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Based on interviews and review of Emergency Department (ED) and Obstetrics (OB) logs, Medical Records, Bylaws of the Medical Staff, Rules and Regulations of the Medical Staff, and Medical Records from other hospitals, the facility failed to accept one patient (#1), to be transferred for stabilizing treatment of an emergency medical condition from an outside hospital emergency department. The patient required speciality care (OB) that the transferring hospital (Hospital A) could not provide. SSM Health St. Joseph Hospital had the capacity and capability to treat this patient's unstable emergency medical condition but transfer was refused by two hospital physicians. A total of 28 ED medical records were reviewed. The facility also failed to ensure that the Bylaws of the Medical Staff or Rules and Regulations of the Medical Staff delineated guidelines to physicians on acceptance of transfers. However hospital Emergency Medical Treatment And Labor Act (EMTALA) policy stated that if a transferring facility desired to appropriately transfer the patient and the hospital has the capacity to treat, the patient must be accepted. The hospital census was 161. Please refer to A 2411 for details.

Based on interview, record review, and policy review, SSM Health St Joseph Hospital failed to accept an appropriate transfer from another hospital's emergency department (Hospital A) for one patient (#1) of 28 Emergency Department (ED) records reviewed. This failure had the potential to cause harm by delaying stabilizing treatment to any emergent patient that required the specialized capabilities provided at SSM Health St. Joseph Hospital. The ED average daily census was 97. The hospital received an average of 24 patients transferred in from other facilities per month. The facility census was 161.

Findings included:

1. Record review of the facility's Emergency Medical Treatment and Labor Act (EMTALA) policy titled, "EMTALA", dated July 2008, showed that, "Patients appropriately transferred from another hospital anywhere within the boundaries of the United States for specialized care, i.e., Obstetrics (OB), Psychiatry, Pediatrics or Trauma must be accepted if this facility has the capacity to treat the patient. It may be requested of the transferring facility to consider more acceptable alternatives (that is a hospital with specialized capabilities within closer proximity); however if the transferring facility still desires to transfer the patient to this facility, the patient must be accepted."

Record review of the facility's Medical Staff Rules and Regulations, revised 07/27/15, and the Medical Staff By-Laws, dated 09/23/13, showed no direction to medical staff related to acceptance of transferred patients.

2. Record review of Patient #1's ED (referring Hospital A) visit dated 10/02/15 showed the following:
- Arrived in ED at 4:45 AM. Initial vital signs: temperature 100.5, pulse 135 (normal is 60 - 100 beats per minute), respirations 20, blood pressure 129/56, and oxygen saturation 97% (oxygen level in the blood);
- Administered acetaminophen (for fever), intravenous (IV) fluids, and an antibiotic;
- ED physician note indicated patient was 11 weeks pregnant with a several day history of fever, chills, and diffuse joint pain, patient was recently treated for a urinary tract infection (UTI) by her OB Physician, (Hospital B, Physician M). Patient denied vaginal bleeding, spotting, back pain, cramping, rash, lesions, nausea or vomiting.
- ED physician performed bedside Ultrasound (type of imaging that utilizes sound waves to look at internal organs and structures in the body) and noted fetal heart rate of 210 (normal for 11 week fetus is 120 to 160) and a live fetus.
- Laboratory tests showed urine contained protein, blood, white blood cells, red blood cells and leukocytes (indication of infection). Blood test showed blood urea nitrogen (BUN, a kidney function test) with a value of six (normal range 8 to 24), and potassium (K, a mineral in the blood) with a value of 3.2 (normal range 3.5 to 5.1).
- ED Physician L spoke to OB Physician F (a partner of patients regular OB physician) at receiving Hospital B and noted that Physician F refused transfer and to contact "medicine".
- The ED physician noted he spoke with Staff I (House Supervisor at receiving hospital), who stated that she was aware of attempt to transfer the patient and confirmed that they refused to accept the patient. ED Physician explained that patient was a patient of a physician in their facility and had a fever, tachycardia (rapid heart beat), a UTI resistant to antibiotics and that his facility had no OB coverage. Staff I expressed that they still refused to accept the transfer.
- Patient #1 was transferred to a different facility (Hospital C) with diagnoses of fever of undetermined origin, pregnant and abnormal fetal heart rate.

3. During a telephone interview on 01/19/16 at 3:10 PM, Hospital A's Manager of Patient Safety and Regulatory Compliance stated the following:
- The facility had OB/GYN physicians on their medical staff, but their privileges were limited to GYN assessment and treatment.
- The facility made a decision about one and one-half years ago not to admit patients who were pregnant.
- There were no OB evaluations or treatment services provided by OB/GYN physicians to in patients or ED patients within the last year and one-half.
- If a pregnant patient presented to the ED with an emergency medical condition (such as motor vehicle accident or an infection), the patient would be stabilized and transferred to a facility that provided OB services.

During a telephone interview on 01/20/16 at 4:10 PM, Hospital A's Chief of Staff, stated the following:
- The facility did not accept patients who were pregnant.
- The practice was that ED physician transfers pregnant patients if they were in need of hospital care.
- OB/GYN physicians were members of the medical staff but they only had GYN privileges;
- He was not aware of any patient that was pregnant treated within the hospital for at least a year and one-half.
- His specialty was infectious diseases and he did not see any patient that was pregnant for at least a year and one-half, if not longer.
- The facility had OB/GYN physicians on the medical staff, but their privileges were limited to GYN assessment and treatment, and not OB services.

During an interview on 01/21/16 at 10:12 AM, Hospital A's ED Medical Director, stated the following:
- He worked in the hospital's ED for approximately 35 years.
- There were no obstetrical services provided for approximately 15 years.
- The facility was currently not designated as a trauma facility, since approximately 2003.
- There were no obstetric on-call services available.
- If a patient needed obstetric care they were transferred to another hospital that provided specialty care.
- Patients who were in need of inpatient care and also pregnant were transferred to another hospital that had obstetrical services.

4. During a telephone interview on 12/23/15 at 8:40 AM, OB Physician F (SSM Health St Joseph Hospital on call for Physician M, Patient #1's regular OB Physician), stated that:
- She remembered a very brief conversation with ED Physician L, at Hospital A, related to this patient;
- She recalled that this was an 11 week pregnant patient of her partner who presented to an ED at another facility with fever, chills and body aches;
- She recalled that the patient had recently visited her partner in the OB office with the same symptoms;
- She told the ED physician at Hospital A that she would not accept the patient as an OB admit but advised him to call and talk to "medicine" (Hospitalists, staff physicians who provide general medical care of hospitalized patients) about admission;
- It sounded to her like the patient did not need to be admitted to OB but did need to be admitted;
- She stated that the usual course for an 11 week pregnant patient, without OB symptoms, would be to admit to Hospitalist and have a consult by OB;
- She did not recall a conversation about fetal heart tones or rate but that she usually always asked about this when discussing an OB patient.

3. During a telephone interview on 12/23/15 at 10:05 AM, Registered Nurse H (RN), SSM Health St Joseph Hospital access line (a dedicated telephone line where staff coordinated calls between physicians wanting to transfer patients into this system), stated that:
- She received a request from ED Physician L at Hospital A, to speak to the OB physician on call for Staff M.
- She called Staff F (on call for Staff M) and requested that she call Hospital A's ED Physician.
- ED Physician L called back and stated that the OB physician had refused the admission and advised that he speak with a Hospitalist about transfer and admission.
- She paged the Physician Assistant (PA, on call for Hospitalist) and advised him of the request. She stated that she did advise the PA that the OB physician had refused the admission.
- The PA, Staff K, stated that he needed to call his attending (Staff G Hospitalist).
- The PA, called the access line RN back and advised her that the Hospitalist group would not admit the patient without OB support.
- Staff H called the referring facility ED and informed them that this facility was unable to accept the patient transfer for admission.
- Staff H stated that she did not recall ever refusing a transfer for a service that was offered at this hospital.

During a telephone interview on 12/23/15 at 4:10 PM, PA, Staff K stated that:
- He was contacted by the access line RN about a request from an outside facility to transfer an 11 week pregnant patient with fever and chills.
- He stated that the access line RN advised him that the OB Physician had refused to accept this transfer and that the patient had recently seen her primary OB for an office visit.
- Staff K stated that the Hospitalist doesn't typically accept OB patients, they generally were admitted directly to the OB doctors, so he had to check with Staff G, (Hospitalist on call) to get direction.
- After speaking with Staff G he called the access line back and advised them to refuse the transfer for admission.
- Staff K stated that he never spoke directly with the ED Physician. Staff K stated that he could not add anything to the situation so he let the access line RN call the ED back.
- Staff K stated that he did not recall ever refusing a transfer for a service that was offered at this hospital.

During a telephone interview on 12/23/15 at 9:05 AM, Hospitalist G, stated that:
- She received a call from Staff K regarding the transfer of this patient. She stated that it was concerning that OB had refused this patient.
- She called Staff F who stated that this patient was recently evaluated by Staff M in the OB office and that this patient did not need to be admitted to the hospital. Staff G stated that Staff F advised her that there was no indication to admit from an OB stand point and that the sending hospital could handle any medical problem with the patient.
- Staff G stated that she told Staff F she was going to refuse this transfer and Staff F agreed.
- Staff G called Staff K back and advised him to refuse the transfer for admission.
- Staff G stated they never typically refused transfers for admission. She stated that she thought Hospital A was larger than SSM St Joseph Hospital and they should be able to care for the patient there.

During a telephone interview on 12/23/15 at 10:35 AM, Nursing Supervisor I, at SSM Health St Joseph Hospital stated that:
- She received a call from the access line RN to advise her that OB and the Hospitalist had refused a transfer from an outside ED.
- She then received a call from the ED physician at the outside hospital and confirmed with him that this hospital would not accept this transfer.
- Staff I stated that she believed that ED Physician L, from Hospital A, had a legitimate concern and that she did understand why the OB doctor refused the admission (patient was only 11 weeks pregnant), but she did not understand why Staff G, Hospitalist, refused to accept the patient.
- She stated that she felt like the Hospitalist should have accepted the patient and consulted with OB.
- She stated that she was caught in the middle and before she left her shift she emailed her supervisor with the information.
- Staff I stated that she did not recall ever refusing a patient transfer for a service that was offered at this facility.

4. Record review of an email dated 10/02/15 at 7:03 AM from Staff I to the Vice President of Nursing and the Administrator on-call showed the following:
"I received a call this morning from Staff H at the access line. She stated that a patient who was 11 weeks pregnant was in an ED (Hospital A) with Pyelonephritis (kidney infection), and the ED Physician (Hospital A, Staff L), wanted to transfer the patient to our facility, but OB would not accept her. OB physician (Staff F) was on call for Staff M (patient's regular OB physician) and refused the admission. Staff H called our Physician Assistant (Staff K), who spoke with Staff G (on call Hospitalist), who also refused the admission as she wouldn't have OB to consult.

During a telephone interview on 12/23/15 at 1:35 PM, Staff J, Chief Medical Officer, stated that he was made aware of the situation that occurred earlier on that morning (10/02/15) but did not explore it any further because he received a report that the patient did not need admission, so there was nothing to follow up. Staff J stated that he had not spoken to Hospital A ED Physician (Staff L).

5. Record review of Patient #1's Medical Record from Hospital C, (facility that ultimately accepted the transfer), showed Patient #1 was admitted under "Medicine" service with OB consult on 10/02/15.




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