State Health Department Completes Investigation at Long Island Jewish Hospital

Albany, January 4 -- State Health Commissioner Barbara A. DeBuono, M.D., today released a report on the Health Department's extensive investigation of surgical, anesthesia and post-operative care at Long Island Jewish Medical Center.

The Health Department conducted a focused survey of the hospital's surgical and anesthesia units and the recovery room and reviewed a total of 71 patient records after receiving separate complaints from relatives of two patients who were operated on in April 1995. One of the patients died and the other became permanently comatose following surgery.

"We do not believe there are systemic problems at Long Island Jewish Medical Center that would adversely affect patients undergoing anesthesia and surgery," Dr. DeBuono said. "Despite the tragic outcome for both patients, our extensive investigation showed that their cases are dissimilar, and we do not believe other patients are at risk."

Although the Department's on-site investigation uncovered no pattern of problems within its surgical or anesthesia services, Long Island Jewish Medical Center was cited for quality of care concerns in the case of the comatose patient, and in another case that was discovered through the records review. Dr. DeBuono said the Health Department also cited the hospital for technical code violations identified through the survey process.

Background Of The Cases

Case 1 - Lloyd Reback

On April 25, 1995, Mr. Reback underwent a 17-hour operation to remove a benign tumor and reconstruct his jaw. Surgery started at approximately 8 a.m. and continued until early the next morning. Approximately 48 hours after the operation, the patient's endotracheal tube which had been inserted to help him breathe during surgery was removed. Shortly afterward, Mr. Reback lost his airway and could not be intubated again. Despite emergency airway management, he suffered cardiac arrest and a resulting loss of oxygen to his brain, leaving him comatose.

Case 2 - Denise Verbeeck

Ms. Verbeeck also underwent surgery at Long Island Jewish Medical Center on April 25, 1995. She was operated on for realignment of her patella (knee cap), receiving anesthesia through a nasotracheal tube. After the operation, the tube was removed and the patient was taken to the recovery room, where her vital signs were stable.

Approximately 30 minutes after Ms. Verbeeck arrived in the recovery room, she began having trouble breathing. Lung congestion was apparent and a chest X-ray suggested pulmonary edema. In addition, bleeding was noted in her upper airway. A topical decongestant was administered on the advice of an ear, nose and throat specialist.

A chest X-ray the following day showed that Ms. Verbeeck had Adult Respiratory Distress Syndrome (ARDS), believed to be caused by aspiration (inhalation) of blood during the initial nasal intubation. On April 27, the patient's condition worsened and she was transferred to the Intensive Care Unit, where she died on May 7. A New York City Medical Examiner attributed Ms. Verbeeck's cause of death to ARDS following traumatic intubation.

The Department's Investigation

Health Department surveyors spent seven days at the hospital reviewing surgical, anesthesia and post-operative care in these and other cases. A total of 26 cases were pre-selected by the Department for examination. Another 45 patient medical records were chosen at random.

Along with the records review, surveyors conducted interviews with key hospital administrative, medical and quality assurance staff. Further information was solicited from patients' family members. In addition, credentialing and quality assurance information about the attending anesthesiologists was examined, as well as the hospital's quality assurance program and its overall policy and procedures for granting credentials and privileges to medical staff.

The Health Department also brought in anesthesia and surgical expert consultants who reviewed selected case records and assessed quality of care. The Department also consulted with the New York City Medical Examiner's office.

Based on the focused survey, no systemic problems with the surgical or anesthesiology departments were identified. However, the Health Department determined that, in the case of Mr. Reback, while the patient's anesthesia care was appropriate, his surgical management failed to meet acceptable standards of practice. Both the anesthesia and surgical consultants concluded that a planned tracheotomy should have been performed during the initial operation based on the patient's history and the extent of surgery involving his airway.

In Ms. Verbeeck's case, the anesthesia consultant concluded that "meticulous attention" was given to the patient's anesthesia management. Although an autopsy report found Ms. Verbeeck developed ARDS following a traumatic intubation, the Medical Examiner assigned to the case determined that the patient's death was related to the actual process of intubation, rather than poor intubation technique. No deficiencies were cited resulting from this case.

Other Findings

In addition to the Reback case, the Health Department has cited Long Island Jewish Medical Center for one other deficiency related to patient care. That case involved a 47-year-old woman who received an overdose of potassium from a post-graduate trainee physician during surgery. Although the patient subsequently died, the drug administration error was not a factor in her death.

As a result of their investigation, the surveyors also noted technical deficiencies relating to documentation, infection control and pharmaceutical services, which the Department believes are isolated in nature.

Next Steps

A Statement of Deficiencies has been issued to Long Island Jewish Medical Center citing the quality of care concerns detailed in the Department's report along with the technical code violations identified during the course of the focused survey. The citations are as follows:

  • The medical care provided to two patients did not meet acceptable standards of patient practice.
  • The health status of hospital personnel was not adequately reassessed in eight of 17 files reviewed. A total of four files did not contain evidence of a physical examination in the past three years and four did not contain evidence of a PPD (tuberculosis) test in the past two years.
  • Attending physician supervision of surgical and anesthesia residents was not sufficient. In one case, inadequate resident supervision precipitated a drug administration error. In addition, in 18 of 45 medical records reviewed there was insufficient documentation of ongoing resident supervision.

Provided it submits and implements an acceptable Plan of Correction, no other action will be taken against the hospital.

1/4/96-2

OPA Contact: Claudia Hutton, Director, Public Affairs (518) 474-7354
New York State Department of Health Posted: January 23, 1996