Newborns at St. Chris face longer recovery after heart surgery

Newborn babies who undergo heart surgery typically spend twice as long recovering at St. Christopher's Hospital for Children as similar patients at Children's Hospital of Philadelphia, potentially leading to long-term health consequences.

That finding, based on an Inquirer analysis of insurance claims data from 2009 to 2014, comes as St. Christopher's has stopped performing nonemergency heart surgery during an internal review. Last month, the newspaper also found that newborn heart-surgery patients at St. Christopher's were much more likely to die than those at CHOP.

Extended hospitalizations can be costly in many ways. In addition to the financial impact and the emotional toll on families, a long hospital stay means a greater chance of infections and other complications, and it can even mean poorer health years down the road.

One study found that for infants undergoing a complex heart operation called an arterial switch, postsurgical length of stay was linked with the children's cognitive ability eight years later.

Even the best hospitals have at least a few outliers - children so sick they must wait for months to go home - but on average, shorter stays generally reflect better care, said Redmond P. Burke, director of cardiovascular surgery at Nicklaus Children's Hospital in Miami.

"Length of stay is the best proxy data for the excellence of care that a child has received," Burke said.

In a statement Friday evening, St. Christopher's did not provide length-of-stay figures for newborns or any other subset of patients.

The hospital said that it participated in the Society of Thoracic Surgeons (STS) database and that its median postoperative lengths of stay were "in line or below" national benchmarks, grouped by risk category.

"In addition, during this reporting period [July 2011 to June 2015], our program has shown improvement in patient volume and quality outcomes," the hospital said.

The Inquirer asked all six pediatric heart-surgery programs in Pennsylvania and Delaware how long their patients stay in the hospital after surgery. All but St. Christopher's provided numbers by type of surgery. Those hospitals' numbers generally met or exceeded STS norms.

No hospital in South Jersey performs the full range of these complex procedures.

For St. Christopher's, the Inquirer analyzed publicly available insurance claims data, identifying surgical codes using an algorithm developed at Boston Children's Hospital.

The review did not break out different types of heart surgery because the sample sizes were small, meaning that a few extraordinary cases could skew results. Instead, the Inquirer focused on all heart-surgery patients up to 1 month old (newborns), because they undergo some of the riskiest procedures.

Among 121 newborns who underwent complex heart procedures from 2009 to 2014 at St. Christopher's, the median length of stay after surgery was 28 days - meaning half the patients stayed at least that long, and half were there a shorter time. That is more than twice the comparable figure of 13 days for the 784 patients at CHOP.

A spokeswoman for St. Christopher's said that because most of the hospital's patients are covered by Medicaid, the government insurance program for the poor, they may be in worse health upon admission to the hospital due to such factors as poor nutrition or low birth weight.

So the Inquirer compared only Medicaid patients for the two hospitals, and the pattern remained the same.

Among 88 Medicaid-covered newborns who underwent complex heart surgery during the six-year period at St. Christopher's, the median length of stay was 31 days, while the corresponding figure for the 260 Medicaid patients at CHOP was just 17 days.

The difference between the two hospitals remained even when babies with low birth weight were excluded.

In a separate analysis last month, the newspaper found that newborns undergoing heart surgery at St. Christopher's also were much more likely to die - with a mortality rate of 24 percent, compared with CHOP's 8.5 percent.

St. Christopher's stopped performing nonemergency heart surgery in late January to conduct its review, but gave few details. It has not said when it will resume.

St. Christopher's is owned by Tenet HealthCare Corp., a for-profit Dallas company. In mid-August, a West Palm Beach, Fla., hospital owned by Tenet shut down its pediatric heart-surgery program after concerns arose about its patients' death rate.

The success of a hospital's heart-surgery program depends on multiple factors, among them the skills of the surgical team and the talents of the intensive-care specialists who oversee recovery.

Ultimately, the surgeon heading the program is responsible for building the team and ensuring that adequate technology and other resources are available, said Burke, of Nicklaus Children's.

"The surgeon does kind of set the stage," Burke said. "He's responsible when the starter fires the pistol and the runners take off."

The head of heart surgery at St. Christopher's since mid-2009 is Achintya Moulick, who spent more than four years before that at hospitals in Washington, including Children's National Medical Center.

In a 2010 newsletter issued within months of Moulick's arrival, St. Christopher's touted his skills in getting patients home more quickly.

"We're treating more complicated and higher-risk cases, yet I'm routinely seeing the children sitting up in a chair and conversing the next day," hospital anesthesiologist Roy Schwartz was quoted as saying.

Moulick, unlike the heads of the five other pediatric heart-surgery programs in Pennsylvania and Delaware, lacks certification by the American Board of Thoracic Surgery. Four of the five also have a certificate from that board in the subspecialty of congenital heart surgery.

Certification requires that the physician complete a multiyear residency and then pass rigorous written and oral exams. Some hospitals will not hire heart surgeons who lack it.

The credential is not a guarantee of surgical skill but is widely considered a minimum benchmark, said Alistair Phillips, co-chair-elect of the American College of Cardiology's Surgeons Council.

"I think it's important because it shows a dedication to your field," said Phillips, a pediatric heart surgeon at Cedars-Sinai in Los Angeles. "It's an independent body that has set up a review of your basic knowledge base."

In a statement issued late Friday by attorney Lawrence McMichael, Moulick said he was proud of his pediatric heart program.

"In a community where these needs are imperative, we work hard to provide high-level quality care for each patient who requires cardiac intervention," he said.

He said he had been doing cardiac surgery for 20 years, 15 focused on children, and had completed advanced clinical fellowships at the University of Massachusetts, Massachusetts General Hospital, and Emory University.

St. Christopher's said Moulick was "a highly experienced surgeon" and provided a resumé in which he listed a board certification in thoracic surgery at the University of Bombay in India in 1995. Pediatric heart surgery has evolved significantly since then, with many more children surviving such procedures thanks to better techniques.

The American Board of Thoracic Surgery requires surgeons to renew their certifications every 10 years.

La'Kel Alford-Robbins was born at St. Mary Medical Center in Langhorne on Jan. 9, 2012. The next day, doctors at St. Christopher's diagnosed him with multiple serious heart defects. Among them were a double-outlet right ventricle and a large ventricular septal defect - a hole between the heart's left and right pumping chambers.

He began a three-month stay at St. Christopher's, which, his parents allege in a lawsuit against the hospital, was prolonged and ultimately fatal due to inadequate care.

On Jan. 18, St. Christopher's surgeons put in a shunt to improve blood flow to the boy's lungs, according to a lawsuit his parents filed in the Philadelphia Court of Common Pleas. Five weeks later, he apparently was on the mend; a hospital social worker discussed plans for his discharge and offered to help his mother, Kelila, obtain a crib.

But it was not to be. Several weeks later, a heart catheterization revealed excessive blood flow to the lungs, the lawsuit states. On March 23, doctors decided another surgery was needed, and opened the boy's chest to close off his pulmonary artery.

Later that day, La'Kel's blood pressure dropped sharply over a period of several hours and his heart rate soared, at one point hitting 185 beats per minute, court records show. The boy's parents allege that nurses failed to notify physicians promptly.

At 4:07 p.m., a caregiver wrote that he "woke up crying, agitated, and thrashing head," and he went into cardiac arrest.

He was revived, but on March 24, 66 days after his initial surgery, he went into cardiac arrest again. His life-support device, the lawsuit alleges, was operated by a nurse who was not certified to use it. This time, he could not be resuscitated.

His father, Leonard Alford, recalled the emotional drain of those difficult weeks, the optimism followed by devastation.

When his baby died, "it was like everything stopped moving," said Alford, who now lives in Tennessee.

The hospital is contesting the lawsuit and defends its care of La'Kel.

Although the higher death rate at St. Christopher's seems to be an issue solely among newborns, longer stays can affect children of all ages admitted to the North Philadelphia hospital.

Among all 316 pediatric heart-surgery patients on Medicaid at St. Christopher's, 23.7 percent stayed at the hospital more than 30 days afterward.

At CHOP during the same period, 14.4 percent of Medicaid patients stayed more than 30 days.

Heart-surgery patients on Medicaid at St. Christopher's also were more likely than those at CHOP to stay longer than 60 days and longer than 90 days.

David Overman, chief of cardiovascular surgery at the Children's Hospitals and Clinics of Minnesota who has studied length of stay, said he could not comment on data for a specific hospital. But increasingly, he said, faster recovery is seen as a marker of a hospital's success.

"If you can get people to survive, but it's taking them four months to get out of the hospital," he said, "what does that say?"

tavril@phillynews.com

215-854-2430@TomAvril1