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Based on interview, record review, and policy review, the hospital failed to ensure that the on-call pediatric physician responded to a request from the Emergency Department (ED) provider to evaluate one patient (#30), who presented to the ED with an emergency medical condition (EMC, an illness, injury, symptom or condition so serious one should seek care right away to avoid severe harm or serious impairment). 31 ED sampled cases from 10/01/22 through 10/24/22 were reviewed. The hospital's average monthly census over the past six months was 6,442.

Findings included:

Review of the hospital's policy titled, "MW COMPL EMTALA Requirements Policy," dated 08/24/21, showed that Physicians or Qualified Medical Professionals (QMP) who are providing on-call coverage for the ED, shall comply with the requirements of EMTALA to provide medical screening examinations (MSE) and/or stabilizing treatment to covered persons, and all other pertinent obligations under this policy. An on-call physician or QMP is responsible to be available pursuant to the parameters set out in the medical staff bylaws, rules and regulations and medical staff policies when personnel in the ED request such assistance. If there is a disagreement between personnel in the ED and the on-call physician or QMP regarding whether the patient's condition renders it medically necessary for the on-call physician or QMP to go to the ED, the judgement of the personnel in the ED takes precedence over that of the on-call provider.

Review of the hospital's document titled, "Medical Staff Bylaws, Policies, and Rules and Regulations of Mercy Health," dated 11/21/17, showed that active staff responsibilities included providing specialty coverage for the ED and accepting referrals from the ED for follow up care of patients treated in the ED. Courtesy staff member qualifications meet all the same threshold eligibility criteria as other medical staff members, including specifically those relating to availability and response times with respect to the care of patients. The coverage staff, shall assume all Medical Staff functions and responsibilities as may be assigned, including, where appropriate, care for unassigned patients, emergency service care, consultation, and teaching assignments when covering for members of their group practice or coverage group.

Review of the hospital's document titled, "Medical Staff Rules and Regulations," dated 05/21/19, showed that emergency on call duties should be based on the appointee's clinical privileges, and physicians are expected to serve on the on-call roster regardless of their staff category. Practitioners are expected to respond promptly to calls from the hospital's patient care staff regarding their patient. Mercy Hospital Springfield has a responsibility to provide any individual presenting to the hospital with an emergency condition appropriate MSE's within the scope of the hospital's capability, including ancillary services routinely available. The hospital will also provide stabilizing treatment within its capacity, which minimizes the risk to the individual's health. Every effort will be made to carry out the above stated responsibilities.

Review of the hospital's undated document titled "Pediatric Surgery Call October 2022," showed that Staff Y, Pediatric Surgeon, was on call from 10/04/22 at 7:00 AM through 10/11/22 at 7:00 AM.

Review of the hospital's operator's log dated 10/10/22, showed Staff Y, Pediatric Surgeon, received three pages from Staff T, ED Physician, on 10/10/22. The first was at 3:40 PM, the second was at 4:56 PM, and the third was at 6:31 PM.

Review of a clinic schedule for Staff Y dated 10/10/22, showed the last patient that Staff Y saw in clinic on 10/10/22 checked out at 4:12 PM.

Review of the hospital's surgery schedule for 10/10/22, showed that Staff Y, Pediatric Surgeon, had three surgeries scheduled to perform on 10/10/22. The third surgery was scheduled to begin at 10:35 AM, but was cancelled.

Review of Patient #30's medical record showed she was a four year old female with no past medical history. She presented to the ED on 10/10/22 at 9:49 AM with a chief complaint of abdominal pain and vomiting since 10/07/22. A triage note by Staff Q, Registered Nurse (RN), on 10/10/22 at 1:09 PM, showed that Patient #30 was quiet and non-playful, had a distended abdomen with medium softness, had not had a bowel movement (BM) in three days, and had a pain level of six out of ten. Documentation by Staff T, ED Physician, showed Patient #30 reportedly started feeling unwell on 10/07/22 with intermittent vomiting and abdominal pain around her belly button, a low grade fever, decreased activity and a decreased appetite. A physical exam showed that Patient #30 was ill-appearing, tachycardic (very fast heart rate), had absent bowel sounds, abdominal distention, and tenderness with touch. A review of systems (ROS, a technique used by healthcare providers to review of each body system through a series of questions, to determine what signs or symptoms a patient is experiencing) showed that Patient #30 had a bloody bowel movement on 10/10/22 at 2:45 PM. An abdominal x-ray was completed at 3:13 PM and showed a possible small bowel obstruction (partial or complete blockage in the small intestine), which was considered to be a critical result. An abdominal ultrasound (a test that uses sound waves to create images of structures within the body) was performed at 4:02 PM and showed a bowel intussusception (a medical emergency in which part of the intestine telescopes into itself, causing a bowel obstruction) in the right lower portion of the abdomen. Laboratory tests at 3:35 PM showed an elevated white blood cell (WBC, the number of white blood cells [infection-fighting cells] in the blood) count. At 3:40 PM, Staff T spoke with Staff Y, Pediatric Surgeon, for recommendations for treatment. Staff Y recommended an X-ray reduction intussusception (air enema, x-ray guided procedure where air is pumped into the intestine to fix the intussusception) or transferring Patient #30 if there was no radiologist available to perform the test. At 5:15 PM, Staff V, Radiologist, performed an air enema and felt that, while it was successful, there was enough of a concern to warrant an overnight admission. At 6:32 PM, Staff T paged Staff Y, with no response. Upon reevaluation at 6:50 PM, Patient #30 was found to have significant bilious emesis (yellow-green vomit) and a tender abdomen. At 6:52 PM, Staff T re-paged Staff Y. At 6:54 PM, Staff Y responded to the page via telephone and Staff T requested that Staff Y come to the ED and evaluate Patient #30, since her symptoms indicated that the intussusception was not reduced (successfully reversed or fixed). Staff Y indicated that he would see Patient #30 after she was admitted to the pediatric floor, under the pediatric hospitalist service with a pediatric surgery consultation. Staff T expressed his discontent with this decision and requested an emergency department evaluation at the bedside as he was concerned about an ongoing surgical process, and the amount of time it would take to get Patient #30 admitted. Staff T documented that he was very clear in his communication with Staff Y, that Patient #30 did not have a successful reduction with the air enema and that her abdominal exam was consistent with a surgical emergency. Despite being made aware, Staff Y refused to come to the ED and evaluate Patient #30. Patient #30 was admitted to the pediatric hospitalist service under Staff AA, Pediatric Hospitalist, at 9:07 PM on 10/10/22.

During a telephone interview on 10/25/22 at 3:33 PM, Staff T, ED Physician, stated that when he reviewed Patient #30's ultrasound and found it showed intussusception, he reached out to Staff Y, Pediatric Surgeon, for recommendations. Staff Y deferred getting involved, recommended a non-surgical approach and stated that radiology had the ability to do an air enema. Staff T stated that he agreed with that management plan, called the radiologist and scheduled an air enema. Around 6:15 PM, the radiologist called Staff T and stated he thought the intussusception was reduced, but was not confident. He recommended admission of Patient #30 for observation. Around 6:36 PM, Patient #30's abdomen was still distended, she was vomiting bilious emesis, and appeared ill. Staff T paged Staff Y for evaluation of Patient #30 in the ED. Staff Y said he would see Patient #30 after she was admitted to the pediatric floor. Staff T stated that was unacceptable and Staff Y needed to see Patient #30 right away because it could be hours before she was admitted. Staff T stated that Staff Y confirmed that he was not seeing another patient and told Staff T that he was packing his bags and leaving the next day. Staff T paged Staff AA, Pediatric Hospitalist, to admit Patient #30. Staff T stated that when Staff AA called him back, he was told that Staff Y had called him and said that he was overreacting. Staff T stated that there were no guidelines on what to do if an on call provider refused to respond in person, but there was every opportunity to save her bowel when she came in. He said that he was one hundred percent certain that Patient #30 would have had a different outcome had Staff Y acted upon the request to have come to the ED. Staff T stated that there would have been a surgical emergency whether Patient #30 came in with dead bowel or if she had developed dead bowel later because of the intussusception. Staff T reported his concerns to his superiors.

During a telephone interview on 10/26/22 at 11:11 AM, Staff V, Interventional Radiologist (doctor that uses radiologic imaging to guide minimally invasive procedures to diagnose or treat medical conditions), stated that he attempted the air enema three times, but was not able to say with certainty that the intussusception was reduced. Given Patient #30's presentation, and with a bloody stool while in the ED, there was likely damage to the patient's bowel.

During an interview on 10/25/22 at 2:46 PM, Staff S, Radiologic Supervisor, stated that if intussusception was not reduced, it was a surgical emergency.

During a telephone interview on 10/26/22 at 2:51 PM, Staff Y, contracted Pediatric Surgeon, stated that he was the on-call pediatric surgeon on 10/10/22, was aware that Patient #30 had intussusception, and that the radiologist was not certain the intussusception was reduced with the air enema. Staff Y acknowledged that he was contacted by the ED Physician, but did not believe he needed to come in and evaluate the patient because she was not in an emergent condition.

During an interview on 10/26/22 at 2:00 PM, Staff X, Pediatric Surgeon, stated that as soon as she laid eyes on Patient #30 she knew something was not right, so she ordered a CT scan, which showed persistent intussusception, and she called the OR to prepare for surgery. If it was unclear if the air enema was successful in the reduction of the intussusception, then surgical intervention was the next line of treatment.

Review of Patient #30's Operative Report, on 10/11/22 by Staff X, Pediatric Surgeon, showed that on 10/11/22 at 7:12 PM, Patient #30 underwent a diagnostic laparoscopy (type of surgery that checks for problems in the abdomen) with a small bowel resection (removal of part of the small intestine). There was intussusception of the small bowel that could not be reduced by hand and the bowel was clearly non-viable (death of tissue).

Review of Patient #30's Pathology Report, dated 10/13/22, showed a surgical specimen from Patient #30, 41 centimeters (cm, unit of measure) of small bowel, approximately 30 cm of which were purulent (pus) and necrotic (dead tissue).

During a telephone interview on 10/27/22 at 8:43 AM, Staff W, ED Director, stated that if an ED provider requested an in person consultation in the ED, the on-call provider was expected to respond in person, and if a surgeon refused to come in, the ED providers would discuss the case with each other in the ED to see if it could be resolved. If the issue could not be resolved, they would talk to Staff W, who had the ability to loop in other specialty directors to resolve the issue. Staff W stated that Staff T had informed him about Patient #30's case.

During a joint telephone interview on 10/26/22 at 3:29 PM with Staff Z, ED Physician, and Staff DD, ED Physician, Staff Z stated that when ED providers called one of the on-call providers, they were expected to come in and seen the patients in the ED.

During an interview on 10/27/22 at 10:30 AM, Staff M, Director of Emergency Trauma Services, stated that her expectation was that if an ED provider asked an on-call provider to go to the ED to see a patient, providers were to see the patient in the ED.

Staff Y, on-call Pediatric Surgeon, was consulted and requested to come to the ED to evaluate Patient #30, whom Staff T, ED Physician, determined had an EMC. Staff Y refused to evaluate the patient in the ED upon those requests. The patient was subsequently admitted, and with further testing, required abdominal surgery to remove and repair a necrotic portion of her small bowel.

2. Review of the hospital's document titled "Mercy Safety Event Review/Approval Form," dated 10/25/22, was submitted on 10/11/22 at 1:17 PM by an anonymous employee. The event was classified as unprofessional behavior and categorized as failure to respond to patient care needs. The report showed the surgeon (later identified as Staff Y, Pediatric Surgeon) refused to see Patient #30 in the ED, requested Patient #30's admission to a non-surgical service with surgery consulting. A note by the Manager of the Medical Staff on 10/12/22 at 4:35 PM showed that a faculty review determined this report to have been a difference of medical opinion and would not be investigated further. The Patient Safety Manager Review did not indicate that this was a sentinel event (actual events that could or did cause patient harm), a reportable event or an event that senior leadership needed to have been made aware of.

During an interview on 10/25/22 at 1:28 PM, Staff P, RN, stated that the pediatric surgeons normally presented to the ED if asked. She stated that Staff Y was slower to react to situations and was more of a, "wait and see" kind of doctor, compared to the other pediatric surgeons.

Review of the document titled, "National Practitioner Data Bank," dated 11/02/22, showed that Staff Y, Pediatric Surgeon, had a reduction of clinical privileges for a period of one year at Hospital C on 08/12/04 due to a failure to provide medically reasonable and/or necessary items or services. A description of the subject's act(s) or omission(s) showed that an ad hoc peer review committee of the medical executive committee and outside reviewer found that the practitioner's failure to personally evaluate a patient had a negative impact on the patient's clinical condition.

During a joint telephone interview on 10/26/22 at 3:29 PM with Staff Z, ED Physician, and Staff DD, ED Physician, Staff Z stated that sometimes the on-call providers did not appear right away. Staff Z stated, "You don't want to burn bridges with the providers on-call," and sometimes it was reasonable for an on-call provider to have come in after a patient was admitted instead of seeing the patient in the ED. Some providers are more likely to refuse to come in.




46856

Based on interview, record review and policy review, the hospital failed to stabilize within its capabilities, one patient (#30), who presented with an emergency medical condition (EMC, an illness, injury, symptom or condition so serious one should seek care right away to avoid severe harm or serious impairment), out of 31 sampled cases from 10/01/22 through 10/24/22, The failure to stabilize the patient resulted in further deterioration of the patient. The hospital's average monthly ED census over the past six months was 6,442.

Findings included:

1. Review of the hospital's policy titled, "MW COMPL EMTALA Requirements Policy," dated 08/24/21, showed that an EMC was any condition that is a danger to the health and safety of the patient if not treated in the foreseeable future; or any condition that may result in a risk of impairment or dysfunction to a bodily organ or part of the patient if not treated in the foreseeable future. Stabilizing treatment is the treatment necessary to stabilize an EMC. The hospital provides a medical screening examination (MSE) to each patient who comes to the ED. When the MSE indicates that a patient has an EMC, the hospital must provide stabilizing treatment within its capacity and capability or, if the hospital does not have the capacity or capability to provide stabilizing treatment, it must provide a transfer to another hospital having such capabilities. Physicians or Qualified Medical Professionals (QMP) who are providing on-call coverage for the ED, shall comply with the requirements of EMTALA to provide MSEs and/or stabilizing treatment to covered persons, and all other pertinent obligations under this policy. An on-call physician or QMP is responsible to be available pursuant to the parameters set out in the medical staff bylaws, rules and regulations and medical staff policies when personnel in the ED request such assistance. If there is a disagreement between personnel in the ED and the on-call physician or QMP regarding whether the patient's condition renders it medically necessary for the on-call physician or QMP to go to the ED, the judgement of the personnel in the ED takes precedence over that of the on-call provider.

Review of the hospital's policy titled, "Patient Stabilization in the Emergency Trauma Center," dated 06/17/21, showed that a patient will be deemed stabilized if the treating physician attending to the patient in the ED has determined within reasonable clinical confidence that the EMC is being managed appropriately.

Review of the hospital's document titled, "Medical Staff Rules and Regulations," dated 05/21/19, showed that emergency on call duties should be based on the appointee's clinical privileges and physicians are expected to serve on the on-call roster regardless of their staff category. Practitioners are expected to respond promptly to calls from the hospital's patient care staff regarding their patient. Mercy Hospital Springfield has a responsibility to provide any individual presenting to the hospital with an emergency condition appropriate MSE's within the scope of the hospital's capability, including ancillary services routinely available. The hospital will also provide stabilizing treatment within its capacity, which minimizes the risk to the individual's health. Every effort will be made to carry out the above stated responsibilities.

Review of the hospital's undated document titled "Pediatric Surgery Call October 2022," showed that Staff Y, Pediatric Surgeon, was on call from 10/04/22 at 7:00 AM through 10/11/22 at 7:00 AM.

Review of the hospital's operating room schedule for 10/10/22, showed that Staff Y, Pediatric Surgeon, had three surgeries scheduled to perform on 10/10/22. The third surgery was scheduled to begin at 10:35 AM, but was cancelled.

Review of the clinic schedule for Staff Y, dated 10/10/22, showed the last patient that Staff Y saw in clinic on 10/10/22 checked out at 4:12 PM.

Review of the hospital's operator log dated 10/10/22, showed Staff Y, Pediatric Surgeon, was paged three times by Staff T, ED Physician, on 10/10/22. The first was at 3:40 PM, the second was at 4:56 PM, and the third was at 6:31 PM.

Review of Patient #30's medical record showed she was a four year old female with no past medical history. She presented to the ED on 10/10/22 at 9:49 AM with a chief complaint of abdominal pain and vomiting since 10/07/22. A triage note by Staff Q, RN, on 10/10/22 at 1:09 PM, showed that Patient #30 was quiet and non-playful, had a distended abdomen with medium softness, had not had a bowel movement (BM) in three days, and had a pain level of six out of 10. Review of documentation by Staff T, ED Physician, showed Patient #30 reportedly started feeling unwell on 10/07/22 with intermittent vomiting and abdominal pain around her belly button, a low grade fever, decreased activity and a decreased appetite. A physical exam showed that Patient #30 was ill-appearing, tachycardic (very fast heart rate), had absent bowel sounds, abdominal distention, and tenderness with touch. A review of systems (ROS, a technique used by healthcare providers to review of each body system through a series of questions, to determine what signs or symptoms a patient is experiencing) showed that Patient #30 had a bloody bowel movement on 10/10/22 at 2:45 PM. An abdominal x-ray was done on 10/10/22 at 3:13 PM, and showed a possible small bowel obstruction (partial or complete blockage in the small intestine), which was considered to be a critical result. An abdominal ultrasound (a test that uses sound waves to create images of structures within the body) was performed on 10/10/22 at 4:02 PM and showed a bowel intussusception (a medical emergency in which part of the intestine telescopes into itself, causing a bowel obstruction) in the right lower portion of the abdomen. Laboratory tests at 3:35 PM, showed an elevated white blood cell (WBC, the number of white blood cells [infection-fighting cells] in the blood) count. At 3:40 PM, Staff T spoke with Staff Y, Pediatric Surgeon, for recommendations for treatment. Staff Y recommended an X-ray reduction intussusception (air enema, x-ray guided procedure where air is pumped into the intestine to fix the intussusception) or transferring Patient #30 if there was no radiologist available to perform the test. At 5:15 PM, Staff V, Radiologist, performed an air enema and felt that, while it was successful, there was enough of a concern to warrant an overnight admission. At 6:32 PM, Staff T paged Staff Y, with no response. Upon reevaluation at 6:50 PM, Patient #30 was found to have significant bilious emesis (yellow-green vomit) and a tender abdomen. At 6:52 PM, Staff T re-paged Staff Y. At 6:54 PM, Staff Y responded to the page via telephone and Staff T requested that Staff Y go to the ED and evaluate Patient #30, since her symptoms indicated that the intussusception was not reduced (successfully reversed or fixed). Staff Y indicated that he would see Patient #30 after she was admitted to the floor under the pediatric hospitalist service with a pediatric surgery consultation. Staff T expressed his discontent with this decision and requested an emergency department evaluation at the bedside as he was concerned about an ongoing surgical process, and the amount of time it would take to get Patient #30 admitted. Staff T documented that he was very clear in his communication with Staff Y, that Patient #30 did not have a successful reduction with the air enema and that her abdominal exam was consistent with a surgical emergency. Despite being made aware, Staff Y refused to go to the ED and evaluate Patient #30. Staff T considered transferring Patient #30 to another pediatric hospital for treatment, but did not transfer Patient #30. Staff T believed the transfer would have jeopardized Patient #30's care due to potential delays, which included obtaining transport, which could have taken many hours, and the travel time of three hours to the pediatric hospital. Patient #30 was admitted to the pediatric hospitalist service under Staff AA, Pediatric Hospitalist, at 9:07 PM on 10/10/22.

Review of Patient #30's Consultation Note, on 10/10/22 at 10:15 PM, by Staff Y, Pediatric Surgeon, showed that Patient #30 was admitted to the pediatric hospitalist service for intussusception, after an air enema for reduction that was thought to be successful. Staff Y wanted a repeat ultrasound to determine if the intussusception had recurred, and recommended another air enema if intussusception did reoccur.

Review of Patient #30's Operative Report, dated 10/11/22 by Staff X, Pediatric Surgeon, showed that on 10/11/22 at 7:12 PM, Patient #30 underwent a diagnostic laparoscopy (type of surgery that checks for problems in the abdomen) with a small bowel resection (removal of part of the small intestine). There was intussusception of the small bowel that could not be reduced by hand and the bowel was clearly non-viable (death of the bowel tissue).

During a telephone interview on 10/25/22 at 3:33 PM, Staff T, ED Physician, stated that he saw Patient #30 around 1:30 PM on 10/10/22. He ordered laboratory studies, an abdominal x-ray, and an abdominal ultrasound. The ultrasound had not resulted, so he read the ultrasound and stated that it showed intussusception. He reached out to Staff Y, Pediatric Surgeon, for recommendations. Staff Y deferred getting involved, recommended a non-surgical approach and stated that radiology had the ability to do an air enema. Staff T stated that he agreed with that management plan. The official results from the ultrasound showed intussusception. Staff T called the radiologist and scheduled an air enema. Around 6:15 PM, the radiologist called Staff T and stated he thought the intussusception was reduced, but was not confident. He recommended admission of Patient #30 for observation. Around 6:36 PM, Patient #30's abdomen was still distended, she was vomiting with bilious emesis, and appeared ill. Staff T paged Staff Y for evaluation of Patient #30 in the ED. Staff Y said he would see Patient #30 after she was admitted to the pediatric floor. Staff T stated that was unacceptable and Staff Y needed to see Patient #30 right away because it could be hours before she was admitted. Staff T stated that Staff Y confirmed that he was not seeing another patient and told Staff T that he was packing his bags and leaving the next day. Staff T paged Staff AA, Pediatric Hospitalist, to admit Patient #30. Staff T stated that when Staff AA called him back, he was told that Staff Y had called him and said that he was overreacting. Staff T said that he could have transferred Patient #30 to another hospital, but it would have taken longer for Patient #30 to get the care she needed. Staff T stated that there were no guidelines on what to do if an on call provider refused to respond in person. Staff T stated that there was no laboratory study or diagnostic test he could order that would prove with one hundred percent certainty that there was no gangrenous bowel at the time he treated Patient #30. He did state that Patient #30's admission labs were not indicative of acidosis (buildup of acid in the body), which developed after bowel ischemia (lack of blood flow resulting in tissue death). It took approximately eight to 24 hours for bowel to become gangrenous. Staff T stated that there was every opportunity to save her bowel when she came in. He said that he was one hundred percent certain that Patient #30 would have had a different outcome had Staff Y acted upon the request to have come to the ED. Staff T stated that there would have been a surgical emergency whether Patient #30 came in with dead bowel or if she had developed dead bowel later because of the intussusception. Staff T reported this case to his superiors as a possible EMTALA violation.

During a telephone interview on 10/26/22 at 11:11 AM, Staff V, Interventional Radiologist (doctor that uses radiologic imaging to guide minimally invasive procedures to diagnose or treat medical conditions), stated that he spoke with Staff T, ED Physician, about Patient #30. Staff T told him that the pediatric surgeon recommended an air enema to reduce the intussusception, which was an appropriate intervention. Staff V performed the air enema on Patient #30 on 10/10/22. He attempted the air enema three times, but was unsure if the intussusception was reduced, and was unable to determine if there was damage to the bowel. He stated that if there was damage to the bowel, intussusception could have reoccurred, and that given Patient #30's presentation to the ED, and with a bloody stool while in the ED, there was likely damage to the bowel.

During an interview on 10/25/22 at 2:46 PM, Staff S, Radiologic Supervisor, stated that if intussusception was not reduced, it was a surgical emergency.

During an interview on 10/26/22 at 1:58 PM, Staff AA, Pediatric Hospitalist (doctor who cares for children who require hospital care) stated that he started his shift on 10/10/22 at 6:00 PM. He was informed by his counterpart about Patient #30. Staff T, ED Physician, called Staff AA around 7:00 PM to discuss the patient. Per Staff T, Patient #30 had already underwent an air enema, still had an acute abdomen, and the pediatric surgeon had stated that he would see the patient once she was admitted to the pediatric floor. Patient #30 arrived on the floor around 9:00 PM. Staff AA assessed Patient #30 and called Staff Y. Staff Y saw the patient about an hour later and told Staff AA to feed her. Staff Y ordered a repeat abdominal ultrasound, which was completed at 11:58 PM. The report from the ultrasound came back negative for intussusception, but stated that there was edema and fluid in the bowel. Staff AA kept Patient #30 NPO (nothing to eat or drink by mouth) for the rest of the night and started intravenous (IV, in the vein) fluids to keep Patient #30 hydrated and pain medications to control Patient #30's pain. Staff AA signed out Patient #30 to the oncoming pediatric hospitalist at 7:00 AM on 10/11/22 and ended his shift. The oncoming pediatric hospitalist called Staff AA around 8:00 AM and said that the radiologist had interpreted the abdominal ultrasound from 11:58 PM on 10/10/22, and Patient #30 still had an obstruction. Staff AA stated that Staff X, Pediatric Surgeon (who began on-call coverage on 10/11/22 at 7:00 AM) was called. There was a repeat abdominal ultrasound and an abdominal computed tomography (CT, a combination of x-rays and a computer to create pictures of organs, bones, and other tissues, which shows more detail than a regular x-ray) scan performed, and ultimately, Staff X took Patient #30 to surgery for a bowel resection at approximately 7:00 PM on 10/11/22. Staff AA stated that treatment probably should have started sooner.

During an interview on 10/26/22 at 2:00 PM, Staff X, Pediatric Surgeon, stated that if it was unclear if the air enema was successful in the reduction of the intussusception, then surgical intervention was the next line of treatment. From the time the on-call pediatric surgeon heard of Patient #30's case and the time the patient was taken to the operating room (OR), was approximately 18 hours. As soon as she laid eyes on Patient #30 she knew something was not right, so she ordered a CT scan, which showed persistent intussusception, and she called the OR to prepare for surgery. If an ED physician was upset about a patient, she would have responded in person to see the patient.

During an interview on 10/25/22 at 1:28 PM, Staff P, RN, stated that the pediatric surgeons normally presented to the ED if asked. She stated that Staff Y was slower to react to situations and was more of a, "wait and see" kind of doctor, compared to the other pediatric surgeons.

During a telephone interview on 10/26/22 at 2:51 PM, Staff Y, contracted Pediatric Surgeon, stated that he was the on call pediatric surgeon on 10/10/22. The ED physician had called him and thought Patient #30 had intussusception. Staff Y recommended an abdominal ultrasound. If it showed intussusception, he recommended an air enema. Staff Y stated that the radiologist was able to reduce the intussusception with an air enema, but that the radiologist was not one hundred percent sure it was reduced. The ED physician was uncomfortable with discharging Patient #30, so she was admitted to the pediatric floor with pediatric surgery consulting. Staff Y saw Patient #30 around 10:00 PM on 10/10/22. He stated Patient #30 had a repeat abdominal ultrasound to check for reoccurrence of intussusception. He stated that he waited for the official interpretation by the radiologist, but also stated he looked at the ultrasound and saw no evidence of intussusception. The radiologist agreed with his findings, and additionally stated that there was some ascites (fluid in the abdominal cavity), but that was to be expected with intussusception. He transferred care of Patient #30 to Staff X, the oncoming pediatric surgeon, the next morning. He did get a text from the pediatric hospitalist, Staff AA that the oncoming radiologist had reread the ultrasound from midnight and had seen intussusception. Staff X took over Patient #30's care, Staff Y did not participate in Patient #30's care after that time. Staff Y stated that CT scans were not routinely performed for children because of the radiation exposure. Staff Y stated that the first and second time the ED physician had called, he was in clinic, and he might have had a surgical procedure that evening. He did get a text around 6:30 AM on 10/11/22 when he was at the airport. The text was from Staff AA about Patient #30, telling him that the another radiologist reinterpreted the ultrasound from 11:58 PM on 10/10/22, and had identified intussusception. Staff Y stated that he believed there was not an EMTALA violation related to Patient #30, that intussusception was not a surgical problem until it was unable to be reduced, and that the patient was not in an emergent condition. Staff Y stated that the bottom line was that Patient #30 was, "kept in the hospital, observed, and the problem was fixed."

Review of Patient #30's Pathology Report, dated 10/13/22, showed a surgical specimen from Patient #30, 41 centimeters (cm, unit of measure) of small bowel, approximately 30 cm of which were purulent (pus) and necrotic (dead tissue).

Staff Y was the on-call pediatric surgeon when Patient #30 presented to the ED with an acute surgical abdomen. The hospital had the capability to stabilize the patient, however, Staff Y failed to respond to requests for an in ED pediatric surgical consult, when the ED Physician and Radiologist had concerns that the patient may be experiencing continued intussusception of the small bowel. Stabilization of the patient did not occur for approximately 18 hours, when she was taken to surgery and found to have necrotic bowel.