6 serious incidents, including the deaths of 2 infants and a mother, prompt state investigation, changes at Cooley Dickinson Hospital

Monday, April 28, 2014
NORTHAMPTON — Cooley Dickinson Hospital Friday announced it is reorganizing its Childbirth Center in the wake of a Department of Public Health investigation into six serious incidents at the center since 2012, including two that resulted in infant deaths and one in which a mother died.

It also released on its website a redacted copy of a preliminary Department of Public Health report which revealed the failures that led to the deaths. In one case, a mother’s high blood pressure that caused pre-eclampsia, a dangerous, late-pregnancy condition, was not properly treated, leading to a stroke that caused her death.

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The report suggested communication problems contributed to the infant deaths. In one case, the mother had an unusual pelvic anatomy, the seriousness of which was not communicated to the staff overseeing the birth. In the other case, the report indicates, a staff member did not respond appropriately when fetal monitoring before delivery found the infant had an abnormal heart rate.

In an interview at the hospital Friday, Chief Medical Officer and Patient Safety Officer Dr. Mark Novotny said the DPH review as well as the hospital’s independent study suggested improvements were needed in communication, board oversight of staff, fetal monitoring and care of hypertension.

Novotny said the DPH report “by and large overlapped” with Cooley Dickinson’s investigation. “We certainly accept that we need to improve,” he said.

The DPH report and CDH officials don’t agree, however, about one factor in the incidents — that of doctor fatigue.

“Cooley Dickinson staff is aware that fatigue can play a role in the safe delivery of patient care and conducted a review of provider staffing levels in our Childbirth Center. We concluded that OB staffing levels were not an issue in the cases reviewed,” according to a letter to staff that posted on the hospital’s website.

The letter also says: “We acknowledge our conclusion was different from the CMS (Centers for Medicare and Medicaid Services) reviewer. However, because this is always a concern, we feel confident our new policies will allow any concern related to this issue to be quickly communicated and dealt with.”

The letter to CDH staff was signed by Board Chairman Matthew Pitoniak and CDH President Joanne Marqusee.

The letter does note that between October and December, four obstetrical providers resigned to seek other jobs and one went on maternity leave.

Still, Novotny said the hospital has addressed possible fatigue by cutting back on the number of on-call shifts for obstetricians and hiring three temporary physicians and two obstetricians, including one who will start in August.

In response to the DPH report, the hospital, now a part of Massachusetts General Hospital, has reorganized staffing in its Childbirth Center, instituted policies to increase communication between staff as well as other hospitals, required staff to go through additional training and encouraged them to speak up if they are ever concerned about a patient’s safety.

“We believe it’s safe to bring our families to the childbirth unit because of the changes we’ve made,” Novotny said.

He said the hospital reviews any medical case that results in an “unexpected outcome,” such as a mother who has to have a blood transfusion, to see if things could have been done differently. The six incidents, which involved six different families, were all serious, potentially life-threatening occurrences that the hospital was required to report to DPH.

Novotny said the cases alerted the board to a need for a review of practices.

“There was definitely a clustering effect here,” he said. While they were not clinically connected, Novotny said the issues of communication and oversight were common. He said he could not discuss the specific incidents due to patient privacy concerns.

The hospital’s review began in January and officials acknowledged publicly in March that an infant died during birth due to “fragmented communication” among staff during decision-making as the birth progressed — and said the DPH was also investigating.

The Department of Public Health told the Gazette Friday that its investigation of the center it still underway and no report was available.

Changes in place

To improve communication between staff at the Childbirth Center, the hospital has increased the level of collaboration between midwives and physicians and instituted twice daily “safety huddles” where doctors, nurses and midwives review all current patients to assure coordination of care, Novotny said. “It makes communication more standardized, so people have a guide and format in which to communicate,” he said.

They have also established a “trigger phrase” - "Can I have an update?" - that staff can use to signal to co-workers there is a concern they need to address.

While Novotny said hospital staff should feel comfortable informing senior staff members if they have concerns about a patient’s safety, the hospital is also promoting its hotline, which allows staff to anonymously report concerns.

“If there is a difference of opinion, they need someone they can go to,” he said.

The report states that a communication breakdown between hospitals was a problem in the death of a mother. After it became clear she had suffered a stroke during childbirth, staff tried but failed to receive authorization to transfer her to another hospital 18 miles away that could better treat a stroke. Instead, they transferred her by helicopter to a hospital 118 miles away, where she died, according to the report.

In its statement, Cooley Dickinson reported that it has received a commitment from the local hospital to respond to transfer requests within 15 minutes and said this has worked well since.

Staff at the Childbirth Center have also been undergoing training and retraining to be sure they are equipped to deal with unusual deliveries, such as those needed when the patient has an unusual anatomy.

“It was an extremely rare event that occurred,” Novotny said. “Education alone is hard to sustain over a career so we’ve offered people new information and access to information about them.”

Education in spotting and treating pre-eclampsia, a potentially lethal pregnancy complication caused by high blood pressure, is also mandatory now, according to the hospital’s statement.

It has developed guidelines for managing high blood pressure in pregnant women based on the American College of Obstetrics and Gynecology and formatted them into a computerized checklist to “easily allow providers to follow each recommended action.”

“Our treatment of high blood pressure could have been better,” Novotny said. “Whether improving these things would have changed the outcome, we don’t know.”

It has also instituted a requirement that all Childbirth Center nurses be trained in advanced cardiac life support, which includes treating someone in cardiac arrest.

Dianne M. Cutillo, senior director of public affairs at Cooley Dickinson, declined to say how much the changes are costing the hospital.

"Cost is not the issue. This is about investing resources in making care in the Childbirth Center and throughout our organization as safe as possible," she said.

The report said staff needs to better understand how to interpret fetal monitoring, Novotny said. Improvements in technology now make it possible for staff at Massachusetts General to see monitoring results in real time, so staff at the Childbirth Center can seek second opinions, he said.

They are also encouraging “situational awareness” and emphasizing the importance of safety with staff in the whole hospital, he said. “It’s to raise our level of alertness to hints that something could go wrong,” he said.

Novotny said hospital trustees are taking seriously the DPH finding that more board oversight of staff is necessary.

“It’s a challenge to the system to ask, how do we know when things aren’t going well? What kind of questions should we be expected to ask?” he said. The board reviews any unexpected outcome, he said, to see if anything should have been done differently.

Novotny said the morale at the Childbirth Center has taken a hit, but no staff or board members have resigned as a result of the incidents or investigation.

“It’s not been easy. They’re grieving,” he said.

He said he is impressed with how well staff have implemented the changes and said they all send their sympathies to the families affected by the tragic deaths.

Not surprisingly, people who are considering choosing the Childbirth Center for their delivery seem concerned about what they are hearing about the investigation, he said.

“People ask questions and we’re prepared to answer them,” he said. “I think the public knows that health care is risky and harm can happen. We hope by sharing this with the public openly, the public will say, ‘They’re doing something about it.’”

Rebecca Everett can be reached at reverett@gazettenet.com.