Fault found earlier with UTMC transplant program

Low survival rate among citations

The University of Toledo Medical Center's live kidney donor program — voluntarily suspended last month after a botched surgery — has been cited for violating state standards over the last decade, including having a lower-than average survival rate for kidney transplant patients.

The University of Toledo Medical Center's live kidney donor program — voluntarily suspended last month after a botched surgery — has been cited for violating state standards over the last decade, including having a lower-than average survival rate for kidney transplant patients.

Additionally, two people involved in the Aug. 10 transplant attempt at the hospital in which a kidney was thrown away faced disciplinary action in the past, The Blade has learned.

The Ohio Department of Health — which is part of the investigation into how a usable kidney was discarded last month before it could transplanted into the donor’s sister — has conducted several reviews at the hospital in the last decade, records show. Some of the reviews discovered serious problems with the kidney program.

In 2010, an inspection ultimately resulted in a transplant surgeon being barred from doing the procedure and later leaving the hospital, formerly the Medical College of Ohio Hospital.

In October, 2010, the state health department did a survey of the hospital's kidney transplant program based on findings by the Scientific Registry of Transplant Recipients, which "revealed that the actual one-year graft [transplant] survival rate was significantly lower than expected for patients transplanted between Jan. 1, 2007, and June 30, 2009."

The state's report found "the expected number of graft failures was 13; the actual number of graft failures was 22."

"What they were looking at specifically was the percentage of late failure of kidney transplant grafts that was somewhat higher than what was expected based upon the risk of the patients," said Dr. Jeffrey Gold, chancellor and vice president for biosciences and health affairs at UTMC.

"At that time, based upon that review, things changed," Dr. Gold said. "One physician with a higher-than-expected failure rate was stopped from performing transplants and subsequently left the institution."

Dr. Gold said risk factors such as hypertension and heart disease for some patients were "not properly coded" on documents. He said a number of the "premature graft failures" had to do with operating on higher-risk patients whose conditions were not coded properly.

"As you might imagine, patients who have had congestive heart failure or who have had a heart attack, or have severe coronary artery disease, are higher risk than patients who don't," he said.

The hospital also failed state standards during a four-day recertification transplant survey of the adult-kidney-only transplant program in August, 2011.

Dr. Gold said "minor issues were found" in that one surgeon did not sign his name one time on one document.

But the record suggests further trouble.

"After an organ arrives at a transplant center, prior to transplantation, the transplanting surgeon and another licensed health care professional must verify that the donor's blood type and other vital data are compatible with transplantation of the intended recipient," the report stated.

The state health department said the hospital staff failed to do that.

"This standard is not met … based on staff interview, clinical record review, and policy review, the facility failed to ensure blood type verification by the transplanting surgeon and another licensed health-care professional took place for one of 10 sampled kidney transplant recipients."

UTMC spokesman Tobin Klinger said the blood type was in fact checked in that case, but the hospital was cited because of the missing signature on that record.

The state's record also said two kidney patients were not visited by social workers after receiving kidney, which is required.

Many of the hospital's inspections found no problems.

In October, 2005, the medical center underwent a full joint commission, four-day long, three-team-member, hospital and clinic survey. The review resulted in exemplary findings and full-service accreditation of all programs.

In 2007, a complaint was received by the Ohio Department of Health, representing the Centers for Medicare and Medicaid Services. It resulted in no findings or deficiencies.

"It should be noted that half of these and in an ongoing fashion for most hospitals, certainly every hospital I have ever been associated with, any patient, any community member, any staff member is able to lodge a concern, and the university medical center then simply responds," Dr. Gold said. "If the concerns come through CMS they take the format of [these] documents … a good number of these become unfounded complaints. We respond to and take each one extremely seriously."

In 2008, a random survey of the cognitive rehabilitation center found no problems.

In November, 2008, the university medical center underwent an unannounced, four-day-long survey of its hospital and clinics, which resulted in exemplary findings and full service accreditation.

In June, 2009, the Ohio Department of Health conducted a scheduled survey of the catheterization lab and cardiology and open-heart- surgery programs.

"The result found two minor opportunities for improvement," Dr. Gold said.

According to the report, the inspection "revealed a large area of rust on the base of [a] procedure table … used for patients undergoing heart catheterizations."

Dr. Gold said the table was immediately painted, and the discovery prompted a review of all equipment and a preventive-maintenance program.

"Also, there was a finding that a formal morbidity and mortality review conference for the open heart surgery program did not meet regularly, as was required by their standards to meet monthly," he said.

The committee has since met monthly regardless of if there is a case to discuss, Dr. Gold said.

In June, 2009, an unannounced survey by the department of health of the adult kidney transplant program found no problems.

Dr. Michael Rees, the UTMC kidney transplant surgeon at the center of the investigation into how a viable kidney was ruined before it could be implanted into the donor's sister, has been a UTMC employee throughout that last decade of hospital inspections by the state.

His personnel file shows he "instigated a physical altercation with a [university] police officer after getting pulled over for two traffic violations" in June, 2004.

An agreement with the university that helped avoid arrest or dismissal required Dr. Rees to write an apology to the officer, donate $1,000 to the MCO Foundation, and submit to an evaluation — the details of which were redacted from the public record.

Dr. Gold said the incident did not affect patient care or safety.

"People have all kinds of events that occur in their lives," he said. "It is only when there are events that affect ability to care for patients. … if something had affected his licensure, we would have taken immediate action."

According to the 2004 police report, Dr. Rees rolled through a campus stop sign and "charged" out of his vehicle toward a police officer after he was pulled over. He at first refused to get back into his vehicle, yelled at the officer, and then sat down in the vehicle and tried to slam the door shut with the officer in the way. He got back out of the vehicle, threw his wallet onto the ground, and shoved the officer into the next lane of the roadway. He was handcuffed but was released without being charged with assault on a police officer.

Dr. Rees, 49, who is paid $155,450 a year, lost his director title late last month after the kidney surgery went awry. He was surgical director of renal transplantation and assistant director of the transplantation immunology laboratories services but was replaced by Dr. Steve Selman, chairman of the department of urology.

Dr. Rees, who has not returned telephone calls seeking comment, was accused in a lawsuit of having a confrontation with a surgical technician during a kidney surgery in June, 2009. Kelly Haas, the surgical technician who filed the lawsuit, alleged that Dr. Rees kicked her during a surgery at UTMC. The suit was to determine if Dr. Rees would be immune from any action. No further court case was filed in the Court of Claims of Ohio.

The record stated, "Dr. Rees testified that he was focused on the operation and did not realize that plaintiff had left the table until two successive instruments were improperly handed to him, causing him to look up and see that [Ms.] Lemay had relieved [Ms. Haas]. According to Dr. Rees, he believed that [Ms. Haas] was more experienced and better suited for this procedure, so he decided to either discourage plaintiff from taking a break or ask her to keep her break short."

Dr. Lloyd Jacobs, UTMC president, said he recalled the case but that it did not affect Dr. Rees' standing at UTMC in any way.

Regarding the voluntary suspension of the live kidney donor program, Dr. Jacobs said he had no doubt it would be restarted after reviews by the Ohio Department of Health, the Centers for Medicare and Medicaid Services, and the United Network for Organ Sharing, an agency that oversees the nation's transplant programs.

Three people were suspended with pay for their involvement in the Aug. 10 kidney surgery.

Edwin Hall, administrator of surgical services, was notified Aug. 27 that he would be on "paid administrative leave" but was reinstated to his job Friday with no change in title or his $164,999 annual salary.

Two nurses involved in the surgery, Melanie Lemay, a full-time employee, and Judith Moore, a part-time employee, were suspended with pay pending the results of a multiagency investigation.

Ms. Moore resigned on Sept. 10.

Ms. Lemay's personnel file with the university shows several disciplinary actions over the past decade. She received a written or oral warning Feb. 17, 2010, after she was "inappropriate to all staff and borderline harassing to some staff" seven times between Jan. 22, 2010, and Feb. 4, 2010.

"Statements were that you were ranting, hysterical, yelling, extremely upset, crying/crying heavily/crying uncontrollably, irate, talking very loudly and agitated," university records said.

She last was on paid administrative leave in September, 2006, for an unspecified action.

On Jan. 17, 2002, she signed an agreement to avoid a three-day suspension for making repeated demeaning and slanderous statements about management, as well as placing a harassing telephone call to a lead nurse.

Contact Ignazio Messina at:

imessina@theblade.com

or 419-724-6171.