HospitalInspections.org

Based on policy review, memorandum review, closed medical record review, audio recordings review, outside hospital's Transfer Center notes review, outside hospitals' on-call specialty physician schedules review, hospital patient census report review, physician and staff interviews, and e-mail review, the hospital failed to accept the transfer of a patient with an emergency medical condition that required specialized services from an outside hospital's emergency department that did not have the availability of the required specialized services when the hospital had the capacity and capability to provide the specialized services for 2 of 7 sampled patients referred from outside hospitals' emergency departments (Patients #14 and #20).

The findings include:

Review of current hospital Emergency Department (ED) policy entitled "Transfers" dated 11/2011 revealed, "...Reception of Transfer:...II. A participating hospital that has specialized capabilities or facilities....may not refuse to accept from a referring hospital...an appropriate transfer of an individual who requires such specialized capabilities or facilities if the receiving hospital has the capacity to treat the individual...."

Review of current hospital policy entitled "EMTALA COMPLIANCE" dated 04/2011 revealed, "...The capacity to render care is not reflected simply by the number of persons occupying a specialized unit, the number of staff on duty, or the amount of equipment on the hospital's premises. It includes whatever a hospital customarily does to accommodate patients in excess of its occupancy limits....Capabilities of a medial facility means that there is physical space, equipment, supplies, and services that the hospital provides....Capabilities of the staff of a facility means the level of care that the personnel of the hospital can provide within the training and scope of their professional licenses....It is the policy of (Hospital A) that its physicians accept the appropriate transfer of patients from other facilities that require the specialized/emergency medical services that are within the capabilities and capacity of the facility. Where this hospital has the capabilities and capacity to treat the patient with an emergency medical condition, the on-call physician shall accept the patient (subject to the exceptions listed below). The accepting physician shall designate the patient as a direct admission to a particular unit or designate the patient to be received in the emergency department. 1. Patient transfers with emergency medical conditions (as defined by law) may be declined for the following reasons: a. Physician requested i. Lack of available capacity (as defined) to accept and appropriately care for the patient. ii. Lack of current capability (e.g. only neurosurgeon on staff is in surgery). b. Patient requested i. Transferring hospital able to treat...."

Review of current hospital Transfer Center policy entitled "Physician Refusal" dated 09/2011 revealed, "...Any transfer request denial from an outside emergency department that is determined to be due to physician refusal without justification based on capacity and capability will be referred immediately to the Transfer Center Medical Director....Physician refusals will be monitored by the Administrative Review Team consisting of the Transfer Center Manager, Central Region EMS (Emergency Medical Services) Director, Transfer Center Medical Director, and the EMS Medical Director. If the physician refusal is determined to be in violation of EMTALA, then the information will be presented to the Medical Executive Committee by the Transfer Center Medical Director, and the appropriate action will be determined by the Medical Executive Committee....Process In the event a (Hospital A) Physician refuses to accept a patient without justification: 1. Immediately call the Transfer Center Medical Director for involvement. If refusal is felt to be EMTALA violation, Transfer Center Medical Director or designee will contact refusing physician to discuss reason for refusal. If on-call physician still refuses to accept patient after discussion with Transfer Center Medical Director then ED to ED transfer will be coordinated with (Hospital A) Emergency Department and referring facility. 2. Follow the Transfer Center ED to ED acceptance process to complete the transfer to include coordination with ED charge nurse and accepting ED physician. 3. Appropriate on-call physician will be consulted by accepting (Hospital A) ED physician."

Review of a Transfer Center Memorandum (no date) revealed, "Physician Refusals: Always Ask On All Calls: 1. Is this a Medical Emergency? (If No) EMTALA not present. 2. Do you have the capability to care for the patient? (If 'No') then move to step 3; (If 'Yes') EMTALA not present. 3. What care do (you) anticipate the patient needs that you can't provide?...Anytime an ER calls with a patient and the above questions are answered appropriately, we are obligated to accept the patient. If our accepting physician refuses the patient or refuses to speak with the referring physician, then we are to call (Transfer Center Medical Director - Physician #1) immediately. If we have capacity and capability."

1. Closed medical record review for Patient #14 revealed a 94 year-old female that presented to Hospital B's DED (dedicated emergency department) on 02/10/2012 at 1906 with complaints of urethral bleeding. Review of nurse's notes revealed, "1945, (Physician Assistant [PA] #1) to examine pt (patient. Pt does have steady small 'trickle' of bright red blood coming from perineum....(PA #1) to call (Physician #2 - the patient's urologist)...." Review of PA #1's notes at 2336 revealed, "CHIEF COMPLAINT: Bleeding from area of urethral caruncle removal. Bleeding intermittent yesterday but became a constant trickle of blood this morning. S/P (status post) 10 days from surgery. S/P 2 days from urinary catheter removal....NOTES: All other systems were reviewed and are negative except as described above....PHYSICAL EXAM:...GENITOURINARY FEMALE:...Constant trickle of blood from around the urethral area. Soft tissue mucosal swelling in the area makes it very difficult to visualize the exact source of bleeding or the urethral opening...." Further review of PA #1's notes at 2206 revealed, "DW (discussed with) (Physician #2) and tried catheter and local pressure without success. Called (Hospital A - located 35 miles from Hospital B), closest facility. (Hospital A's Transfer Center Staff #1) from transfer center spoke with (Physician #3 - Hospital A's on-call urologist) and stated that he would not accept my call. I did not have the opportunity to present the case or speak to the urologist before he refused to accept the patient." Review of PA #1's notes at 2236 revealed, "DW (Physician #4) from Urology at (Hospital C - located 92 miles from Hospital B) and will see patient but asked for ER to ER tx (transfer). Spoke with (Physician #5) from the ER and is accepting the patient." Review of nurse's notes at 2245 revealed, "Pt daughter wanting to sign pt out and take pt to (Hospital A) herself. (PA #1) and (charge nurse) and myself in to talk with pt and pt's daughter. Pt's daughter and pt opted to go to (Hospital C) as planned." Record review revealed at 2353 the patient was transferred to Hospital C in stable condition via ambulance.

Review of Hospital A's Transfer Center audio recordings of calls regarding Patient #14 revealed on 02/10/2012 at 2145 staff at Hospital B's DED called the Transfer Center and spoke with Transfer Center Staff (TCS) #1. Review revealed Hospital B staff told TCS #1 "We need to speak to the urologist that's on-call and set up for a transfer". Review revealed Hospital B staff provided the patient's name, date of birth, and diagnosis of uncontrolled urethral bleeding. Review revealed TCS #1 said he would page the urologist. Review of audio recordings revealed at 2150 TCS #1 called Hospital B's DED and requested the name of the referring physician and for the staff to fax the patient's demographic sheet to the Transfer Center. Review revealed TCS #1 told Hospital B's staff he had paged the urologist and he should be calling back at anytime. Further review of audio recordings revealed at 2201 TCS #1 called Physician #3 (Hospital A's on-call urologist). Review of the call revealed the following:
? TCS #1: "...I received a call from (PA #1), who's a PA in (Hospital B). They've got a there...a 94 year-old female, has uncontrolled urethra bleeding and want to speak to urology on-call in reference to try to transfer the patient to (Hospital A)."
? Physician #3: "Yeah, but I don't take call from (Hospital B)."
? TCS #1: "Okay. Do you want me to relay that to them?"
? Physician #3: "Yeah."
? TCS #1: "Okay, Sir. I'll definitely do it."
Further review of audio recordings revealed at 2204 TCS #1 called Hospital B's DED and and told the staff that Physician #3 was not accepting any patients and was not going to be able to accept Patient #14. Review revealed TCS #1 then spoke with PA #1. Review of the call revealed the following:
? PA #1: "So, he is not accepting the patient?"
? TCS #1: "He is not."
? PA #1: "He won't even talk to me about it?"
? TCS #1: "Mmm mmm (no). He said 'I'm not accepting the patient' and then that was it."
? PA #1: "Interesting....Because, you guys are the closest facility, I'm just letting you know."
? TCS #1: "Yeah, I understand, Sir."

Review of Hospital C's Transfer Center notes revealed documentation of information provided by Hospital B's staff to Hospital C's Transfer Center staff regarding Patient #14's condition and the transfer request. Review of the notes revealed, "...EMTALA Information: Emergent Condition: Yes. Capability/Capacity: No. Urologist is out of town....Diagnosis:...uncontrollable bleed of urethra...." Review of hospital C's Urology February 2012 on-call schedule revealed that on 2/10/2012 a Urologist was on call.

Closed medical record review for Patient #14 revealed the patient arrived at Hospital C's DED on 02/11/2012 at 0146. Review of nurse's notes at 0204 revealed, "...no acute distress....Scant vaginal bleeding present (urethral)...." Review of urology consult note dictated by Physician #6 (resident urologist) at 0516 revealed, "...treated at an outside hospital approximately 10 days ago for a urethral carbuncle (caruncle)....the patient was seen by another urologist who excised the urethral carbuncle...The patient reappeared at the outside hospital on Wednesday (02/08/2012) to have the Foley catheter removed....The family noted that on Thursday the patient was doing well, but they noted some spotting in her diaper. By Friday, that had turned into bleeding that was concerning enough for them to present to the outside hospital. Per report, the outside urologist was temporarily unavailable and recommended that if the patient was bleeding, she be seen by another urologist for further management. She was transferred to (Hospital C) and was seen by Urology at approximately 3 a.m....At the time of exam, no bleeding at all was appreciated. She did have some spotting on her adult diaper. The emergency room staff noted that when she came in, she did have some spotting...but they never appreciated any active bleeding either....PHYSICAL EXAMINATION:...GENITOURINARY: On inspection, the Foley catheter is seen protruding form the urethra. There still appears to be a urethral carbuncle present. There is no bleeding appreciated....no evidence of active bleeding was noted....DISCUSSION:...Her hemoglobin and hematocrit have remained stable since her transfer from the outside hospital. Given the lack of evidence of active bleeding, plan at this time will be to have the patient return to see her urologist, who is due to potentially see her as early as tomorrow....PLAN: 1. The patient may return to her primary care urologist for further care. She is not in need of acute urologic intervention...." Record review revealed at 0547 the patient was discharged to home in stable condition.

Review of Hospital B's schedule of physicians on-call to provide specialty care to the ED for the month of 02/2012 revealed no urologist was on-call on 02/10/2012 when Patient #14 was in the ED.

Review of Hospital A's "Nursing Administration Communication Report" dated 02/10/2012 revealed at 2100 the hospital's inpatient census was 226 (out of 320 general acute beds) and no patients were being held in the ED awaiting beds.

Interview on 03/30/2012 at 1500 with PA #1 revealed the PA worked in Hospital B's DED and examined Patient #14 on 02/10/2012 when she presented to Hospital B's DED. Interview revealed the patient had bleeding in her vaginal area and had a history of urethral carbuncle surgery performed by Physician #2 10 days prior to the date she presented to the DED. Interview revealed, "She had started bleeding the day before presentation....She had seen (Physician #2) a time or two after surgery....She had bleeding around her urethra. It was very swollen. I couldn't see the urethra. There was a trickle, a constant ooze of bright red blood." Interview revealed Hospital B did not have on-call urology coverage on the evening of 02/10/2012. Interview revealed, "I called (Physician #2). He wasn't on-call, but I called him since this was his patient. He will usually answer, even if he's not on-call. He was out of town. He suggested we try some different things." Interview revealed staff tried applying direct pressure, followed by insertion of a Foley catheter and then applying more pressure, at the direction of Physician #2. Interview revealed, "She was still oozing (blood), so we needed to transfer her. I think it was an emergency medical condition. (She had) uncontrolled bleeding. There was no way I could send her home." Further interview revealed the PA called (Hospital A) first, because it was the closest facility with urology coverage. Interview revealed, "We always call the closest first....(TCS #1) told me that (Physician #3) wouldn't even talk to me. I don't think that was right. Who doesn't even talk to somebody? At least talk to me and find out what's going on before you say no." Interview revealed the PA then called (Hospital C) and arranged the patient's transfer there. Interview revealed, "She was stable, but had the ongoing emergency medical condition. It would not have been appropriate to discharge her to follow up with an outpatient urologist."

Interview on 03/28/2012 at 1230 with Physician #3 revealed the urologist had been on staff at Hospital A for 25 years. Interview revealed, "We get lots of calls from outside hospitals requesting consults. Sometimes the hospitals have services there. I try to let the hospitalist arrange the acceptance of patients for transfer. Its (the patient's condition) not always what it seems to be....I've never seen a case that was transferred here that didn't have other medical issues....They (outside hospitals) cherry pick the patients and we get calls for the patients they don't want to see....We like to accept that patient if its from an ER and they don't have the coverage." Further interview revealed the physician thought Patient #14 was an inpatient when Hospital B requested to transfer the patient. Interview revealed, "I told them I don't take call for (Hospital B). It was misrepresented or misunderstood. I thought it was an inpatient at (Hospital B)....Yes, I'm available to see any patient with urology needs when I'm on-call. As far as I know, we take whatever they send our way." Further interview revealed the physician had never had an EMTALA class with an expert before. Interview revealed EMTALA training had always been by "word of mouth". Interview revealed the physician was planning to attend an EMTALA conference at Hospital A on the evening of 03/29/2012.

Interview on 03/28/2012 at 1500 with Transfer Center Staff (TCS) #1 revealed during the initial call from an outside hospital's DED requesting transfer to Hospital A, the TCS should ask 3 questions to determine if EMTALA applied to the situation. Interview revealed, "We ask if it is an emergent situation and will the patient require immediate intervention....We ask if they can handle it there and if not, what are they lacking to be able to care for the patient....Sometimes I don't remember to ask the questions." Interview revealed if an outside hospital requests specialty services, the TCS called the on-call physician for the requested specialty, who then provides consultation and determines if they can provide care for the patient. Interview revealed, "If we have a bed available and (requested services) are within the on-call specialist's scope, then he should take the patient....If the on-call physician refuses, I should contact (Physician #1) and (Transfer Center Manager) and advise them it may be an EMTALA violation....We offer the referring facility an ED to ED transfer if its something we can reasonable handle." Interview revealed when the TCS speaks with an on-call specialist regarding a requested transfer, the TCS reports the patient's condition to the specialist and then the specialist speaks to the physician at the referring hospital. Interview revealed, "I connect the referring physician and the receiving specialist physician and they discuss the patient. After the conversation, the on-call specialist says whether or not they accept the patient....They don't refuse patients very often." Further interview revealed the TCS was on duty on 02/10/2012 when Hospital B called and requested to transfer Patient #14 to Hospital A. Interview revealed, "(Hospital B) called and said they needed the urologist on-call due to heavy urethral bleeding and they needed to transfer for urology. I paged (Physician #3)....He said something like 'I don't take patients from there'. I said, 'So, you're not going to talk to the referring physician?' He said, 'No.' I called them back an told them he refused. I thought about doing an ED to ED transfer, but worried with her age she had other issues that we might not could handle. In my mind, I was thinking of getting her the best care. I was worried that if (we transferred her) ER to ER, then we find out she had to be transferred to a tertiary care center, it would delay her care." Further interview revealed the TCS forgot to call the Transfer Center Medical Director when Physician #3 refused to accept the patient. Interview revealed, "We have a protocol to follow for physician refusal, but I didn't follow it. I forgot. I was more worried about the patient's stabilization." Further interview revealed the TCS initially forgot to ask the EMTALA questions (during the call intake process). Interview revealed, "When I called then (Hospital B) back they told me it was an emergent situation. I didn't call the urologist back to tell him it was an emergent situation." Interview revealed the Transfer Center Medical Director (Physician #1) called him about the refused transfer early the next morning (02/11/2012). Interview revealed, "He asked why he wasn't notified and why the process wasn't followed, I told him I forgot. He reminded me of EMTALA obligations and said I needed to be careful." Further interview revealed the Transfer Center Manager also spoke with TCS #1 the following day and told him to take the online EMTALA training at the hospital as soon as possible and reviewed the Physician Refusal policy with him.

Interview on 03/28/2012 at 1545 with the Transfer Center Manager revealed the Transfer Center received 250-275 calls per month from other facilities requesting transfer to Hospital A. Interview revealed, "We don't have a lot of physician refusals...I don't know how many physician refusals....We have a Physician Refusal policy. I, (Physician #1), (ED Medical Director), and the EMS Medical Director review (all physician refusals) to see if the policy was followed." Interview revealed TCS #1 e-mailed the Manager on 02/10/2012 after Physician #3 refused to accept Patient #14's transfer. Interview revealed, "I e-mailed him back and told him to e-mail (Physician #1). The case was already over. (Physician #1) contacted (TCS #1) the next day and reminded him of the policy, the 3 EMTALA questions, and to notify him immediately....The following Monday (02/13/2012) I pulled the recordings....The questions weren't asked and we didn't follow our policy....I developed an action plan. Moving forward (we will): review refusal calls; follow up with (TCS #1), I did that; CBL (computer based learning) EMTALA (training), all staff completed; and (Physician #1) and I met with all Transfer Center Staff and discussed EMTALA (on 02/16/2012)." Interview revealed audits of all physician-refused transfers began in March 2012 (rather than February 2012, due to problems with the Transfer Center's call/computer system in February. Interview revealed, "The audits so far, they (TCS) are doing good."

Interview on 03/27/2012 at 1500 with Physician #1 revealed the physician was the Transfer Center Medical Director. Interview revealed the physician helped develop and start the Transfer Center, which opened in October 2010. Interview revealed the Transfer Center takes all calls from outside facilities requesting patient transfers to Hospital A. Interview revealed patient placement staff are located in the same place as Transfer Center Staff, which makes bed availability information readily available to Transfer Center Staff. Interview revealed prior to the Transfer Center opening, all Transfer Center Staff were provided education "to help them define EMTALA". Interview revealed the staff had received further EMTALA training "3 times in the past 18 months". Further interview revealed, "If a physician refuses (to accept a transfer), staff are supposed to call me, unless there is a legitimate reason. We can do ER to ER transfer....(Regarding the refusal of Patient #14) the Transfer Center Staff dropped the ball." Further interview revealed in 2011 an EMTALA Subcommittee of the Medical Executive Committee (MEC) was formed and the Physician Refusal policy was developed after Physician #1 presented a case of a urologist's refusal to accept a transfer to the MEC. Interview revealed the EMTALA Subcommittee reviews all physician refusals. Interview revealed Physician #1 was notified the day after Physician #3 refused to accept Patient #14's transfer, so Physician #1 called a meeting of the EMTALA Subcommittee. Interview revealed, "We discussed this case. He (Physician #3) was not presented with enough information to decide if the patient had an EMC (emergency medical condition) or not. We reminded him he is an agent for the hospital, encouraged him to attend the upcoming EMTALA training (on 03/29/2012), and reminded him EMTALA compliance is required to be a member of the medical staff here."

2. Closed medical record review for Patient #20 revealed a 53 year-old female that presented to Hospital B's DED (dedicated emergency department) on 12/22/2011 at 1857 with complaints of having a fish bone lodged in her throat. Review of triage nurse's notes at 1901 revealed the patient complained of burning pain that she rated 5 out of 10 (on a scale of 0-10, with 10 being the most intense pain). Review of nurse's notes at 2027 revealed, "Patient arrives ambulatory with steady gait to treatment area....Patient appears in pain distress....Patient has throat pain. Pt (patient) reports having fish bone in throat since 1700. Pt denies difficulty swallowing or SOB (shortness of breath). Pt c/o throat irritation and discomfort...." Record review revealed Physician Assistant (PA) #2 examined the patient. Review of PA #2's notes at 2014 revealed, "CHIEF COMPLAINT: Patient presents for the evaluation of sore throat, Patient is able to tolerate PO (by mouth) fluids, no drooling, no dysphonia, dysphagia present. There is no shortness of breath....QUALITY: Pain is described as stabbing....EXACERBATED BY:...eating, drinking. RELIEVED BY:...nothing. NOTES: thinks that she has a fish bone stuck in her throat. had coke and bread but it is still there." Review of PA #2's Physical Examination notes at 2015 revealed, "...ENT (ears, nose, throat): Posterior pharynx normal, No stridor, trismus. Oropharynx not injected, normal tonsils, no uvular edema, no uvular deviation, no exudates, no pharyngeal swelling, no pharyngeal asymmetry, Mouth normal to inspection, no drooling or pooling of secretions, elevation or protrusion of tongue. mucus membranes moist, no lesions, no lacerations...." Record review revealed the patient had a CT (computed tomography) scan of the neck done. Review of the CT results documented by the radiologist revealed, "IMPRESSION: thin linear 1.9 cm (centimeter) radiopaque foreign body, with the appearance of a thin bone, extending horizontally within the left palatine tonsil/pharyngeal wall at the level of the oropharynx. Uncertain if it extends through the pharyngeal wall as there is much (illegible) artifact from adjacent denture. There is possibly very minor left parapharyngeal inflammatory fat stranding. No free fluid or soft tissue emphysema within the left neck. Advise urgent ENT (specialty physician) consultation. Airway patent. Normal epiglottis. Degenerative changes of the spine. Case discussed with (PA #2) in the ED at 827 PM ET." Review of PA #2's notes at 2110 revealed, "Discussed case with (Physician #7 - ENT at Hospital B)...NOT ON CALL AND DID NOT RETURN PAGE." Review of PA #2's notes at 2131 revealed, "Neck soft tissue film interpretation shows, neck tissue negative, normal epiglottis, no retropharyngeal swelling, no steeple sign, however, Foreign body present, F/B (foreign body) POST PHARYNX....1.9CM WITHIN THE LEFT PALINTINE TONCIL/PHARENGEAL (sic) WALL." Review of PA #2's notes at 2133 revealed, "Discussed this case with (Hospital A) TRANSFER CENTER, ENT REFUSED PT, THEY HAD NE (ME) SPEAK W/A GI (gastroenterologist) DOC WHO ALSO REFUSED THE CASE. TRANSFER CENTER GUY CALLED THE HOSPITAL DIRECTOR WHO RECOMMENDED THAT WE SHIP TO (Hospital D - located 95 miles from Hospital B)." Record review revealed at 2259 the patient was transferred to Hospital D for "ENT Specialty Care" in stable condition via ambulance.

Review of Hospital A's Transfer Center audio recordings of calls regarding Patient #20 revealed the initial call from Hospital B's staff to Hospital A's Transfer Center Staff on 12/22/2011 was not available. Review of recordings revealed the first available audio recording regarding Patient#20 was on 12/22/2011 at 2048, a conversation between Transfer Center Staff (TCS) #2 and Physician #9 (on-call ENT at Hospital A). Review of audio recording at 2048 revealed the following:
? TCS #2: "(Hospital B) has a patient in their emergency department. A 53 year-old female. This patient has a fish bone stuck in her throat."
? Physician #9: "We don't take patients from (Hospital B) because we tried to work out a deal with them and they wouldn't work with us. So, they have arrangements for ENT coverage with Charlotte (Hospital D) and so they'll need to honor their agreement."
? TCS #2: "Alright. Good deal. Thank you very much (Physician #9). Thank you for giving me a call back so quickly."
? Review of audio recordings revealed TCS #2 called the Transfer Center Manager at 2049 and left a voice mail requesting a call back in regards to Physician #9's refusal to accept the patient's transfer. Audio recordings review revealed at 2053 TCS #2 called the Critical Care Coordinator (CCC) and inquired about the possibility of having a hospitalist physician accept the patient as an ED to ED transfer. Review of the audio recording at 2053 revealed the following:
? TCS #2: "I contacted the ENT, (Physician #9), and they pretty much don't accept any patients from (Hospital B) because (Hospital B) has a contract with (Hospital D)."
? CCC: "Correct, exactly."
? TCS #2: "That being said, what's the other option that we have to get that patient here instead of sending them to (Hospital D)? Can a hospitalist accept that patient?"
? CCC: "Not without somebody that's willing to treat that patient."
? TCS #2: "Is that something that we can bring to the Emergency Department?..."
? CCC: "Well, then you're transferring the patient. You have to have an accepting physician here....If you have the ER accept them here for our (hospitalist's) services, but then we've got to have a GI or ENT that will take them. You know what I'm saying?"
? TCS #2: "Yeah. I've been looking through my policy book to see what our process is with that and just cannot seem to put my finger on it right now at the moment...."
? CCC: "Its sort of a catch 22, because if the guys that can fix the problem won't take the patient, we can't take the patient....Because what we would do is turn around and consult them and then if they said 'look I can't touch this patient', then what are we going to do? We are sitting on the patient....But (hospitalist on duty) would have the final say in that."
? TCS #2: "Thank you man. Appreciate your time."
? Review of audio recordings revealed at 2056 the Transfer Center Manager called and spoke with TCS #2. Review revealed TCM #2 informed the Manager of Hospital B's request to transfer the patient for ENT services and Physician #9's refusal to accept the transfer. Review revealed the Manager instructed TCS #2 to call the Transfer Center Medical Director, Physician #1. Review of audio recordings revealed at 2101 TCS #2 spoke with Physician #1. Review of the audio recording at 2101 revealed the following:
? TCS #2: "(Hospital B) has a 53 year-old female patient with a fish bone stuck in her throat....I advised him (Physician #9) the (interrupted)..."
? Physician #1: "Get the GI (physician)."
? TCS #2: "You want me to get a GI on that?"
? Physician #1: "Yep."
? TCS #2: "Good deal...."
? Physician #1: "What did (Physician #9) have to say?"
? TCS #2: "The same song and dance. We've tried to have a contract with (Hospital B) but they'd rather go to (Hospital D). Patient needs to go to (Hospital D)...."
? Physician #1: "Just call (Physician #10 - on-call GI physician) and let him know the situation....This is a patient that could be brought ER to ER, because sometimes if you just get this, get something out the patient can even go home from there."
? TCS #2: "...I went ahead and called (the Critical Care Coordinator) and just ran it by him, to talk to (name of hospitalist) or the on-call hospitalist and see...if we wanted to take that route, to bring him directly to the Emergency Department. But they're like 'well, without ENT on board we're not going to accept the patient'. So I just needed to follow up and see what we needed to do from this point forward."
? Physician #1: "Yeah, I would give GI a call and see if he's going to be able to support that....If we do that we would need to make sure that patient got here at lightening speed."
? Review of audio recordings revealed at 2104 TCS #2 discussed the patient's condition and transfer request with Physician #10. Review of the audio recording at 2104 revealed the following:
? TCS #2: "I spoke with (Physician #9), the ENT physician. He declined to speak with the patient based on contractual issues. I was then referred to (Physician #1)...and he suggested that I give you a call and see if you would consider consulting with this patient."
? Physician #10: "He's going to come into the emergency room. I have no control over that. And I will see the patient if that's what they want. I need to speak with the doctor. Who is transferring him?"
? TCS #2: "...I will get you connected."
? Review of the audio recording at 2104 revealed PA #2 (from Hospital B) was then connected to Physician #10. Review revealed the following:
? PA #2: "I've got a fish bone stuck in a throat."
? Physician #10: "How do you know?"
? PA #2: "Got a CT."
? Physician #10: "Okay. Where is it?"
? PA #2: "Its horizontally within the left palatine tonsil and the pharyngeal wall left of the (interrupted)."
? Physician #10: "That's a ENT problem."
? PA #2: "Yeah. That's who I told them to call."
? Physician #10: "Yeah, that's who they called and apparently he turned you down. I really can't deal with that because you have to protect the airway."
? PA #2: "Right. So we don't have an ENT available?"
? Physician #10: "I don't know....I will give the guy at the Transfer Center a call back and have him get up