases but he said when the program was started a decision was made not to turn any patients away. A month or so into the program, stricter selection was instituted, he said.
When St. Joseph restarts its heart program, its mortality rate will undoubtedly be scrutinized. In the increasingly competitive hospital business, heart programs are often judged by the numbers.
The federal government keeps tabs on all Medicare patients (62 years and older). According to figures from the 1991-95 report, the national average mortality for bypass surgeries was 5.1 percent following initial surgery. Redding Medical Center, a high-volume program, performed 1,468 bypasses during that period, with a mortality rate of 3.1 percent. Its neighbor hospital, Mercy Medical Center, which started its own heart program in 1991, has a rate of 3.6 percent deaths in 375 operations.
"A good coronary bypass (mortality) rate should be 1 to 3 percent, with 3 percent max," said Dr. Ed Olsgard, a Eureka family practitioner.
However, valve replacements and angioplasties are more difficult. Lock estimated, for example, that 10 percent of angioplasty patients do not survive the initial surgery.
The St. Joseph Heart Institute performed "an array of cases ... that included valve cases and bypass cases," said Chodkowski. "What we really need is some advice to look at that array. We are going to look at the risk level of the patients who have been operated on.... We want to look at our case selection."
"We've made a formal request to the American Society of Thoracic Surgeons to provide us with an on-site expert team to review all the cases that have been performed in our program," Chodkowski said.
In the meantime, the state Licensing and Certification Division of the Department of Health Services in Santa Rosa sent its own team to review the program during the week of Aug. 18. The team, consisting of two nurse evaluators and one physician, reviewed all cases and will issue its own findings.
"If there are any deficient practices, that has to be communicated to the hospital and they will respond with a plan of correction," said Health Services spokesperson Helgi Teixeira.
Teixeira said her office was responding to a specific complaint filed July 29. The complaint is confidential. "Anyone can file one," she said.
There was also speculation last month about the fate of some hospital personnel.
Chodkowski, who has been with the hospital for six years, has accepted a position as hospital administrator at St. Clare's in his hometown of Schenectady, N.Y. He said the position is the "realization of a lifelong dream" and his decision was unrelated to the troubles at the heart program at St. Joseph.
"But the timing is terrible, I admit," he said.
And it was erroneously reported that the heart surgeon, Charles Dietl, was leaving the program.
"Dr. Dietl is assisting in the review process," Chodkowski said. "But we are seeking additional surgical coverage" due to the higher volume of cases.
At the rate of 40 cases in three months, the hospital may eventually perform 160-200 procedures per year.
"Dr. Dietl had already made the recommendation that we look for an additional surgeon for backup and relief," Chodkowski said.
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