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REVIEW OF PAEDIATRIC CARDIAC SERVICES IN QUEENSLAND
Brisbane, March 2006
REVIEW PANEL: Professor Craig Mellis (Chair)
Professor Tim Cartmill
Professor Annette Dobson
Dr Tom Gentles
Professor Frank Shann
TABLE OF CONTENTS
INTRODUCTION .............................................................................................4
EXECUTIVE SUMMARY .................................................................................4
BACKGROUND ...............................................................................................7
HISTORICAL DEVELOPMENT OF CARDIAC SERVICES AND TERTIARY PAEDIATRIC SERVICES IN QUEENSLAND ..................................................7
QUESTIONS LEADING TO THE CURRENT ENQUIRY .................................9
TERMS OF REFERENCE .............................................................................13
METHODOLOGY OF CURRENT REVIEW ...................................................14
COMPOSITION OF REVIEW PANEL .......................................................... 16
METHOD OF CONSULTATION ....................................................................16
ACKNOWLEDGING THE CONTRIBUTIONS OF STAKEHOLDERS............17
DECISION NOT TO IDENTIFY THE CONTRIBUTING PARTIES .................18
REVIEW PANEL: FINDINGS AND RECOMMENDATIONS ..........................18
WHAT WAS NOT FOUND.............................................................................19
FRAGMENTATION AND CASELOADS ........................................................19
ESSENTIAL INTERIM MEASURES ..............................................................20
PROBLEMS WITH CARE OF CARDIAC INFANTS AND CHILDREN IN A TERTIARY ADULT HOSPITAL......................................................................21
GOVERNANCE .............................................................................................23
PAEDIATRIC CARDIAC SURGERY..............................................................24
PAEDIATRIC CARDIAC NURSING...............................................................24
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QUALITY MONITORING ...............................................................................27
STATISTICAL DATA ANALYSIS: METHODOLOGY AND RESULTS ..........29
CARDIOLOGY: SPECIFIC FINDINGS AND RECOMMENDATIONS............31
CARDIAC CATHETERISATION SESSIONS.................................................33
DIGITAL CARDIOLOGY SERVICES.............................................................33
ECHOCARDIOGRAPHY TECHNICIANS .....................................................34
OUTREACH CLINICS FOR PAEDIATRIC CARDIOLOGY............................35
DEVELOPMENT OF A FUNDED TELEMEDICINE AND TELE-ECHOCARDIOGRAPHY SERVICE...............................................................35
PAEDIATRIC CARDIOLOGY TRAINING PROGRAM...................................36
TRANSITION CLINIC AND FORMALISATION OF THE ADULT CONGENITAL HEART SERVICE..................................................................37
ADOLESCENTS AND ADULTS WITH CONGENITAL HEART DISEASE.....37
OUTREACH / LIAISON NURSES..................................................................38
PAEDIATRIC INTENSIVE CARE...................................................................38
PAEDIATRIC CARDIAC ANAESTHESIA ......................................................41
PAEDIATRIC CARDIAC SURGERY..............................................................42
HEART LUNG TECHNICAL SERVICES .......................................................42
EXTRACORPOREAL CIRCULATORY SUPPORT TECHNIQUES ...............43
ANCILLARY STAFF: PAEDIATRIC THERAPIES AND ALLIED HEALTH.....44
RISKS AND BARRIERS TO THE PROPOSED SOLUTIONS .......................45
FAILURE TO ACT..........................................................................................45
CAPITAL COSTS OF MAJOR HOSPITAL CONSTRUCTION.......................45
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WEIGHT OF HISTORY AND TRADITION.....................................................45
QUEENSLAND HAS A SMALL POPULATION WHICH CANNOT SUPPORT WORLD-CLASS ARRANGEMENTS .............................................................45
QUEENSLAND HAS A RAPIDLY GROWING POPULATION WHICH WILL SOON BE ADEQUATE TO SUPPORT TWO MAJOR CHILDREN’S HOSPITALS ..................................................................................................46
RESISTANCE OF STAFF TO CHANGE .......................................................46
RESISTANCE OF MAJOR INSTITUTIONS TO CHANGE ............................47
CONSOLIDATED RECOMMENDATIONS ....................................................47
SUMMARY AND CONCLUSIONS: ADDRESSING THE SPECIFIC TERMS OF REFERENCE OF THE CURRENT INQUIRY ..........................................54
APPENDIX 1 - BIBLIOGRAPHY....................................................................58 World-wide web sites
APPENDIX 2 - SUMMARY OF HOSPITAL SITE VISITS ..............................64
3
INTRODUCTION
In 2005 Queensland Health made a commitment to the people of Queensland
to transform the public health system. The Action Plan: Building a better
health service for Queensland, provides the framework for this health reform.
One of the recommendations was to review the system of providing paediatric
cardiology and paediatric cardiac surgery in Queensland to improve the health
outcomes for Queensland children. This review of paediatric cardiac services
in Queensland was commissioned to make recommendations to Queensland
Health with an emphasis on system factors that will improve the health
outcomes for children in Queensland.
Briefly, the Review Panel sought to:
• Review the adequacy of paediatric cardiac services in Queensland.
• Make recommendations for appropriate improvements in the system of
service provision necessary to ensure the high quality health care for
Queensland children with congenital or acquired heart disease over the
next 10 -20 years.
• Determine the optimal configuration of paediatric cardiology and
cardiac surgery services for Queensland.
EXECUTIVE SUMMARY
The present review of paediatric cardiac services was requested by the
Director-General of Queensland Health. This arose as a consequence of
several factors; concerns expressed by clinicians regarding a series of deaths
following paediatric cardiac surgery at The Prince Charles Hospital (TPCH);
findings from a coroner’s inquest into a cardiac death at the Royal Children’s
Hospital, Brisbane (RCH); and comments in the Forster Report (2006) on the
need to rationalise tertiary paediatric services in Queensland.
4
This review is one of a series that have been undertaken of paediatric cardiac
services in Queensland over a number of years. The explanation for these
repeated reviews is the unusual system in place in Queensland for paediatric
tertiary services. First, there are two competing tertiary children’s hospitals in
metropolitan Brisbane – a situation that is far from ideal for clinical care,
training, resource allocation, and research. Second, all infants and children
with cardiac disease are assessed and operated on in an adult cardiac unit at
TPCH, rather than at one of the two Children’s Hospitals. While this model for
cardiac services may have been an effective one in the past, with the
increasing subspecialisation of paediatrics generally, and of paediatric
cardiology, and paediatric cardiac surgery in particular, this model of care is
outmoded, does not produce ideal patient outcomes, is potentially dangerous,
and is an inefficient use of scarce resource. Moreover, the current model has
serious implications for the training of paediatric intensive care physicians,
paediatric cardiologists, and paediatric anaesthetists in Queensland. The
sustainability of the current setup for tertiary paediatric care, including cardiac
services, is in serious question.
The Review Panel carried out an extensive, statistical comparison of 30 day
survival rates of children having cardiac surgery at TPCH and the Starship
Hospital in New Zealand. We found a trend for higher death rates at TPCH.
However, because numbers are small, the power to detect differences is poor,
confidence intervals are wide, and consequently these differences did not
reach statistical significance. Stated simply, these differences could be
explained by chance, rather than a true difference in death rates.
The Review panel uncovered major problems of dissatisfaction and low
morale in many disciplines and at many levels within TPCH paediatric cardiac
service. However, we found no evidence of professional incompetence nor
negligence among the responsible clinicians. Our major concern is that the
current model is unsustainable. The existence of three Paediatric Intensive
Care Units (PICUs), and two tertiary children’s hospital (neither of which has
any real experience with cardiac conditions in infants and children) is illogical
for both optimal service and training. It is simply impossible to adequately staff
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three PICUs in Brisbane. Moreover, the present system means gross
underutilisation of all three PICUs, despite the huge expense of staffing these
three units. There is a major shortage of paediatric cardiologists in
Queensland, and because of this shortage, it is not possible to train the next
generation of paediatric cardiologists in this state. Because of the
fragmentation of PICUs, the Joint Faculty of Intensive Care Medicine, which
oversees training, does not recognise Queensland PICUs as adequate sites
for advanced training – meaning Queenslanders cannot complete their
training in this state. This situation must not continue.
We recommend an obvious solution. Namely, that Queensland needs to
construct a single, integrated, purpose built, new Queensland Children’s
Hospital (QCH) in metropolitan Brisbane. Once commissioned, the existing
children’s hospitals would close and all their resources would be consolidated
into the new, well resourced QCH. Paediatric cardiac services would move
from TPCH to the new QCH, and all paediatric cardiac surgery at TPCH would
cease. To achieve this goal within five years, a strong commitment from the
Government is required, and planning for the new Queensland Children’s
Hospital should commence immediately.
Interim measures will need to be put in place immediately to achieve safe and
effective paediatric cardiac services at TPCH. In addition, steps needs to be
taken to achieve adequate training of medical, nursing and allied health staff
at the two children’s hospitals in all aspects of paediatric cardiology and
cardiac surgery, prior to opening the new cardiac service at the new QCH.
The Review Panel has made a number of recommendations for both the
short-term and long-term care of infants and children with cardiac disease in
Queensland. The report details the reasons for each of our areas of concern,
followed by our specific recommendations.
6
BACKGROUND
HISTORICAL DEVELOPMENT OF CARDIAC SERVICES AND TERTIARY PAEDIATRIC SERVICES IN QUEENSLAND
Cardiac surgery and associated services developed some 50 years ago at the
Chermside Hospital (now The Prince Charles Hospital, TPCH), which had
been built as a chest hospital for tuberculosis patients. That centralised
service developed into a successful department enjoying an excellent
reputation for clinical services and outcomes. Research was of high quality
and world-wide importance. Their high quality audit and development of a
computerised database set the standard for Australia.
In the early years of cardiac surgery, diagnosis and surgical treatment of
congenital heart disease were a major component of all cardiology and
cardiac surgery. However, from the 1970s onwards the growth in cardiac
valve surgery, and subsequently, coronary artery surgery resulted in adult
cardiac surgery dominating cardiac surgery from the point of view of caseload,
numbers of specialists involved and expense. Meanwhile paediatric cardiology
and cardiac surgery made rapid advances in complexity, especially in the very
young. Many babies born with congenital heart disease were soon treated by
curative rather than temporary palliative procedures, and results of surgery
steadily improved.
Over the past two decades paediatric cardiac services, has evolved in many
ways:
• Specialist paediatric cardiologists and cardiac surgeons have
concentrated increasingly, often exclusively, on paediatric work.
• In most large centres paediatric work has totally been separated from
adult work, and done increasingly in dedicated paediatric cardiac units.
• With very few exceptions these paediatric cardiac units have been
developed within tertiary paediatric hospitals to take advantage of:-
7
o Availability (‘on site’) of highly trained, experienced, specialist
paediatric anaesthetists and paediatric intensive care
physicians. This enables high quality intra- and post-operative
care of infants and children undergoing cardiac surgical
procedures.
o Ready availability of ‘on site’ paediatric colleagues skilled in
associated non-cardiac paediatric medical and surgical
specialties, including paediatric respiratory physicians, paediatric
neurologists, paediatric nephrologists, and paediatric surgeons.
o Specialist Paediatric Nurses skilled in the many extra aspects of
caring for sick infants and children.
o ‘On-site’ availability of paediatric trained allied health staff, and
special therapies specifically designed for children. Particularly
paediatric physiotherapists, paediatric occupational therapists,
and paediatric play therapists.
o Dedicated paediatric intra- and post-operative equipment,
designed specifically for use in neonates, infants and children.
• Tertiary paediatric hospitals afford significant non-clinical advantages of
an administrative, sociological and political nature:
o Discretionary funding is generally more liberal within a paediatric
institution, and competition within and between hospitals for
resources is avoided. This is particularly important in the fields of
cardiology and cardiac surgery where procedures are similar in
the adult and paediatric areas, but costs, volumes, and
outcomes are entirely different.
o Charitable donations are more easily attracted for paediatric
patients.
o In a paediatric hospital there is no need to repeatedly justify the
special needs of sick children and the cost structure inherent in
their treatment. This is an agreed and powerful element of the
paediatric hospital ethos.
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• Increasing sub-specialisation within paediatric cardiology has
introduced further refinements in diagnoses, including:
o paediatric electrophysiology
o paediatric CT and MRI
o fetal cardiology including fetal echocardiography
o interventional cardiology
• As results have continued to improve so have public expectations. This
is not peculiar to cardiology, but reflects current societal values.
Occasional failure to achieve perfect diagnosis or a healthy patient
after surgery is less likely to be accepted as a normal (or expected
outcome) than in the past. The current indemnity problems aggravate
these expectations, while media attention often fails to celebrate
success - but is ever ready to seize upon perceived failure.
QUESTIONS LEADING TO THE CURRENT ENQUIRY This current Review was commissioned as a result of the following:
• There have been several previous attempts to address the divergent
views between those who believe that all tertiary services should be at
a single location (recognising that children with cardiac problems often
have other associated medical complications, and children with other
medical problems often require cardiac review and investigations) and
those who believe that all cardiac services should be concentrated in
one location (to increase the team functioning and communication, and
where all cardiac backup and services are readily available).
• Following the death of a child at the RCH with cardiac tamponade, a
Coroner made a recommendation that Queensland Health consider the
best approach to delivery of specialist paediatric services - particularly
cardiac services - to the children of Queensland.
(www.justice.qld.gov.au/courts/coroner/findings.htm)
9
• The recent Forster Report stated (p.157): “The duplication of expensive
tertiary paediatric sub-speciality services at both the Royal Children’s
Hospital and the Mater Children’s Hospital did not appear to be a
sustainable model. Rationalisation is recommended to improve
services sustainability, maximise available resources and reduce
pressure on staff currently experiencing onerous on-call
arrangements”. A specific recommendation in the Forster Report (7.20)
stated: “The development of tertiary paediatric sub-speciality services
should be reviewed”. (Reference: http://www.healthreview.com.au/
Health Systems Review Final Report - September 2005, Peter Forster).
• Queensland Health’s commitment (2005 Action Plan) to building a
better health service for Queensland.
There has been concern about recent paediatric surgery outcomes achieved at
TPCH, particularly following a sequence of deaths after the Norwood procedure
for palliation of Hypoplastic Left Heart Syndrome (HLHS), including six of the
seven patients operated on in 2003 through 2005. Currently there is a
temporary suspension of the Norwood procedure in Queensland pending
revision of treatment protocols. A decision is now needed to decide whether this
high risk procedure should continue in Queensland. A study was recently
undertaken to compare the outcomes of Norwood procedures achieved by the
TPCH and the Royal Children’s Hospital (Melbourne). (Sharples L. “Comparison
of outcomes for Norwood procedures for The Prince Charles Hospital and the
Royal Children’s Hospital, Melbourne,” 2005).
• While the Sharples study found that patient outcomes were “not
statistically significantly different”, the low number of cases meant a
substantial lack of statistical power to detect any differences.
Therefore, the results were not definitive. Regardless, the clinicians at
TPCH decided to stop operating on children with HLHS. At present,
families from Queensland with a child requiring a Norwood procedure
10
have to relocate to Melbourne for their child’s surgery.
The recent cluster of deaths at TPCH after staged surgical palliation of Hypoplastic
Left Heart Syndrome (by the “Norwood Operation”, and subsequent “Hemifontan” or
“Fontan” operations) has aroused further concern surrounding paediatric cardiac
services at TPCH.
More generally, however, this cluster of Hypoplastic Left Heart Syndrome
(HLHS) deaths has again drawn attention to numerous broader concerns
about the adequacy, effectiveness, efficiency and sustainability of the current
Queensland paediatric cardiac services. Particularly given its atypical
configuration and its isolation from other paediatric subspecialty services. In
some respects these recent deaths are a warning signal of possible
underlying systemic problems at TPCH re paediatric surgery.
It is crucial to closely examine the recent deaths following surgery for HLHS.
The Norwood Procedure is but the first of a sequence of palliations for the
HLHS. This is a very important distinction, as is the timing of deaths after
these procedures. The Review Panel are aware of only 3 of 19 consecutive
patients whose deaths might have been directly due to perioperative causes
related to surgery. The late deaths (7 of the 16 early survivors of HLHS)
occurred at varying times, and in various modes suggesting a number of
separate causes. Thus it is more appropriate these are referred to as “HLHS
deaths”, rather than “Norwood” deaths.
The cluster of HLHS recent deaths needs to be placed in perspective, and is
elucidated clearly in an internal TPCH report , which we summarise verbatim
here:
“Of the 4 deaths (of 12 operations) in the first cohort, 2 deaths were in patients
with high pre-operative risk (supra-systemic pulmonary hypertension and low
birth weight & poor right ventricular function - unclear whether this was
present pre-op). One death occurred in the community following a febrile
illness and the other probably was related to acute bronchopneumonia.
11
In the second cohort, of the 6 deaths (of 7 operations), the 2 early deaths
were in very high risk patients, both with ascending aorta < 2.5mm. This
raises the question of use of exclusion criteria. Two later deaths were
expected and resulted from right ventricular failure; in one mediastinitis after
the Glen procedure probably contributed. The remaining two deaths occurred
in the community after febrile illnesses, raising questions about follow up of
these patients prior to the second stage of surgery.”
In summary, although there were seven consecutive deaths in patients
operated on with HLHS from December 2002 to January 2005, these deaths
occurred at periods ranging from 0 to 198 days post surgery.
While our comparison study between TPCH and Auckland found patient
outcomes were “not statistically significantly different”, the low number of
cases meant poor statistical power to detect any differences. Therefore, the
results were not definitive. It is the view of the Review Panel that the Norwood
procedure should not be performed in Queensland, at least until a properly
staffed Paediatric Cardiac Service has been established at TPCH, and
independently administered (for example via the RCH). Even then, any
decision to perform the Norwood procedure in Queensland should take into
account the evidence that mortality may be lower in centres that do the
operation more often. In a study in the United States, mortality was 60% in 16
centres doing less than 6 procedures a year, and 45% in 5 centres doing
more than 14 procedures a year (Gutgesell HP, Massaro TA. “Management of
hypoplastic left heart syndrome in a consortium of university hospitals”. Am J
Cardiol 1995;76:809-11). On present figures, Queensland is unlikely to do
more than 6 Norwood operations per year.
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TERMS OF REFERENCE
1. To specifically review the adequacy of paediatric cardiac services in Queensland including but not limited to: a. The health outcome of children with congenital and acquired heart disease
with reference to both cardiac and general paediatric aspects of health.
b. The adequacy of paediatric cardiology services in Queensland.
c. The adequacy of support services for paediatric cardiac interventions
including anaesthesia, intensive care, extracorporeal support, medical
imaging, nursing and allied health, as well as consultative support from
paediatric medical and surgical subspecialties.
d. The outcome of paediatric cardiac interventions both overall and within
different risk groups using, wherever possible, outcome data benchmarked
against data from other national and/or international centres factoring
casemix.
e. The optimal configuration of paediatric cardiac services with consideration
given to the geography of Queensland.
2. To make recommendations in respect of: a. Any appropriate improvements in the system of service provision necessary
to ensure the high quality health care for Queensland children with
congenital or acquired heart disease over the next 10 – 20 years.
b. The need for administrative and geographic reorganisation of services to
ensure best practice health care for children.
13
c. Improvements in the system at present, and over the next 2 – 5 years. This
will include recommendations for any organisational improvements in the
following subspecialties with the aim of ensuring present and future delivery
of high quality, sustainable, and cost effective services:
i.) Paediatric cardiac surgery
ii.) Paediatric cardiology
iii.) Paediatric intensive care
iv.) Paediatric anaesthesia
v.) Paediatric allied health services
d. The need for organisational improvements in the systems of providing
paediatric research, education and training across medical, nursing and
allied health disciplines.
e. The intensive care infrastructure required to establish an extracorporeal
circulatory support service with reference to nursing, medical and
perfusionist staff numbers, education, training and skill maintenance.
f. The advisability of centralising selected high risk paediatric cardiac surgery
procedures to a single Australian centre.
g. Appropriate implementation strategies for system improvements or re-
organisation.
METHODOLOGY OF CURRENT REVIEW
The Director-General of Queensland Health, Ms Uschi Schreiber,
commissioned the Paediatric Cardiac Services Review on the 31st August,
2005.
A Project Officer was appointed to coordinate the Paediatric Cardiac
Services Review.
14
The initial Terms of Reference were drafted to investigate the current
paediatric cardiac service, including both the cardiology and cardiac surgery
components of the service. When the Review Panel met via teleconference
for the first time, it was thought that the Terms of Reference were too broad
and unlikely to be achievable in the limited time allocated for the Review. The
Terms of Reference were revised to focus on cardiac surgery and circulated
to the key clinical stakeholders for comment. However, there was an
overwhelming demand by local stakeholders to revert back to the original
Terms of Reference, and this request was agreed by the Review Panel.
A Call for submissions was sent out to key stakeholders and all Queensland
District Health Areas inviting interested parties to respond in writing to the
Terms of Reference.
A Review Panel Advisory Group was established to assist the Paediatric
Cardiac Services Review Panel to understand the Queensland Health
Paediatric Cardiac Service as it currently operates. This role was created:
• To provide information on areas of the current and future Queensland
Health paediatric cardiac service regarding particular issues or data, if
requested by the Paediatric Cardiac Services Review Panel.
• To participate in data collection, if requested by the Paediatric Cardiac
Services Review Panel.
• To distribute the Call for Submissions and Qld Health Paediatric
Cardiac Services Review Terms of Reference as widely as possible so
key stakeholders have an opportunity to submit a written response
within the given timeframe.
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COMPOSITION OF REVIEW PANEL
Invitations were issued to internationally recognised specialists who were
experts in the fields of paediatric cardiology, paediatric cardiac surgery,
paediatric intensive care and biostatistics to participate as members of the
Review Panel. The Review Panel membership included:
Prof. Craig Mellis (Chair) –Associate Dean and Head, Central Clinical School,
Faculty of Medicine, University of Sydney, Sydney, NSW
Prof. Frank Shann – Director, Paediatric Intensive Care Unit, Royal Children’s
Hospital, Melbourne, Victoria
Prof. Annette Dobson – Biostatistician, School of Population Health, University
of Queensland, Queensland
Prof Tim Cartmill AO - Paediatric Cardiac Surgeon, NSW
Dr Tom Gentles – Clinical Director, Paediatric and Congenital Cardiac
Service, Starship Children’s Hospital, Auckland, New Zealand
Although the project was managed by the Central Area Health Service, due to
the state-wide nature of paediatric cardiac services, every Queensland Health
District Manager was notified of the Review via email and asked to
disseminate the Call for Submissions to all health professionals within their
district.
METHOD OF CONSULTATION
Interested parties had the opportunity to respond to the Call for Submissions
and/or request an interview (or teleconference) with the members of the
Review Panel.
Invitations to respond to the Call for Submissions were sent to the Review
Panel Advisory Group, Queensland Health District Managers, various
Indigenous and Torres Strait Islander groups, consumer groups, Australian
Medical Association (Queensland branch) and Queensland Division of
General Practice. These groups were asked to disseminate the Call for
16
Submissions as widely as possible to ensure the key stakeholders had an
opportunity to participate in the Review consultation process.
A total of 37 submissions were received in response to the Call for
Submissions, and these represented the major consumer groups and
clinicians involved in delivering or receiving paediatric cardiac services.
Members of the review panel read the submissions in preparation for the four
day on-site review period.
Site visits were made to The Prince Charles Hospital (twice), Mater Children’s
Hospital and the Royal Children’s Hospital (a brief summary of these hospital
visits is attached below as Appendix 2). All interviews were conducted during
the four day Review period, either at the hospital site visits, or at the
Queensland Health offices in Herston. This allowed the panel to clarify
opinions expressed in written and verbal submissions and to directly elicit
further information about the current service, including the quality, strengths
and weaknesses, and to canvass responses to our suggested
recommendations.
Unfortunately, the Review Panel was made aware of some difficulties in
process encountered by some key stakeholders. Some line managers did not
distribute the review information as intended. Consequently, some of the key
groups were not made aware of the Review until the week preceding arrival of
the Review Panel in Brisbane. However, on completion of the Review week,
the Review Panel felt that all key groups had access and the opportunity to
submit their views either in writing or at interview.
ACKNOWLEDGING THE CONTRIBUTIONS OF STAKEHOLDERS
As mentioned above, thirty-seven submissions were received and all were
relevant and of high quality. The committee was received courteously at The
Prince Charles Hospital (TPCH), Mater Children’s Hospital (MCH) and the
Royal Children’s Hospital (RCH), and we express our thanks to management
17
and staff members who gave freely of their time and expertise to help our
deliberations.
DECISION NOT TO IDENTIFY THE CONTRIBUTING PARTIES
Due to the highly sensitive nature of this Review, issues of confidentiality and
privacy are paramount. Therefore, all names have been purposely omitted
from this Report to protect the identity of individuals who made submissions
and/or met with the Review Panel.
REVIEW PANEL FINDINGS AND RECOMMENDATIONS
The Panel found the Queensland paediatric cardiac services to be in an
unsatisfactory and unsustainable condition. The service is characterised by
chronic understaffing, dysfunctional governance, lack of infrastructure, lack of
clinical leadership, and unsympathetic line managers regarding specific
paediatric needs. With few exceptions morale is poor, ranging through
frustration and anger to cynicism, hopelessness and despair. It is abundantly
clear that systems and arrangements, which had been satisfactory in the past,
are no longer able to meet current expectations and standards.
However, the Review Panel must point out that it is remarkable that clinicians
(surgeons, physicians, nurses, and allied health staff), through very hard work
and goodwill, have risen to these mounting challenges, and in the main,
continue to render a high level of patient service. Indeed, it was clear to the
Review Panel that, overall, patients and their families, and the broader
medical community continue to hold the service in high regard.
Nevertheless, 30 day mortality rates were consistently higher at The Prince
Charles Hospital than for similar patients at Starship Hospital in Auckland
(across all levels of severity and omitting patients receiving Norwood-type
procedures). Although there was a trend for higher death rates at TPCH, the
18
difference was not statistically significant, due to the small numbers of patients
included in the analysis, and is consistent with chance.
WHAT WAS NOT FOUND
The Review Panel found no evidence of professional incompetence,
professional incapacity, or negligence among the responsible clinicians. On
the contrary, the current senior staff are well trained, generally well
experienced, and held in high repute by their peers.
FRAGMENTATION AND CASELOADS
The current fragmentation of the three tertiary paediatric services between
The Prince Charles Hospital, The Royal Children’s, and the Mater Children’s
Hospital has unfortunate and on-going consequences for the children of
Queensland. For example, attempting to adequately staff three high quality
PICUs in a city the size of Brisbane is illogical, dangerous, expensive and
unsustainable. The present situation makes it impossible to provide paediatric
services at an optimal standard, greatly increases cost, impairs training of the
next generation of paediatric clinicians (particularly in Intensive Care and
Anaesthesia), and makes high-quality research difficult – if not impossible.
The definitive solution to the problem of providing high class health services to
the children of Queensland is obvious – but politically difficult. Namely, the
establishment of a single, tertiary Queensland Children’s Hospital.
Recommendation 1
Historical and current fragmented tertiary paediatric services should be subsumed into a single, purpose built new Queensland Children’s Hospital. Ideally, this facility should be situated adjacent to a major Adult Teaching Hospital, that provides all medical and surgical specialties, and in close proximity to a major Obstetric Unit.
19
The ideal site for such an institution should be determined by a local
committee of key Queensland stakeholders. The Review Panel did not see
the ideal site of this new Queensland Children’s Hospital as part of our brief.
However, we do suggest, as a matter of some urgency, the Director-General
of Health establish a ‘Planning Group’ to examine possible options for such a
facility. Broadly, our Panel considered the following options; on the site of one
of the existing Children’s Hospitals (RCH or MCH); on TPCH campus; or an
appropriate ‘greenfield’ site. Inherent in such a plan is the subsequent closure
of the three existing tertiary paediatric facilities (RCH, Mater Children’s, and
paediatric facilities at TPCH), once this new Queensland Children’s Hospital is
commissioned.
Recommendation 2
The Queensland Children’s Hospital should serve as the hub of a state-wide network of paediatric services, with responsibility for all sick children in Queensland and all tertiary paediatric care for the state, including cardiac services.
ESSENTIAL INTERIM MEASURES
Even if a definite decision was made today, it will take at least four to five
years to plan and build an appropriate, new tertiary paediatric hospital to
serve the needs of the children of Queensland for the next 15-20 years.
Consequently, urgent interim measures are required to support the delivery of
existing cardiac services to children at The Prince Charles Hospital during this
difficult period. Morale is very low among many of the key staff delivering
cardiac services to children in Queensland. If morale continues to deteriorate
there will be an increasing risk of adverse events including total system
failure. The following two issues are addressed with urgency: First, an
unequivocal commitment from the Queensland Government that inpatient
cardiac services will be moved to a purpose-built, single, central tertiary
Queensland Children’s Hospital as soon as practicable; and second,
20
immediate steps are taken by Queensland Health to improve the existing
service and the care of children with congenital heart disease at TPCH.
Recommendation 3
In the interim (while awaiting the building of a Queensland Children’s Hospital), and in preparation for this definitive model, existing services require reinforcement. This will require substantial additional medical, nursing and allied health staff, more paediatric beds, strengthened outreach capabilities, and a dedicated structure of governance clearly aligned with current paediatric structures and clearly distinct from adult cardiac services. Detailed planning of optimal interim manpower requirements should be undertaken immediately. A key ingredient will be to ensure the current triplication of Paediatric Intensive Care Units is supported by all involved in the current ‘roster’ system via the Queensland Paediatric Intensive Care Service (QPICS).
Recommendation 4
The new paediatric intensive care facility and paediatric ward currently planned for Prince Charles Hospital should not be built. The number of paediatric beds planned are fewer than the number currently available, and the money allocated for this should be put towards the cost of the new tertiary children’s hospital.
PROBLEMS WITH CARE OF CARDIAC INFANTS AND CHILDREN IN A TERTIARY ADULT HOSPITAL
The current cardiac service arrangements reflect the historic centralised care
of adults and children with Heart disease in Queensland. This arrangement is
no longer consistent with best paediatric practice worldwide. The recent shift
of all paediatric cardiac services in New Zealand from Green Lane Hospital,
and adult chest and cardiac hospital to the Starship Children’s Hospital is a
21
clear example of what is now required in Queensland to optimise service
configuration. It is acknowledged that there are some valid countervailing
arguments, notably relating to concentration of cardiac technical expertise,
and the value of continuity of cardiac care “from cradle to grave”. Although
some significant institutions around the world follow this model, almost all are
collocated adjacent to a major paediatric hospital. It is overwhelmingly held
that the best interests of the child trump all other arguments. In short, infants
and children with serious illnesses (including cardiac disease) are best cared
for in a tertiary Children’s Hospital. This point was made very clearly in the
Bristol Enquiry, “Learning from Bristol: the report of the public inquiry into
children’s heart surgery at the Bristol Royal Infirmary 1984-1995, Command
Paper CM5207”. To quote directly from page 422 of that report: “The optimal
arrangement for children’s acute hospital services is that they be located in a
children’s hospital. Ideally, the children’s hospital should be physically as
close as possible to, but separate from, an acute general hospital.”
(http://www.bristol-inquiry.org.uk/final_report/rpt_print.htm. This point is also
listed under recommendations: numbers 177-183, although
recommendations: numbers 184-186 are also highly pertinent to the current
report (page 459-460).
Children with cardiac disease often have, or acquire, serious non-cardiac
conditions or complications. Similarly, children in a children’s hospital
frequently require the services of a paediatric cardiologist, or a cardiac
surgeon. Separation of the patients on the basis of diseased organs (or
systems) is a major deficiency in the present arrangements in Queensland.
For example, at present, when a paediatric specialist respiratory physician
from one of the two tertiary Children’s Hospitals is asked to consult on
children at TPCH the request is dealt with on a goodwill or grace and favour
basis, rather than any systematic, ‘on-call’ roster system. Alternatively, sick
children are shuttled from hospital to hospital during various phases of their
treatments, a costly exercise and a potent opportunity for errors and poor
outcomes, plus a source of extreme frustration, confusion and cost for
families. (Kanter RK, Boeing NM, Hannan WP, Kanter DL. “Excess morbidity
associated with interhospital transport.” Pediatrics 1992;90:893-8; and,
22
Hellstrom-Westas L, Hansens K, Jogi P, Lundstrom NR, Svenningsen N.
“Long-distance transports of newborn infants with congenital heart disease.”
Pediatric Cardiology 2001;22:380-4.) Both options are clearly unsatisfactory.
Recommendation 5
As a statement of principle, and in any definitive planning for Queensland, children with heart disease requiring tertiary care should be cared for in the new Queensland Children’s Hospital.
GOVERNANCE
Present reporting structures whereby staff treating children report to non-
paediatric heads of department disempowers staff and sets the stage for
inequitable resource utilisation, poor staff morale and system failure. While the
recent appointment of a Director of Paediatric Cardiac Services goes some
way to addressing this issue, governance remains inadequate. The Director of
the Paediatric Cardiac Services reports to the Director of Adult Cardiology –
while this relationship has been described as one of mentoring, such
paternalistic sentiments are common in combined adult/paediatric
environments and inevitably result in infrastructural deficiencies (in the
broadest sense) and under-resourcing of the lower volume, higher cost
paediatric service. These deficiencies are readily apparent at TPCH and are
likely to continue in the absence of organisational and financial independence
of the paediatric infrastructure.
It was apparent, from staff interviews, that the adult department had little
understanding of the core business of the Paediatric Cardiac Service and that
there were significant interpersonal issues that would further undermine any
working relationship. It was also clear that the Director of Paediatric Cardiac
Service had insufficient time available to manage the department effectively,
given his very large clinical workload.
23
PAEDIATRIC CARDIAC SURGERY Existing paediatric cardiac surgeons should be recognised as a distinct sub
department of Paediatric Cardiac Services with a designated head. There are
distinct advantages to reporting through the head of Paediatric Cardiac
Services (who could be a cardiologist or cardiac surgeon) - a separate
reporting structure would detract from a cohesive service-driven planning and
is likely to make a small group vulnerable and potentially dysfunctional. Many
successful Paediatric Cardiac Services have a combined cardiology/cardiac
surgery administration to facilitate optimal service organisation and resource
utilisation. The head of paediatric cardiac surgery would be responsible, in
collaboration with the head of Paediatric Cardiology, for development of
surgical protocols, audit, research, as well as for Post graduate training of
Registrars and fellows in the specialty.
PAEDIATRIC CARDIAC NURSING Nurses working in paediatric cardiac wards, clinics, ICU and OT should be
designated within a recognised Paediatric Nursing Unit. The head of this unit
should report ultimately to Hospital management. In selected cases, rotations
and educational exchanges should be fostered between PCH and the Mater
and Royal Children’s Hospitals.
Recommendation 6
Governance structures must reflect paediatric cardiac services as a separate identity, independent of and distinct from adult cardiac services. Wherever possible these structures should delineate funding and management for paediatric cardiac services that is separate from their adult cardiac counterparts. This separation of finance and management foreshadows future arrangements, in which paediatric cardiac services will be unified with other paediatric services in the new Queensland Children’s Hospital.
Devising suitable governance models and financial and administrative
arrangements for the interim will be challenging.
24
One option is to take immediate steps to establish an integrated paediatric
cardiac program, to include all staff who currently treat cardiac problems in
children. Reporting could be centralised through existing administrative lines
at the Royal Children’s Hospital, and with quarantined funding (as a separate
tranche from Queensland Health) provided through the Royal Children’s
Hospital (RCH).
We suggest this interim measure because we found clear evidence that the
administration of TPCH has failed to recognise serious deficiencies in
paediatric services in their hospital for the past decade, despite strong
advocacy from the clinicians. This is a direct consequence of having a tertiary
paediatric service sited in an adult hospital. Therefore, in addition to
developing independent governance at departmental level, it is recommended
that the administration of the Royal Children Hospital assume administrative
responsibility for Paediatric Services at TPCH as soon as possible.
Using the RCH in this way during this interim period, rather than the Mater
Children’s hospital, is recommended to avoid logistic issues related to the
Mater Children’s Hospital being ‘outside’ the jurisdiction of Queensland
Health.
Wherever possible any new structural arrangements should delineate
separate funding and management for paediatric cardiac services separate
from their adult cardiac counterparts.
Ideally, a local ‘governance’ committee, with representation from key
stakeholders, should be established immediately to determine the most
suitable interim governance model.
25
Recommendation 7
As an interim measure, paediatric cardiac staff and structures at the TPCH will need to be substantially increased in numbers, skills, and formal attachments to existing paediatric hospitals. Those staff members who elect to follow a paediatric career should be clearly recognised as paediatric specialists, with their own departments, answering to their own hierarchy of management. These arrangements are specifically intended to create a paediatric cardiac “staff in waiting”, in preparation for the definitive move to the new Queensland Children’s Hospital.
Recommendation 8
Immediate steps should be taken to provide an integrated paediatric cardiac program, with all staff currently treating children, reporting to the Royal Children’s Hospital, and additional funding from Queensland Health provided through the Royal Children’s Hospital.
Recommendation 9
All existing and future inpatient, outpatient and outreach paediatric cardiac services should be incorporated as integral parts of the new Queensland Paediatric Network, to clarify and define these services as part of the overall care of children. Recommendation 10 Specific arrangements will need to be developed to accommodate those patients with congenital heart disease who have grown to adulthood. Various models exist for this transition from paediatric to adult care. Whether selected adult cardiac and non-cardiac specialists are cross accredited to the new Queensland Children’s Hospital, or some (or all) Queensland Children’s hospital staff are accredited to selected adult
26
hospitals, will need to be determined locally according to need and opportunities.
Managing the transition from the present while controlling the emotional
political and nostalgic grip of the past will rely heavily on the force and
credibility of the vision for a much better future in the new Queensland
Children’s Hospital. However, there must be no perception that this enhanced
transitional arrangement could be hijacked into a tolerable long term solution
at TPCH.
Recommendation 11 The enhanced transitional arrangements must not be seen as a tolerable long term solution.
QUALITY MONITORING
The Review Panel found that mortality and morbidity reviews were not
conducted regularly at The Prince Charles Hospital in a manner that involved
all clinical disciplines. This appears to be both caused by and to have
contributed to lack of adequate communication among the various
professional groups involved in patient care. There did not appear to be
mechanisms for implementing and evaluating protocols to standardise or to
change clinical practice.
There are local clinical databases at TPCH from which reports are produced
(e.g. Annual Reports on Cardiac Services at The Prince Charles Hospital) and
contributions are made to the ANZ Paediatric Intensive Care Registry.
However the Review found that much of this information was not readily
useable for benchmarking against other institutions or for comparison with
other routinely collected data.
Recommendation 12
27
Quality monitoring activities data should be collected and regularly analysed on all paediatric cardiac inpatients (surgical and non-surgical). (Reference: “Monitoring Clinical Performance: a statistical perspective.”
Spiegelhalter et. al., & based on the Bristol Royal Infirmary Inquiry Report
http://www.bristol-inquiry.org.uk/final_report/rpt_print.htm)
Specific issues that need to be addressed are as follows:
i) Data on diagnoses and procedures should be coded using
internationally recognised systems to facilitate future benchmarking
against other institutions.
ii) Clinical databases should regularly be reconciled against the
official hospital morbidity records (which are used for resource
allocation) to improve the quality and credibility of both data
collections. This should be done electronically according to a protocol
for mapping codes to reduce need for clinical reconciliation to
complex cases only.
iii) These clinical databases should be regularly reconciled against
Queensland mortality records to ensure all deaths are included on the
databases (Queensland Health, Health Information Centre can
undertake the record linkage).
iv.)To be effective, performance monitoring data needs to yield
results that are understandable and credible for clinicians and are
epidemiologically and statistically valid. An appropriate system should
be established and monitored with clinical and statistical input.
28
STATISTICAL DATA ANALYSIS: METHODOLOGY AND RESULTS
For the present Review, it was decided to examine mortality rates, not just for
severe cases with a poor prognosis, but for all patients undergoing cardiac
surgery at The Prince Charles Hospital over a five year period. Outcomes
over the full spectrum of severity were compared with similar data for the
Starship Children’s Hospital, Auckland. This analysis provides a better
indicator of the overall quality of performance and has greater statistical power
to detect a significant difference in outcome in another hospital with some
similar features to The Prince Charles Hospital.
The outcomes for patients receiving Norwood-type procedures at The Prince
Charles Hospital has previously been reviewed and use of the procedure has
been suspended. Therefore to ensure that comparable data were analysed
from The Prince Charles Hospital and Starship Hospital, all patients receiving
Norwood-type procedures were excluded from both centres.
To take account of possible differences in case mix (that is, differences in
severity between the two hospitals), risk adjustment was used based on the
RACHS-1 classification (Jenkins et. al, Journal of Thoracic Cardiovascular
Surgery 2002; 123: 110-8).
The records for the analysis were as follows:
• Each hospital admission which included cardiac surgery for repair of
congenital heart defects among children less than 16 years.
• For The Prince Charles Hospital, admissions for children living outside
Queensland were excluded because completeness of ascertainment of
death could not be quickly achieved.
• Exclusions were: patients with Norwood type procedures; the exclusion
categories listed by Jenkins et al (op. cit.); patients undergoing surgery
for rheumatic heart disease; procedures for patent ductus arteriosis
29
undertaken in neonatal units; and any other procedures that could not
be categorised by the RACHS-1 classification.
• The outcome was mortality within 30 days of the date of the first
operation within the admission.
For patients with multiple admissions only the most recent admission was in
the analysis. The analysis was performed using Stata 9.
The main results of the comparison between outcomes for The Prince Charles
Hospital and Starship Children’s Hospital, Auckland are shown in Table 1.
Table 1. Number of patients and deaths within 30 days of surgery categorised using the RACHS-1 risk classification
The Prince Charles Hospital
Starship Hospital
RACHS-1 category
Number of patients
Deaths within 30 days
% deaths
Number of patients
Deaths within 30 days
% deaths
Mortality rate ratio
1 246 2 0.81 153 1 0.65 1.242 409 6 1.47 452 5 1.11 1.333 332 14 4.22 403 11 2.73 1.544 40 6 15.00 114 8 7.02 2.145 0 0 - 3 0 0 -
6 9 4 44.44 3 1 33.33 1.33
The case mix (distribution of cases by RACHS-1 categories) was slightly
different between the two hospitals with The Prince Charles Hospital having
relatively fewer high risk cases. However, the mortality rate was higher at The
Prince Charles Hospital for all categories of risk. The Mortality Rate Ratio
(MRR) estimate for The Prince Charles Hospital compared to Starship,
adjusted for risk using the Mantel-Haenszel method, was MRR= 1.58 (95%
confidence interval 0.93 – 2.67). Although this suggests a higher mortality rate
at The Prince Charles Hospital, the difference is not statistically significant. In
view of the wide 95% confidence interval, the true difference could be very
small and favouring TPCH (MRR= 0.93), to a large difference favouring
Auckland (MRR= 2.67).
30
Stated simply, these differences could be explained purely by chance.
Moreover, as the analysis was retrospective, exact comparability and
completeness of the data remains uncertain. Consequently this
“benchmarking” has produced a non-definitive result. Nevertheless, it does
indicate the need for future high quality prospective data collection and regular
“benchmarking” of results between centres.
CARDIOLOGY: SPECIFIC FINDINGS AND RECOMMENDATIONS
At present, paediatric cardiology in Queensland is provided by a total of 3.8
FTE paediatric cardiologists. The service covers a vast geographical area and
provides inpatient and outpatient consultation to the two children’s hospitals in
metropolitan Brisbane, foetal cardiology services at the Mater Women’s
Hospital, an outreach service to the remainder of Queensland, as well as core
activities at The Prince Charles Hospital. These core activities include pre-
operative assessment, outpatient services, peri-operative and intra-operative
echocardiography, electrophysiology and diagnostic and interventional cardiac
catheterization, and cardiac MRI and CT.
British and European guidelines recommend one paediatric cardiologist per
500,000 population. Current paediatric cardiologist numbers in Queensland
fall well short of this recommended staffing level.
(References: Report of the Paediatric and Congenital Cardiac Services
Review Group United Kingdom December 2003
(http://www.advisorybodies.doh.gov.uk/childcardiac/), Daenen W, Lacour-
Gayet F, Aberg T, Comas JV, Daebritz SH, Di Donato R, Hamilton JR,
Lindberg H, Maruszewski B, Monro J; EACTS Congenital Heart Disease
Committee. Optimal structure of a Congenital Heart Surgery Department in
Europe, Eur J Cardiothorac Surg. 2003 Sep;24(3):341-2.
(http://www.ctsnet.org/file/OptReqCHS28April2003.pdf)
31
Recommendation 13
Given the rapidly increasing population in Queensland, the servicing of the population of northern New South Wales, the widely dispersed population demographics outside the major metropolitan area, and the high incidence of rheumatic heart disease in the Indigenous population, the number of paediatric cardiologists needs to be increased to a minimum of 9.0 FTE over the next five years.
It is not possible to provide an adequate service with the currently available
paediatric cardiologists. Indeed, it is a tribute to the individuals involved that
this service has been delivered with the current volumes and high quality.
However, the sustainability of this service with existing paediatric cardiologist
numbers is now under threat from overwork and burn-out.
Clearly, the current system inevitably results in multiple deficiencies of service
delivery, including extreme dependence on a small number of individual
overworked cardiologists, for essential aspects of paediatric cardiac care.
Deficiencies can be broadly categorised as:-
• Those within The Prince Charles Hospital
o Preoperative assessment
o Intraoperative imaging
o Post operative ICU consultation
• Those within the Brisbane children’s hospitals and women’s hospitals
o Foetal cardiology
o consulting newborns with suspected heart disease in the
neonatal intensive care units
o consulting paediatric inpatients with multiple co-morbidities
(including presumed cardiac disease) at the two children’s
hospitals
• Provision of adequate outpatient cardiac services in metropolitan
Brisbane
32
• Development and delivery of echocardiographic services
• Development and delivery of telemedicine and outreach services
• Training of staff and sustainability of the service
• Development of cardiac catheterisation and interventional cardiology
• Development of the foetal cardiology service
Some of these issues will be resolved with additional paediatric cardiologists
(to at total of 9.0 FTEs). However, the following areas need to be specifically
addressed with defined policy decisions, and resourced, as soon as possible:
CARDIAC CATHETERISATION SESSIONS
Currently the paediatric cardiac service utilises three cardiac catheterisation
sessions and undertakes 210 catheter procedures per year. Approximately
40% of these are interventional. These numbers (for both total and proportion
which are interventional) are substantially less than those undertaken at
Starship Children’s Hospital which services a similar population (2004-05 year
339 cardiac catheterisation procedures). In addition, the percentage of
interventional catheter studies is less than the 60% of cardiac catheterisation
procedures which were interventional at Starship Children’s Hospital in year
June 2004-June 2005). The primary constraint on total paediatric cardiac
catheterisation numbers in Queensland appears to relate to the unavailability
of both paediatric cardiologists and paediatric anaesthetists.
Recommendation 14 Cardiac catheterisation sessions should be increased from three to four per week initially, and ideally to five sessions per week. DIGITAL CARDIOLOGY SERVICES
Those treating children with heart disease are entirely dependent on a
thorough knowledge of the patient’s past history. Servicing the highly
33
fragmented paediatric cardiology patient load in Brisbane, together with
servicing the large dispersed population of rural Queensland, necessitates the
use of digital archiving with ability to remote access. To do this effectively
requires appropriate echocardiography, a remotely accessible PACS system,
and a clinical notes management system.
Recommendation 15 A digital archiving system should be implemented for echocardiograms, angiograms and clinical letters, operating notes, and other records to enable this data to be retrieved from remote locations on demand.
ECHOCARDIOGRAPHY TECHNICIANS
While there are echocardiography technicians within the adult department at
The Prince Charles Hospital, the scanning techniques and spectrum of heart
disease are entirely different from that required for congenital heart
echocardiography. A paediatric cardiologist should not be expected to perform
their own echocardiograms, nor to rely on technicians who are trained in adult
methodology. This is a significant quality issue for the service and presents a
substantial and unnecessary workload for the consultant paediatric staff.
Paediatric cardiologists should be assisted by appropriately trained cardiac
sonographers at both The Prince Charles Hospital and their clinics at the
children’s hospitals. These technicians should not only be trained in
congenital heart disease, but have a substantial exposure to infants and
children to ensure their scanning techniques can be developed in a ‘child
friendly’ environment.
Recommendation 16 Dedicated paediatric cardiac sonographers at The Prince Charles Hospital need to be available to travel to both outreach clinics, and consultation sessions at the two children’s hospitals.
34
OUTREACH CLINICS FOR PAEDIATRIC CARDIOLOGY
The current outreach clinic structure is inadequate. Submissions from
paediatricians outside Brisbane have uniformly indicated that, while the
outreach clinics are provided in a professional and excellent manner, there
are not enough of them. Each centre with a district hospital should have the
opportunity to run a paediatric cardiology clinic on a basis that is agreed upon
between the paediatric cardiac services and the paediatricians at the local
hospital. It may be that some of these clinics can be combined if the District
Hospitals are located in close proximity. While it is outside the scope of this
report to state the location and frequency of clinics, it is estimated that the
current 0.5 FTE paediatric cardiologist currently involved in outreach clinics
would need to be expanded to at least 1.0 to 1.5 FTEs over the next two years
if the outreach clinic is expanded to meet the need.
Recommendation 17 The current outreach clinic program should be expanded to all District Area Health Services where there is a demonstrable need.
DEVELOPMENT OF A FUNDED TELEMEDICINE AND TELE-ECHOCARDIOGRAPHY SERVICE
Queensland has been a world leader in the provision of telemedicine services,
largely as a result of its widely dispersed population base. Telemedicine,
particularly tele-echocardiography has the potential to allow infants and
children to access the skills of a paediatric cardiologist, expedite transport, or
avoid transport in cases where this is not necessary. In addition, it is desirable
that telemedicine be used as an adjunct to outreach clinics. There is already a
foetal telemedicine program in which the Queensland paediatric cardiologists
currently participate. At present, there is insufficient manpower to expand this
service. The recommended increase in FTEs in paediatric cardiology will allow
greater penetration of foetal cardiology into the non-metropolitan areas of the
State.
35
Recommendation 18 A specifically funded telemedicine and tele-echocardiogram service should be developed so that infants and children can be assessed remotely - prior to, or in lieu of, transfer to Brisbane.
PAEDIATRIC CARDIOLOGY TRAINING PROGRAM
There is currently only one funded Fellowship position in Queensland. This
person is by necessity a Junior Fellow (Basic trainee) as facilities for
Advanced training are not available in Queensland. Consequently,
Queensland paediatric cardiologists constantly train junior staff with little
knowledge of paediatric cardiology. Further, because these trainees need to
move interstate to complete their Advanced training, consultant paediatric
cardiologists and trainees do not benefit from the longer term relationship with
trainees that normally exists. Not surprisingly, there is no pool of local
Queensland cardiologists-in-training. Those Queenslanders who wish to
pursue a career in paediatric cardiology are forced to leave Queensland to
receive approved training. When fully qualified these cardiologists will be
reluctant to return to a poorly resourced programme, which is unable to accept
Advanced Trainees. This is demoralising for the service, and is unsustainable
for the health of Queensland children. Because of the poor resourcing at
consultant cardiologist level it is not possible to expand the Cardiology
Fellowship Program immediately.
Recommendation 19 As soon as additional paediatric cardiologists are employed, two further Fellowship positions should be funded, bringing the total number in training to three. This will allow extension of training from the current Basic Trainee positions only, to Advanced Trainee positions. The latter will enable training in advanced areas of sub-specialisation, which can
36
only be developed once the number of staffed paediatric cardiologists has increased.
TRANSITION CLINIC AND FORMALISATION OF THE ADULT CONGENITAL HEART SERVICE
A transition clinic needs to be set up to introduce adolescent patients to the
adult medical system. This needs to be set up in concert with a cardiac liaison
nurse for case management. The adult congenital heart service should also
utilise this person.
ADOLESCENTS AND ADULTS WITH CONGENITAL HEART DISEASE
Although the growing population of long-term survivors with congenital heart
disease may be relatively well catered for within the cardiac service at TPCH,
the Review Panel was unconvinced that the service for these patients was
adequate. It did not appear that there were sufficient cardiologists given the
workload involved. Indeed, the Panel was informed by consumer
representatives that the adult CHD clinic was specifically for one Brisbane
cardiologist’s patients only. Thus, although this ‘continuum of care’ is seen as
a strength of dedicated heart hospitals, the current shortage of congenital
heart disease cardiologists risks under-servicing of this patient population,
with significant medical and fiscal consequences.
Recommendation 20 A transition clinic should be established and the adult congenital heart disease service put on a formal basis to enable adolescents to access ongoing care aiming at independent responsibility during adult life.
37
OUTREACH / LIAISON NURSES
Outreach and liaison nurses play a fundamental role in the delivery of
cardiology services and will play a vital role in reducing interim mortality such
as has been seen with the Norwood experience. For a full description of the
role of these nursing staff see the UK Report (Report of the Paediatric and
Congenital Cardiac Services Review Group United Kingdom December 2003)
(http://www.advisorybodies.doh.gov.uk/childcardiac/).
Recommendation 21
At least two senior, appropriately trained registered nurses need to be recruited to provide case management and liaison with the community.
PAEDIATRIC INTENSIVE CARE
Despite strenuous attempts to improve intensive care services for children
with congenital heart disease, the service remains in a perilous state. This is
because paediatric intensive care has to be provided at three separate sites:
The Prince Charles Hospital, The Royal Children’s Hospital and the Mater
Children's Hospital.
In 2003, the average number of children ventilated per day in paediatric
intensive care in Brisbane was 1.2 at TPCH, 1.5 at RCH, and 1.2 at MCH. On
average, only 1.3 children were ventilated in each PICU at any given time.
These are tiny numbers, which mean that no unit is big enough to gain
adequate experience. There is strong evidence that mortality rates are lower
in children looked after in large regionised PICUs rather than small
fragmented units (Pearson G, Shann F, Barry P, et al. “Should paediatric
intensive care be centralised? Trent versus Victoria”. Lancet 1997;349:1213-
7; Tilford JM, Simpson PM, Green JW, et al. “Volume-outcome relationships in
pediatric intensive care units”. Pediatrics 2000;106:289-94; Ruttimann UE,
Patel KM, Pollack MM. “Relevance of diagnostic diversity and patient volumes
for quality and length of stay in pediatric intensive care units”. Pediatr Crit
38
Care Med 2000;1:133-9; Marcin JP, Song J, Leigh JP. “The impact of
pediatric intensive care volume on mortality: a heirarchial instrumental
variable analysis”. Pediatr Crit Care Med 2005;6:136-41).
In 2003, there were 284 days (78%) in which at least one of the three PICUs
had no ventilated patients for at least part of the day. That is, on 78% of days
a whole paediatric intensive care unit (nurses, doctors and equipment) was
ventilating no children for at least some of the day - this is an extraordinary
waste of resources.
In 2003, there were 814,000 children less than 16 years old in Queensland
with an average of only 1.3 children ventilated in each PICU at a cost of
$4130 per bed day. It is instructive to compare Queensland with Victoria in
2003, where there was a single large PICU serving 1,000,000 children with an
average of 9.6 children ventilated at a cost of only $2340 per bed day. Note
the large difference in cost - $4130 per bed day in Queensland compared to
$2340 in Victoria.
Because so few children are ventilated at The Prince Charles Hospital, there
is a high turnover of medical and nursing staff, a chronic shortage of intensive
care beds for children at The Prince Charles Hospital, and a major shortage of
paediatric cardiac intensivists prepared to work at The Prince Charles
Hospital. It is quite clear to the review panel that Brisbane cannot adequately
staff three Paediatric ICUs.
Paediatric intensive care is a prime example of the damaging effects of
dividing paediatric services between three separate hospitals in Brisbane –
but many other paediatric specialities are similarly affected, including
cardiology and paediatric anaesthesia. Fragmentation makes it impossible to
provide services at an optimal standard, greatly increases cost, impairs
training and make high-quality research very difficult.
39
Recommendation 22 A Queensland Paediatric Intensive Care Service (QPICS) Nursing Director should be appointed to work with the Queensland Paediatric Intensive Care Service Medical Director. In particular, the new Nursing Director should have governance over all the paediatric intensive care nurses at The Prince Charles Hospital – this would allow nurses to work entirely with children if they so choose, and encourage more nurses to undertake formal training in paediatric intensive care.
There is a predictable, and ongoing serious shortage of nurses in paediatric
intensive care at the Prince Charles Hospital. The 12.5% loading for night shift
in the award has been inadequate to attract nurses into this demanding but
important work.
Recommendation 23 The QPICS’ Nursing Director should be empowered to pay above award-rates to nurses who work night shift in Paediatric intensive care.
Recommendation 24
As an interim measure, there should be an increase from three to four funded paediatric intensive care beds at The Prince Charles Hospital. Recommendation 25 Four Paediatric Intensive Care Fellows positions should be funded to provide mid-level cover at The Prince Charles Hospital, Royal Children’s Hospital, and Mater Children’s Hospital. This would provide more senior cover for paediatric intensive care out-of-hours, provide training positions for Queensland graduates, and reduce the large out-of-hours commitment of paediatric intensive care consultants.
40
Recommendation 26 The number of paediatric intensive care consultants should be increased from 11 FTE to 12 FTE to allow adequate cover for the paediatric ICUs at The Prince Charles Hospital, Royal Children’s Hospital and Mater Hospital. With 12 FTE, three consultants would be expected to be on leave at any given time, so the remaining staff would have a one-in-three roster for nights and weekends.
Unfortunately, because of the fragmentation of paediatric intensive care into
three separate units in Brisbane, it may be very difficult to attract 4 Fellows
and 12 Consultants – but every effort should be made to do this so that
Queensland can achieve adequate standards of intensive care for children.
PAEDIATRIC CARDIAC ANAESTHESIA
There has been a long-standing shortage of paediatric cardiac anaesthetists.
This is a highly skilled job calling for the special techniques of cardiac
anaesthesia as well as the demanding requirements for anaesthesia of
children and infants. Consequently, very few people are adequately qualified
in paediatric cardiac anaesthesia. All too often, soon after new people have
been trained in paediatric cardiac anaesthesia, they have left for the far more
lucrative private practice in adult cardiac anaesthesia.
Recommendation 27 To address this shortage, the Director-General of Queensland Health should authorise generous, above-award payments to paediatric cardiac anaesthetists, plus access to satisfactory private practice arrangements. .
41
PAEDIATRIC CARDIAC SURGERY
Three part-time surgeons, each with significant other responsibilities, provide
this service and expressed to the Review Panel that they are satisfied with the
current paediatric cardiac service arrangements.
They report to the Director of Cardiac Surgery at TPCH, an adult cardiac
surgeon.
There are sufficient paediatric surgeons to cover the interim period provided
they elect to remain. Although 2.0 FTE is sufficient workforce to cover present
workloads it is advantageous to share the work among three individuals to
facilitate on-call and leave arrangements and protect safe-working
arrangements.
Excellent paediatric cardiac surgeons are in short supply worldwide, and the
current TPCH surgeons would not be easily replaced.
Recommendation 28 The present surgeons should be encouraged to confine their work to a geographical full time arrangement. To make this viable they should be offered above award remuneration and satisfactory private practice arrangements.
HEART LUNG TECHNICAL SERVICES
Perfusion services at The Prince Charles Hospital are provided from the pool
of seven technologists (‘perfusionists’). There is no sharply delineated
paediatric group, but those who have mastered the overall skills of Perfusion
proceed to learn the finer points of Paediatric Perfusion.
42
The existing perfusionists at TPCH consider themselves capable of expanding
to cover a new paediatric cardiac service on a new site, though this would
require an appropriately enhanced workforce
Recommendation 29 In the definitive arrangements for the new Queensland Children’s Hospital consideration should be given to enlarging the pool of paediatric trained perfusionists at The Prince Charles Hospital to cover the new service.
EXTRACORPOREAL CIRCULATORY SUPPORT TECHNIQUES
For reasons which were not apparent to the review panel, the support
technique of Ventricular Assist Device (VAD) is not made available to children,
despite being well established in adult practice at TPCH for many years. The
equipment and techniques are essentially identical for children, with the
exception of the smaller disposable bypass circuits.(Duncan BW. Mechanical
circulatory support for infants and children with cardiac disease. Annals of
Thoracic Surgery. 73(5):1670-7, 2002 May.) The only logical reason for not
using VAD in children at TPCH is that it would put further pressure on the
current under resourced and under staffed PICU. Consequently, VAD should
not be introduced at TPCH until the shortage of PICU beds and PICU nurses
has been addressed.
Recommendation 30 The VAD technique should be extended to paediatric patients at TPCH according to clinical need, after the shortage of PICU beds and PICU nurses has been addressed.
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ANCILLARY STAFF: PAEDIATRIC THERAPIES AND ALLIED HEALTH
Recent enhancements in social work staff at TPCH have been welcome, and
the current senior administrators at TPCH should be applauded for addressing
this obvious deficiency. However TPCH remains deficient in other allied health
disciplines, including specialist paediatric occupational therapists,
physiotherapists, dietitians, pharmacists, clinical psychologists, and others
who make important contributions to the therapeutic environment of a
specialist children’s hospital.
There is an opportunity in the interim period leading up to the new
Queensland Children’s Hospital to develop a cadre of specialised paediatric
dietitians, educators, and physiotherapists as a bridge from the existing
services to the proposed comprehensive staff for the new Queensland
Children’s Hospital.
Recommendation 31 Either RCH (Brisbane) or The Mater Children’s Hospital should be funded to supply adequate paediatric allied health services at The Prince Charles Hospital for paediatric physiotherapy, psychology, social work, occupational therapy, speech pathology and dietetics – as part of an integrated paediatric cardiac services program. This will also ensure there are trained allied health staff in sufficient numbers for the future integrated cardiac service in the new Queensland Children’s Hospital.
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RISKS AND BARRIERS TO THE PROPOSED SOLUTIONS
The panel has recommended a bold, but difficult course of action, and there
will be many serious and predictable barriers to its implementation:
FAILURE TO ACT: The review panel has described a barely functioning system staffed by
dedicated and talented, but overworked, under-resourced and increasingly
worried, depressed and anxious staff. We are also well aware of previous
reviews of paediatric cardiac services in Qld. To raise expectations with yet
another review, and do nothing will further compound the insecurity and
despair, leaving conditions ripe for dangerous underperformance.
CAPITAL COSTS OF MAJOR HOSPITAL CONSTRUCTION: One-off costs will be substantial, and there will be significant costs in any
interim arrangement. However, offsetting these one -off expenses will be large
and ongoing savings from avoidable wastage from duplication and
unproductive competition. Furthermore, with its current rapid population
growth and robust economy Queensland is in an ideal position to construct a
superb centre of excellence in child care. Further, this is an excellent
opportunity to fix a number of very serious long-range problems.
WEIGHT OF HISTORY AND TRADITION: Deep emotional ties and loyalties reflect what is good and praiseworthy of the
past. But times, expectations and circumstances also change. It is through the
creative destruction of the old that Queensland can build new and better
institutions for the future.
QUEENSLAND HAS A SMALL POPULATION WHICH CANNOT SUPPORT WORLD-CLASS ARRANGEMENTS: We have no sympathy with this argument. Queensland is a prosperous and
rapidly growing state, soon to host 4 million people, thus surpassing Victoria,
and of comparable population to New Zealand. There are ample resources to
45
support an excellent integrated, single Queensland Children’s Hospital, which
potentially could become the best in the Southern Hemisphere. Even with
sustained growth and current low birthrates there will not be sufficient
population (nor resources) for the foreseeable future to support two or more
such hospitals in the state.
QUEENSLAND HAS A RAPIDLY GROWING POPULATION WHICH WILL SOON BE ADEQUATE TO SUPPORT TWO MAJOR CHILDREN’S HOSPITALS : Most of the growth in Queensland’s population is not the result of high
birthrates, and there is no evidence to suggest this is likely to change soon.
Internationally, most major children’s hospitals are sustained by populations of
much greater than 4 million. In NSW a considerably larger population is poorly
served by fragmentation of its three tertiary paediatric services (two in Sydney
and one in Newcastle), while in Melbourne plans are now afoot to further
expand the single hospital. The latter (The Royal Children’s Hospital,
Melbourne) is a world famous institution, in terms of both outstanding quality
of clinical care and internationally recognised research into child health.
Queensland could duplicate this excellence in child health and research if
resources (funds, personnel, and equipment) were centralised into a single,
tertiary children’s hospital in Brisbane.
RESISTANCE OF STAFF TO CHANGE: Experience with moving major hospitals to distant sites teaches us to expect
reluctance ranging from inertia and foot dragging through to active vocal and
political resistance. These reflect human nature and resistance to change and
various degrees of special pleading, often disguised as altruistic regard for
history and tradition. A fully credible, transparent plan for a timely move to the
new Queensland Children’s Hospital will enlist the goodwill of many. The
planning process needs to employ as many stakeholders as possible to
ensure their buy-in. As the project nears completion most staff and other
players will embrace the move and prosper from it; a few will hold out and
take their chances elsewhere, and some who can may retire, or restrict their
practices to suit the new reality. Two of the review panel have experienced
46
this personally when the New, Westmead Children’s Hospital (Royal
Alexandra Hospital for Children) moved from its old downtown Sydney site to
a new site, 25 km west, over 10 years ago.
RESISTANCE OF MAJOR INSTITUTIONS TO CHANGE: Queenslanders frequently refer to traditional schisms between north and
south of the river. The Mater organisation has a major commitment to its
established institutions and traditions. The Prince Charles Hospital stands to
lose a significant and heart-tugging part of its practice. But with few
exceptions the people involved recognise that current arrangements are
inconvenient, inefficient, hazardous, unsustainable and cannot continue. This
latter view was repeatedly expressed both in written submissions and during
interviews, by staff at all levels, in all disciplines, and from all three institutions
(TPCH, MCH, RCH). Here is a real opportunity for strong leadership to
harness the undoubted professionalism of the best elements of all the
institutions to build a new world class Queensland Children’s Hospital for the
ongoing long term good of the children in this state.
CONSOLIDATED RECOMMENDATIONS
For convenience, the major recommendations of this report are here listed
together:
Recommendation 1Historical and current fragmented tertiary paediatric services should be subsumed into a single, purpose built new Queensland Children’s Hospital. Ideally, this facility should be situated adjacent to a major Adult Teaching Hospital, that provides all medical and surgical specialties, and in close proximity to a major Obstetric Unit.
Recommendation 2 The Queensland Children’s Hospital should serve as the hub of a state-wide network of paediatric services, with responsibility for all sick
47
children in Queensland and all tertiary paediatric care for the state, including cardiac services. Recommendation 3 In the interim (while awaiting the building of a Queensland Children’s Hospital), and in preparation for this definitive model, existing services require reinforcement. This will require substantial additional medical, nursing and allied health staff, more paediatric beds, strengthened outreach capabilities, and a dedicated structure of governance clearly aligned with current paediatric structures and clearly distinct from adult cardiac services. Detailed planning of optimal interim manpower requirements should be undertaken immediately. A key ingredient will be to ensure the current triplication of Paediatric Intensive Care Units is supported by all involved in the current ‘roster’ system via the Queensland Paediatric Intensive Care Service (QPICS).
Recommendation 4The new paediatric intensive care facility and paediatric ward currently planned for Prince Charles Hospital should not be built. The number of paediatric beds planned are fewer than the number currently available, and the money allocated for this should be put towards the cost of the new tertiary children’s hospital.
Recommendation 5 As a statement of principle, and in any definitive planning for Queensland, children with heart disease requiring tertiary care should be cared for in the new Queensland Children’s Hospital.
Recommendation 6Governance structures must reflect paediatric cardiac services as a separate identity, independent of and distinct from adult cardiac services. Wherever possible these structures should delineate funding and management for paediatric cardiac services that is separate from their adult cardiac counterparts. This separation of finance and
48
management foreshadows future arrangements, in which Paediatric Cardiac Services will be unified with other Paediatric services in the new Queensland Children’s Hospital.
Recommendation 7 As an interim measure, paediatric cardiac staff and structures at the TPCH will need to be substantially increased in numbers, skills, and formal attachments to existing paediatric hospitals. Those staff members who elect to follow a paediatric career should be clearly recognised as paediatric specialists, with their own departments, answering to their own hierarchy of management. These arrangements are specifically intended to create a paediatric cardiac “staff in waiting”, in preparation for the definitive move to the new Queensland Children’s Hospital.
Recommendation 8 Immediate steps should be taken to provide an integrated paediatric cardiac program, with all staff currently treating children, reporting to the Royal Children’s Hospital, and additional funding from Queensland Health provided through the Royal Children’s Hospital. Recommendation 9All existing and future inpatient, outpatient and outreach paediatric cardiac services should be incorporated as integral parts of the new Queensland Paediatric Network, to clarify and define these services as part of the overall care of children.
Recommendation 10Specific arrangements will need to be developed to accommodate those patients with congenital heart disease who have grown to adulthood. Various models exist for this transition from paediatric to adult care. Whether selected adult cardiac and non-cardiac specialists are cross accredited to the new Queensland Children’s Hospital, or some (or all) Queensland Children’s hospital staff are accredited to selected adult
49
hospitals, will need to be determined locally according to need and opportunities.
Recommendation 11 The enhanced transitional arrangements must not be seen as a tolerable long term solution.
Recommendation 12 Quality monitoring activities data should be collected and regularly analysed on all paediatric cardiac inpatients (surgical and non-surgical).
Recommendation 13Given the rapidly increasing population in Queensland, the servicing of the population of northern New South Wales, the widely dispersed population demographics outside the major metropolitan area, and the high incidence of rheumatic heart disease in the Indigenous population, the number of paediatric cardiologists needs to be increased to a minimum of 9.0 FTE over the next five years.
Recommendation 14Cardiac catheterisation sessions should be increased from three to four per week initially, and ideally to five sessions per week.
Recommendation 15A digital archiving system should be implemented for echocardiograms, angiograms and clinical letters, operating notes, and other records to enable this data to be retrieved from remote locations on demand.
Recommendation 16Dedicated paediatric cardiac sonographers at The Prince Charles Hospital need to be available to travel to both outreach clinics, and consultation sessions at the two children’s hospitals.
50
Recommendation 17 The current outreach clinic program should be expanded to all District Area Health Services where there is a demonstrable need.
Recommendation 18A specifically funded telemedicine and tele-echocardiogram service should be developed so that infants and children can be assessed remotely - prior to, or in lieu of, transfer to Brisbane.
Recommendation 19As soon as additional paediatric cardiologists are employed, two further Fellowship positions should be funded, bringing the total number in training to three. This will allow extension of training from the current Basic Trainee positions only, to Advanced Trainee positions. The latter will enable training in advanced areas of sub-specialisation, which can only be developed once the number of staffed paediatric cardiologists has increased.
Recommendation 20 A transition clinic should be established and the adult congenital heart disease service put on a formal basis to enable adolescents to access ongoing care aiming at independent responsibility during adult life.
Recommendation 21At least two senior, appropriately trained registered nurses need to be recruited to provide case management and liaison with the community.
Recommendation 22A Queensland Paediatric Intensive Care Service (QPICS) Nursing Director should be appointed to work with the Queensland Paediatric Intensive Care Service Medical Director. In particular, the new Nursing Director should have governance over all the paediatric intensive care nurses at The Prince Charles Hospital – this would allow nurses to work
51
entirely with children if they so choose, and encourage more nurses to undertake formal training in paediatric intensive care.
Recommendation 23 The QPICS’ Nursing Director should be empowered to pay above award-rates to nurses who work night shift in Paediatric intensive care.
Recommendation 24As an interim measure, there should be an increase from three to four funded paediatric intensive care beds at The Prince Charles Hospital.
Recommendation 25 Four Paediatric Intensive Care Fellows positions should be funded to provide mid-level cover at The Prince Charles Hospital, Royal Children’s Hospital, and Mater Children’s Hospital. This would provide more senior cover for paediatric intensive care out-of-hours, provide training positions for Queensland graduates, and reduce the large out-of-hours commitment of paediatric intensive care consultants.
Recommendation 26The number of paediatric intensive care consultants should be increased from 11 FTE to 12 FTE to allow adequate cover for the paediatric ICUs at The Prince Charles Hospital, Royal Children’s Hospital and Mater Hospital. With 12 FTE, three consultants would be expected to be on leave at any given time, so the remaining staff would have a one-in-three roster for nights and weekends.
Recommendation 27To address this shortage, the Director-General of Queensland Health should authorise generous, above-award payments to paediatric cardiac anaesthetists, plus access to satisfactory private practice arrangements.
52
Recommendation 28The present surgeons should be encouraged to confine their work to a geographical full time arrangement. To make this viable they should be offered above award remuneration and satisfactory private practice arrangements.
Recommendation 29 In the definitive arrangements for the new Queensland Children’s Hospital consideration should be given to enlarging the pool of paediatric trained perfusionists at The Prince Charles Hospital to cover the new service.
Recommendation 30The VAD technique should be extended to paediatric patients at TPCH according to clinical need, after the shortage of PICU beds and PICU nurses has been addressed.
Recommendation 31Either RCH (Brisbane) or The Mater Children’s Hospital should be funded to supply adequate paediatric allied health services at The Prince Charles Hospital for paediatric physiotherapy, psychology, social work, occupational therapy, speech pathology and dietetics – as part of an integrated paediatric cardiac services program. This will also ensure there are trained allied health staff in sufficient numbers for the future integrated cardiac service in the new Queensland Children’s Hospital.
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SUMMARY AND CONCLUSIONS: ADDRESSING THE SPECIFIC TERMS OF REFERENCE OF THE CURRENT INQUIRY
The objective of the current inquiry was to undertake a review of the system of
providing paediatric cardiac surgery in Queensland with specific focus on resources
and system factors that will improve the health outcomes for children in Queensland.
Below the review panel have briefly addressed each of the many parts of these
Terms of Reference.
The Terms of Reference were:
1. To specifically review the adequacy of cardiac services in Queensland including
but not limited to:
a. The health outcome of children with congenital and acquired heart disease
with reference to both cardiac and general paediatric aspects of health.
Available data do not allow meaningful analysis of these questions. This is not
surprising as they have not been collected prospectively with these questions
in mind. (See 1.d below)
b. The adequacy of paediatric cardiology services in Queensland
Numerous deficiencies and inadequacies in Queensland paediatric cardiology
services have been identified, and have been addressed in the body of this
report.
c. The adequacy of support services for paediatric cardiac interventions including
anaesthesia, intensive care, extracorporeal support, medical imaging, nursing
and allied health, as well as consultative support from paediatric medical and
surgical subspecialties.
54
In general, and with few exceptions, the support services are clearly deficient
in various ways, including staff numbers and training, organisation and
governance, siting, and effective coordination.
d. The outcome of paediatric cardiac interventions both overall and within
different risk groups using, wherever possible, outcome data benchmarked
against data from other national and/or international centres factoring casemix.
Comparative analysis of risk stratified postoperative mortality rates with a
somewhat comparable service in New Zealand form a major section of this
report. As expected, considerable difficulty was encountered with the
consistency of the data, and with the statistical power of analyses, given the
diversity of the conditions and the relatively small number of patients in many
of the higher risk groups. The panel identified ways in which future data
collection and analysis might be more fruitful.
e. The optimal configuration of paediatric cardiac services with consideration
given to the geography of Queensland.
The panel considers that paediatric cardiac services should be reconfigured
as part of an overall paediatric service network for Queensland, separate from
and independent of adult cardiology services. Existing fragmentation and
duplication of paediatric services is a major contributor to present
inefficiencies and staff shortages, and should cease.
2. To make recommendations in respect of:
a. Any appropriate improvements in the system of service provision necessary to
ensure the high quality health care for Queensland children with congenital or
acquired heart disease over the next 10 – 20 years.
Definitive solutions needed to ensure high quality paediatric cardiology
services include separation of paediatric from adult services and providing the
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cardiac services as an integral part of a consolidated Queensland paediatric
service.
b. The need for administrative and geographic reorganisation of services to
ensure best practice health care for children.
The panel perceives that such reorganisation, as outlined in 2.a above, is
essential.
c. Improvements in the system at present, and over the next 2 – 5 years. This will
include recommendations for any organisational improvements in the following
subspecialties with the aim of ensuring present and future delivery of high quality,
sustainable, and cost effective services:
Paediatric cardiac surgery
Paediatric cardiology
Paediatric intensive care
Paediatric anaesthesia
Paediatric allied health services
Such short to mid-term improvements are essential to a better service now,
and also as a necessary transitional bridge to a radically reorganised service
in the longer term. Such interim improvements are detailed in the body of this
report.
d. The need for organisational improvements in the systems of providing
paediatric research, education and training across medical, nursing and allied
health disciplines.
Paediatric research, education and training across medical, nursing and allied
health disciplines were found to be deficient. These activities require
adequate staffing, organisation and resources. Failure of training and
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education compounds future staff shortages and leads ultimately to
unsustainability.
e. The intensive care infrastructure required to establish an extracorporeal
circulatory support service with reference to nursing, medical and perfusionist
staff numbers, education, training and skill maintenance
Regular deployment of extracorporeal circulatory support techniques requires
a full equipped and staffed ICU facility, including round the clock specialised
nursing and readily available medical, surgical and technological backup.
f. The advisability of centralising selected high risk paediatric cardiac surgery
procedures to a single Australian centre.
In the short term there is no practical alternative with respect to surgical
treatment of the Hypoplastic Left Heart Syndrome than to transport the
patients to Melbourne as at present. In the long term there are significant
arguments against such arbitrary limitations on clinical practice in
Queensland. It is beyond the scope of the present enquiry to specify the
precise conditions in which such a service could begin, but it would only be
after substantial shortcomings in present services have been corrected.
g. Appropriate implementation strategies for system improvements or re-
organisation.
Implementation of the extensive measures outlined in this report will require
political decision at the highest level, and buy-in from major institutions. For
the interim strategies to be effective the definitive vision must be totally
credible.
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APPENDIX 1 - BIBLIOGRAPHY
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Aylin, P., Bottle, A., Jarman, B., Elliott, P. (2004) Paediatric cardiac surgical
mortality in England after Bristol: descriptive analysis of hospital episode
statistics 1991-2002. BMJ, 329, p825-829
Birkmeyer, J., Siewers, A., Marth, N., Goodman, D. (2003) Regionalization of
high-risk surgery and implications for patient travel times. Journal of the
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Chang RR, Klitzner TS. (2002) Can regionalization decrease the number of
deaths for children who undergo cardiac surgery? A theoretical analysis.
Pediatrics, 109, p173-181.
Chang, R., & Klitzner, T. (2003) Resources, use, and regionalization of
pediatric cardiac services. Current Opinion in Cardiology, 18, p98-101
Connor, J., Arons, R., Figueroa, M., Gebbie, K. (2004) Clinical outcomes and
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Found under Related documents
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APPENDIX 2 - SUMMARY OF HOSPITAL SITE VISITS
The Review Panel visited three hospitals to tour the facilities and met with the
key clinicians involved with children who have cardiac problems:
• The Prince Charles Hospital – Two separate visits were made. One
included a tour of the Paediatric Ward and PICU. Consultation with
staff and interviews during these site visits included opinions from
clinicians (medical, nursing, allied health) within the Cardiology
Program, Paediatric Cardiac Services Program, Cardio-thoracic
Program, Anaesthetic Program and from clerical staff plus senior
hospital administrators.
• Mater Children’s Hospital – A tour was conducted of the Wards,
Intensive Care Unit, Radiology, Cardiology, Sleep Laboratory,
Maternal-Foetal Medicine Unit, Operating Theatre. The review panel
met with a number of senior clinicians (particularly paediatricians and
nurses) and administrators.
• Royal Children’s Hospital - A tour was conducted of the PICU,
Operating Theatre, Radiology, and Neonatal ICU. The review panel
met with a large number of senior clinicians, registered nurses, allied
health staff, and senior administrators.
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