Australian Nursing and Midwifery Federation state secretary Elizabeth Dabars today told InDaily there was “a very real risk” of more deaths without a local surgery unit.
“It could give rise to significant patient care risks and concerns,” she told InDaily.
Her comments echo concerns by prominent obstetrician Associate Professor John Svigos, following a “second opinion” review released yesterday by SA Health, which reiterated findings from an initial review that a paediatric cardiac surgery unit should not be established in South Australia because there wouldn’t be enough cases to ensure its sustainability and safety.
Svigos, who is convenor of the WCH Alliance lobby group, this morning said: “We did not wish to participate further in this debate in public, but faced with the prospect of more deaths caused by political game-playing, we felt we had a responsibility to make our position clear.”
The deaths of four babies in four weeks at the hospital were revealed in a parliamentary committee hearing last week by Svigos and South Australian Salaried Medical Officers Association chief industrial officer Bernadette Mulholland.
In a statement issued this morning, the WCH Alliance said “we disagree with the decision to not establish cardiac surgery at the WCH”.
“Around 100 babies and children each year are transferred interstate for treatment. The many problems with this arrangement became apparent with the recent deaths of four babies.”
The second review by clinical experts found paediatric cardiac surgery at the WCH should not be reintroduced, but a heart and lung life support service known as ECMO (Extra Corporeal Membrane Oxygenation) should.
Adelaide is the only mainland capital city without a paediatric cardiac surgery unit or ECMO services.
SA stopped paediatric heart surgery in 2002 because of low case numbers, with a recent initial review rejecting calls to reinstate it.
Babies and children are usually sent to Melbourne’s Royal Children’s Hospital for life-saving heart surgery services but due to COVID-19 have instead been going to Sydney.
The findings of the latest cardiac services review argue while “it may be possible to set up a [surgical] programme that could work for a period of time… the risks of failure would be high and the consequences could well be severe, not only for the individual team members but also for the administration and reputation of the institution”.
The authors, Dr Tom Gentles, Dr John Beca and Dr Nelson Alphonso, noted there had been several “high profile system failures in paediatric cardiac surgery [which] have most often occurred at low-volume centres with few participating cardiac surgeons and/or low staff morale”.
“There has been a trend away from small volume centres internationally [and] it would be difficult to justify the establishment of a low volume unit based on a single paediatric cardiac surgeon in Adelaide,” they found.
But, they added, “in relation to the recommendation to establish an ECMO programme in Adelaide, we do not consider the absence of paediatric cardiac surgery to be a contra-indication”.
“There are many such programmes internationally, with excellent outcomes,” they said.
“We agree that a paediatric ECMO program should be established in Adelaide.”
However, they added that they believed the estimated 10-20 patients a year the original review suggested could require ECMO without related surgery “to be optimistic and most likely unrealistic”.
But the WCH Alliance said “based on our own expert information, it is clear that an ECMO (heart lung support) facility as suggested by the ‘review group’ is inherently dangerous in the absence of on-site surgical expertise”.
“This is why there are no ‘stand alone’ ECMO services in Australia, New Zealand or the UK. This danger was confirmed yesterday by local cardiac surgeon, Associate Professor Jayme Bennetts,” the alliance stated.
Bennetts, a paediatric cardiac surgeon at the WCH, yesterday told reporters that “most institutions do [ECMO services] that are associated with a cardiac surgical service”.
“ECMO is a high risk service associated with complications and high mortality just because of the nature of the indications of which babies are supported in the first place,” he said.
“Those risks mean that if you establish a service you have to be able to provide enough support structure and expertise around that that allows you to deal with complications and make sure you’re not actually exposing babies to a higher risk than if you had no service.
“There are current discussions underway about how that service can be established – how that can be done in a safe manner that allows that service to be delivered.”
Clinicians are now considering either an ECMO service supported by an interstate team or a full standalone service.
Asked whether a cardiac surgical unit was now completely off the table, Bennetts said: “It’s not that there might never be a service, it’s that at the moment the numbers don’t allow for those justifications to exist. That may change as things evolve and services change.”
Dabars labelled the proposal to have ECMO services without a surgical unit as “imperfect”.
“It sounds like they’re planning to have machinery or machines without the support and a backup plan required in order to make it work, first and foremost in the interest of patient safety but also in terms of just making sure that it can operate effectively,” she said.
Dabars said Svigos’s concerns “should be taken on face value” and she believed “it would make sense” to establish a local cardiac surgery unit.
“We would absolutely support having a system that makes sure that patients receive appropriate and timely care locally,” she said.
Dabars said the argument that there wouldn’t be enough cases in SA to make a surgical unit sustainable didn’t stack up.
“We do know equally that there are other areas that have a slim market… that they still manage to perform and sustain in SA,” she said.
“Liver and lung transplants are a small market but they still manage to perform those in SA, so one would have thought this cardiac surgery, even though it’s a slim market, should still be capable of being sustainable in SA.
“We do know that sending people to Melbourne has for a very long time been traumatic for the family of the children involved and so from that perspective it’s certainly undesirable let alone the immediacy of their treatment and care.”
Dabars believes there would be “sufficient activity” locally to make a surgical unit sustainable.
“From the numbers we’ve heard… we think there would be enough activity to sustain the practice,” she said.
“The current plan the department has announced we don’t think it’s productive.
“We think it’s very imperfect and could result in significant problems. We believe it should have a proper surgical backup.”
Senior cardiologist Dr Gavin Wheaton, who is the medical director of paediatric medicine at the WCH, said yesterday that he wanted an ECMO service established as soon as possible and he believed that would happen “within a year”.
“There are examples of ECMO services without an in-house cardiac surgeon elsewhere and we’ve certainly had a recommendation from the experts that we’ve consulted with that we can and should develop such a service in South Australia,” he said.
“I believe we can do that safely and it’s our undertaking to do that work as quickly as possible.”
SA Health is conducting a review into the recent four baby deaths.
Wheaton said he stood by the decision to temporarily stop sending babies to Melbourne because of COVID risks and he supported the review findings not to establish a local surgery unit.
“I don’t believe the lack of a local surgical service did have any significant impact on the unfortunate deaths of those babies, but we should not pre-empt the outcome of the formal review,” he said.
“We guarantee that children will have ready access to high quality surgical services whether that be in Sydney or in Melbourne.”
An open letter from a dozen senior WCH clinicians published last week by News Corp rejected “misinformation” being peddled by critics, saying: “In line with a recent external review we, as a group, do not believe that there should be paediatric cardiac surgery in SA until a safe, high-quality and clinically sustainable service can be assured with outcomes equivalent to national and international standards.”
However, the group remained open to a local ECMO service if it was proved “viable” and could lead to improvements in care.
Health Minister Stephen Wade said two independent reviews from renowned cardiologists had now made it clear “that a paediatric cardiac surgery service in SA would not be safe”.
“They’ve also come to the view that an ECMO service could be safely delivered in SA and that would be an appropriate enhancement to the services for SA babies and children,” he said.
“The government appreciates that advice needs to go to the (WCH) Board now for them to finalise their consideration but considering they’ve had two strong independent reviews validating that option I certainly believe it’s a legitimate option for the board to look at.”
Wade argued there were “many standalone paediatric ECMO services around the world”.
“The advice of nation leading cardiologists is that it could be safely delivered here,” he said.
“The (WCH) Board hasn’t made a decision, the board will receive the second review and other advice at a later meeting and make a decision.”
He added: “When you’ve got two independent reviews that highlight that the caseload is just not there for SA to have a safe (surgical) service it would be surprising to see another conclusion.”
Opposition health spokesman Chris Picton accused the Government of “rushing to make a decision” on ECMO and surgery services before the findings from the investigation into the baby deaths.
“Clearly the status quo has risks,” he said.
“These (deaths) should properly be investigated so that we can balance the risks that are clearly inherent in the system at the moment before making any decision.
“If it wasn’t for those doctors revealing this publicly we may never have known what occurred and there may never have been an independent review undertaken.”
The deaths were revealed in a parliamentary committee hearing last week by Svigos and South Australian Salaried Medical Officers Association chief industrial officer Bernadette Mulholland.
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