Health Ministry finds severe flaws at Tel Aviv hospital's ICU

A recent Health Ministry report found "systemic failings" in the functioning of the intensive care unit at Ichilov Hospital in Tel Aviv. The hospital said in response that lessons have been learned and implemented.

The report examined the circumstances of the death of a 70-year-old woman from Ashdod who was a patient in Ichilov some three years ago. The patient, who suffered from acute breathing difficulties following pneumonia, developed lung congestion and was initially hospitalized at Kaplan Hospital in Rehovot. She was later transferred to Ichilov to begin a phased withdrawal from the respirator.

Five days after her transfer to Ichilov, the patient underwent a tracheotomy. After another five days, on December 22, 2006, the intensive care staff decided to disconnect her from the respirator.

About four hours later, during a change of shifts by the nursing staff, the woman was found dead in her bed.

The Health Ministry set up an investigative committee chaired by Dr. Sylvian Burstein. In its report, the committee criticized both the unit's operation and its staff, including the department head, Prof. Patrick Sorkin. The hospital administration, it noted, was aware of some of the shortcomings even before the death in question occurred.

The report found that the unit's physical layout did not allow full-time visual monitoring of the patients by the medical staff. "The department is divided into several rooms, and unless you are in a given patient's room, eye contact with him is severely limited," it said.

On the day of the incident, the report found, the nurse responsible for the patient lost eye contact with her for 20 to 30 minutes, during which time the level of oxygen in the patient's blood began to drop.

Patients with respiratory difficulties are normally connected to monitors that track oxygen levels and breathing, among other factors. The investigation found that shortly before the woman died, a staff member whose identity could not be ascertained had lowered the volume on her monitor. Thus the alarm was not heard by the staff.

Moreover, a key system designed to alert ICU staff to emergencies was malfunctioning on the day of the incident. One of the nurses had told the hospital's maintenance department several times, but the problem remained unfixed until after the patient's death. "The excuse was that an outside company was responsible for fixing the malfunction," the report noted.

"The fact that the patient remained unmonitored and unexamined by the nurse responsible was a significant failing on the part of the nurse and the entire staff," it added.

The committee also criticized the medical staff's decision to disconnect the patient from the respirator. "The decision was made despite warnings from a nurse who knew the patient well," the report said. At the time of the incident, it continued, the department was staffed by two duty anesthesiologists and a third anesthesiologist on call, who had only superficial acquaintance with the patient's condition and thus "could not have received an adequate impression of the difficulty the patient would face in the weaning process."

The report also said that on the day of the incident, the department was overloaded, with four nurses monitoring 14 patients and the head nurse monitoring two more patients. The deputy director of Ichilov's intensive care unit, Dr. Adi Nimrodi, testified to the committee that the staff was exhausted by the unit's excessive workload. "The overall feeling one gets from the testimonies is that equipment problems and shortages of nursing staff have become routine, and everyone knows it, but just keeps going," the report said.

"Systemic failures were manifest in the circumstances of the patient's demise, and those failures are chronic, endemic to the intensive care unit and well known to the nursing staff and to the hospital administration," it concluded.

The committee recommended increasing the staff to match the department's workload. Currently, it said, the size of the staff "is unreasonably small, contradicts the recommendations of the intensive care association and represents a failure of the entire administrative system - the hospital administration, the unit's administration and the nursing administration."

It also recommended better communication among the medical staff, adherence to regulations with regard to checking the operation and alarm volume of patient monitors, ensuring proper maintenance of medical equipment, and establishing a clear procedure for weaning patients off of respirators. "Changing the layout of the department and cutting windows in the internal partitions should also be considered," the report said.

The hospital said in a statement that it has already begun implementing the report's recommendations. "The patient's demise was a regrettable and exceptional incident at the general intensive care unit, from which lessons have been learned and implemented," the statement said. "Since the incident, we have made sure there is one nurse for every two patients at the unit, and even at times of overload, there is at least one nurse for every 2.5 patients.

"Exchanges of information between shifts are today conducted by one of the unit's own physicians, who knows the patients well," the hospital continued, while the intensive care unit has been defined by the maintenance department as a critical location, which means all malfunctions are fixed within minutes. The default setting for alarms on all monitors is now top volume, and a new regulation has been put in place that obliges anyone who alters the volume of an alarm to immediately inform the nursing staff.

"As for better eye contact with the patients, we are now planning a new system to monitor patients in all the rooms, and a new set of regulations for weaning them from respirators has been introduced and implemented," the statement concluded.