Doctors wonder what's causing so many Cape Breton hospital deaths

No one seems to know exactly why so many patients are dying in four Cape Breton hospitals.

Federal data from the Canadian Institute for Health Information shows 44 per cent more patients than expected are dying in the Cape Breton Health Complex, which includes the regional hospital in Sydney, N.S., and community hospitals in North Sydney, Glace Bay and New Waterford.

The Nova Scotia Health Authority says it is looking closely at the numbers to determine what's going on, but answers could be weeks away.

Dr. Ronen Jhirad, a vascular surgeon who used to practise in Cape Breton, said he doesn't know why the region's mortality ratio is so high.

However, Jhirad said he challenged a number of doctors about their care and coding of patients during his time on the island, and alerted officials at the health authority about his concerns.

Jhirad said there may be a number of cases in which patients were coded as more severe than they actually were in order to avoid having to provide more aggressive — and appropriate — care.

That may have led to skewed mortality numbers, he said.

'I was concerned when I was there'

Jhirad said he occasionally found staff relying on clinical judgment rather than industry standards, such as Apache critical care scoring, which estimates a patient's mortality chances based on a variety of criteria.

He said raising concerns about that resulted in the health authority taking away his hospital privileges.

"I was concerned when I was there that this was something that wasn't being properly addressed, and never really was," said Jhirad, who now works out of the Ontario coroner's office near Toronto.

"It was something I lobbied for when I was a staff surgeon there and I also felt like, to some degree, reprisals were raised against me for raising these concerns."

Pleasing family members

Jhirad said in some cases, staff might not have provided correct information to patients or families.

"I suppose it's unethical, yes, but I don't know how often it's conscious," he said. "Sometimes people convince themselves that they're giving accurate information when they're trying to potentially spare harm to the patient."

"The medical staff didn't sort of take the patients' interests and preferences as much into account as the family, it was my feeling," he said.

"At one point I wanted to discuss the prognosis in the room, and the nurse actually asked me to leave the room because the patient might hear.

"And I said well look, it involves him, and so the clinical care team is often left with the family, who may or may not be unhappy with the care, so oftentimes they're sometimes focused more on pleasing the family than focusing on the patient who, if they're dying, can't raise their complaint."

Jhirad previously reprimanded

The health authority declined to comment on Jhirad's allegations or their possible connection to the high mortality ratio.

"To our knowledge, we have no evidence of circumstances such as Dr. Jhirad alleges, nor any indication that he raised these concerns while he had privileges with NSHA, or since he left," the authority said in an emailed statement.

Jhirad left the region after his privileges were revoked. He was subsequently reprimanded by the College of Physicians and Surgeons of Nova Scotia after a few patient records were found in a dumpster at the regional hospital.

Jhirad insists, though, that he raised a number of issues with several officials in the health authority, and said so in a 2016 CBC interview.

Dr. Margaret Fraser, head of the Cape Breton medical staff association, said she couldn't comment on Jhirad's claims.

Fraser said no one has spoken to her about coding patients improperly in order to improve the statistics.

She also said it's not uncommon to have family express concern about the cost of sending a patient to Halifax or the cost of travelling with the patient.

"I had a pediatric case a few years ago where I actually admitted the child, and then had the child transferred to Halifax as a hospital-to-hospital transfer in an ambulance, because the parents had no way to get the child to Halifax, and that was the only place the child could get the definitive care they needed, so I just made it happen," Fraser said.

'There's literally nothing we can do'

Mortality ratio is a complex issue with no simple answers, but Cape Breton patients are usually older and sicker than expected in hospital, she said. Some patients don't have a family doctor to consult or they take a wait-and-see approach to an illness.

"You have patients showing up with advanced cancers. You have patients showing up in extremes of heart failure. You have patients showing up a week after they've had their heart attack. You see patients who are extremely septic by the time they come into the emergency department," said Fraser.

"Sometimes people do wait too long before they seek care, and by the time they come in, there's literally nothing we can do for them."

Some services may be lacking

Fraser said the local hospitals do some things well, and others not as much.

For example, she said, a study earlier this year showed patients outside Halifax needing special catheterization after a heart attack are twice as likely to die as patients who are in the Halifax region.

"The elephant in the room to a certain extent is we are lacking in some services down here. If you have cardiogenic shock after a heart attack, you should be going to the cath lab to see if there's anything that can be done to reverse that. You know, if there's any arteries that can be opened up that will relieve the strain on your heart and give you an increased chance of survival. Our death rate from those is twice that in Halifax because it takes too long to get our patients to the cath lab."

There are high rates of heart disease in Cape Breton, said Fraser, and patients are left waiting "an unconscionably long time" to get treatment in Halifax.

"I've seen a patient sit upstairs for three weeks waiting to go to Halifax to get a cardiac cath that in any other part of Canada they'd get the next day. I know people who practise in Iqaluit, and if you're in Iqaluit, you'll get your cath faster than you will in Sydney."

2 new geriatric nurses

The health authority announced last week the hiring of two new geriatric physicians and the reopening of a geriatric clinic in Sydney, which Fraser said is good news.

"On the downside, since August we have lost approximately 10 per cent of our medical staff to resignations," she said. "That's not good."

That means 21 physicians have left Cape Breton. Fraser said the bulk of them were family physicians, but many were specialists.

"We've had some retirements. We've had some very abrupt resignations. We've had some illnesses. We've had some relocations. But when you lose 10 per cent of your medical staff in a four-month period, you have to look at that and wonder why."

What is a mortality ratio?

The hospital standardized mortality ratio is an internationally recognized number based on 100, which is considered average, representing the number of actual deaths compared to the number of expected deaths.

The number is standardized, meaning the data factors out things like aging patients or patients with multiple health problems. A number at or near 100 is good. Below that is better, but above 100 is a concern.

The data from previous years shows the Cape Breton ratio was above average for several years, but was trending slightly downward. In 2013-14, the ratio was 119.

The following year it fell to 116 and in 2015-16 it slipped to 114. But the last year the number rose significantly to 123, and this year's data shows the Cape Breton hospitals have the highest mortality ratio in the country at 144.