HospitalInspections.org

Based on record review, policy review, review of meeting minutes, review of hospital documents, and staff interview, it was determined the hospital failed to ensure ED services were integrated with Medical Imaging services for 2 of 7 patients (#2 and #12) who received a CT scan and whose records were reviewed. This resulted in a delay in the care of Patient #2 and Patient #12 and had the potential to effect all patients who required Medical Imaging services while in the ED. Findings include:

1. A Medical Imaging document "SCOPE OF SERVICE," dated 10/04/14, was reviewed. It stated "A member of the [name of radiology group] will interpret all imaging procedures. 95%-100% of transcribed reports will be available for the referring physicians/clinicians within 4 hours of the completion of the procedure. When requested, a stat interpretation of the procedure will be provided to the referring physician." There was no time frame defining stat orders.

The Director of the ED was interviewed on 7/06/16 beginning at 9:00 AM. She stated that all radiology and lab orders from the ED were stat orders. She stated they generally expected CT results within 90 minutes. When asked if there was a procedure to cue staff that a result had not been received within 90 minutes, she stated it was the expectation the charge nurse and the bedside nurse electronically monitor for overdue results. She stated there was not any specific alert, such as an electronic alert, to cue staff that a result was overdue and needed follow-up inquiry. When asked if there was any written protocol that defined when to expect medical imaging results, such as within 90 minutes, and the responsibilities for follow-up, she stated there was no written procedure to her knowledge, that it was more an informal understanding.

The Director of the ED was asked if she was aware of delays in Medical Imaging for the ED. She stated she was aware of the delays and shortly after she took the position as director, 1 year ago, she began meeting with the director of Medical Imaging to address the delays. When asked whether there was data or documentation related to the recognized delays, or documentation related to changes in the process, the Director of the ED stated she did not have "hard data" or documentation she could present.

2. Hospital grievances were reviewed, for the time period 1/01/16 to 4/30/16, related to ED services. Several of the grievances were related to delays in care, for services related to their medical condition, received in the ED. Examples include:

a. Patient #2 was a 69 year old female admitted to the ED at 4:42 PM on 2/13/16, for severe abdominal pain. She had a sleeve gastrectomy (a surgical weight loss procedure in which the stomach size is reduced) 6 weeks prior to her ED visit. Patient #2 stated she was experiencing increasing pain and a mass at one of her incision sites.

Patient #2's record included documentation of a physical exam, by the ED physician, which stated her abdomen was soft with tenderness over the incision site. Additionally, the exam stated there was firmness under the incision site. The ED physician documented the physical findings "...could represent thrombosis [clotting of blood] versus strangulate it [sic] fat through a hernia..."

The ED physician ordered an abdominal CT with oral contrast for Patient #2 at 5:05 PM. The CT of her abdomen was performed at 8:30 PM. The CT report documented the radiologist had spoken to the ED physician at 10:24 PM, more than 5 hours after the initial order. The CT report documented Patient #2 had a small bowel obstruction and a hernia. The radiologist stated Patient #2 had "Mild-to-moderate small bowel obstruction caused by a right of midline ventral hernia containing a small knuckle of small bowel ..."

At 10:39 PM the ED physician consulted with a surgeon regarding Patient #2's CT results. The ED physician documented the surgeon recommended Patient #2 be admitted and taken to the OR for reduction of her hernia. Patient #2 was taken to the OR at 12:20 AM on 2/14/16.

The process for the CT exam took more than 5 hours, from the time the CT of the abdomen was ordered until the ED physician received the results.

During an interview on 7/06/16 at 9:00 PM, the Director of the ED reviewed the record and confirmed the receipt of the CT results were outside the 90 minutes for a stat order.

b. Patient #12 was an 81 year old female admitted to the ED at 1:37 PM on 7/05/16, for a fainting episode and fall. She had bleeding on the back of her head, from a cut, due to the fall.

Patient #12 was triaged as an Emergency Severity Index (ESI) Level 2. According to the Agency for Healthcare Research and Quality (AHRQ) website, accessed 7/07/16, the ESI triage algorithm is a tool for use in ED triage. The AHRQ states "The ESI triage algorithm yields rapid, reproducible, and clinically relevant stratification of patients into five groups, from level 1 (most urgent) to level 5 (least urgent). The ESI provides a method for categorizing ED patients by both acuity and resource needs." The AHRQ stated "Patients who meet ESI level 2 criteria should be evaluated as soon as possible."

A hospital policy, "[name of hospital] Emergency Department Triage Policy," dated 5/28/15, stated the ESI triage algorithm will be used in determining the urgency for treatment. The policy stated an acuity level of 2 was considered "Emergent." An emergent medical condition, as defined by the Merriam-Webster dictionary, is "Arising suddenly and unexpectedly, calling for quick judgment and prompt action."

Patient #12's record included documentation of a physical exam at 2:14 PM, by the ED physician, which stated she had a small area of swelling to the back of her head. The ED physician ordered a CT of the head at 2:33 PM. The radiologist read the results of the CT at 4:11 PM and reported them to the ED physician, almost 2 hours after the initial order. Patient #12 had bleeding within her brain tissue.

Patient #12 was transferred in stable condition to another acute care hospital at 6:48 PM, for further treatment.

During an interview on 7/06/16 at 9:00 AM, the Director of the ED reviewed the record and confirmed the CT results were outside of the 90 minutes for stat orders.

3. The ED administrative and medical staff attended regional meetings for ED Operations monthly. Meeting minutes were reviewed for a time period of 4 months, 3/2016 to 6/2016. The meeting minutes included documentation of Medical Imaging service delays. The 6/21/16 meeting minutes stated "Continuing to work on Medical Imaging Delays, will meet with Director [Medical Imaging Department]." However, there was no documentation of how the delays were being addressed.

The ED did not integrate effectively with medical imaging to ensure established policies defined time frame expectations for stat results and processes for ED staff to follow-up with results that did not meet expected time frames.