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Based on record review, and interview, the facility failed to ensure On-Call Physicians come to the Emergency Room (ER) when called by the ER physician to come and treat a patient who presented at the ER with an emergency medical condition.

The facility further failed to ensure On-Call Physicians comply with the facility's Medical Staff Regulations which require the On-Call Physician respond to the Emergency Room when called by the ER Physician. Citing three (3) on-call physicians that were called to the ER, #s 51, 54 and Pulmonologist B.

Findings:

Review of clinical record for Patient #1 ( Named in a complaint ) revealed the following information:

Emergency Room (ER) Registration record dated 8/17/11 documented 55 year old Patient #1 arrived in the ER at 22:09.

Triage notes timed at 22:10 documented the patient entered the ER via Emergency Medical Services (EMS) with history of choking during dinner at a restaurant. He was intubated in the field by EMS.

On arrival to the ER the patient was unconscious and was given an acuity level of 1-Critical. Vital signs was as follows:

Blood pressure (B/P) 107/71, pulse 110 beats per minute and respiration 14 breath per minute. Oxygen saturation was 70% on 15 liters of oxygen via ambu ventilation.

Nurses notes dated 8/17/11 at 22:14 documented Patient #1 had sinus tachycardia on monitor, diminished lung sounds on the right side and diminished chest movement with respiration on the right side.

ER Physician notes dated 8/17/11 at 22:10 documented the patient was seen by the ER Physician (#50). He ordered Stat X-ray at 22:14. The report at 22:34 documented impression as follows:

Opacification of the right hemithorax with shifting of the trachea to the right suggests atelectasis.

Obstruction of the right main stem bronchus by foreign body is a consideration as it is not visualized.

The ER physician wrote his clinical impression as Cardiopulmonary Arrest and Aspiration.

Review of Physician notes revealed documented that "Physician #51 was called multiple times. Patient is intubated by EMS. Patient with low 02 saturation. Multiple attempts to secure doctors but no answer."

Review of ER nurses notes dated 8/17/11-8/18/11 revealed the patient was on continuous monitoring, vital signs were fluctuating and was outside the normal ranges at times. Oxygen saturation was persistently low.
On 8/17/11 at 23: 07 the B/P was 134/78, pulse 116 bpm, respiration 18 , oxygen saturation 54%.
At 23:27 Oxygen saturation dropped to 40%.
At 23:58 critical arterial blood gas results of pH 7.1 was called to the ER physician. Arterial temperature was 37.0 degrees centigrade.

Review of vital signs documented on 8/18/11 at 00:28 revealed blood pressure (B/P) had dropped to 62/43, pulse 101, respiration 12 and oxygen saturation at 44%.

At 1:55 B/P was 101/60, pulse 109, respiration 24 and oxygen saturation at 70%. (Physician #55 had been treating the patient with flexible bronchoscope).

Review of ER telephone communication record dated 8/17/11 revealed calls placed to Physician #51, Cardiovascular Surgeon on-call, were as follows:
At, 22:43, 22:50, 22:57, 23:02, 23:10, 23:17, 23:22, 23:28, 23:36. There was no documented call back from the physician.

Further review of communication logs dated 8/17/11 revealed Physician # 54 on-call for Internal Medicine, was called at 23:16 and called back to the ER at 23:55. There was no documentation of what was discussed with the ER physician.
There was no documentation that Physician #54 went to the ER to see the patient.

Review of ER telephone Communication log dated 8/17/11 revealed Pulmonologist B on-call for Pulmonary services was called at 23:32 and called back to the ER Physician at 23:40. There was no documentation that Pulmonologist B went to the ER to evaluate the patient.

Review of credential files for Pulmonologist B revealed he was re-appointed at the hospital effective 9/22/11 as an active staff. His Specialty area was listed as Pulmonary Diseases with additional privileges to perform Arterial Line Placement, Bronchoscopy with biopsy, Moderate Sedation and pulmonary function interpretation.

Review of credential files for Physician # 51 Cardiovascular Surgeon revealed he was re-appointed at the hospital effective 8/26/10 as an active staff. His Specialty area was listed as Cardiovascular Surgery with special request for privileges to include Endovascular procedures, Bronchoscopy- Fiberoptic.

Review of the facility's Emergency Center policy/procedure revised 6/2011 documented the following information regarding On-Call Physician:

"On-Call Physicians list are provided from each Medical Section for medical specialty call. The call list is prepared by each Section and sent to the ED for posting. The physicians are called as follows:
1. To admit a patient in the hospital when the patient does not have a primary physician on the hospital staff.
2. To provide the patient with a referral physician upon discharge when the patient does not have one of their own".

Review of Medical Staff Regulations approved by the MEC on 2/25/10 and 3/25/10 #s 2 and 6 regarding On-Call Physicians documented the following information:
1. "Each service or subspecialty represented on the medical staff, as approved by the Hospital Executive Committee shall submit a schedule of specialists available for referral for patient admission, Emergency Department evaluation, or out patient office follow up.
The on-call specialist shall be obligated to respond to requests of the Emergency Department.
Return of phone pages shall occur within 30 minutes. Response directly to the Emergency Department shall be within a time appropriate to the patient's condition.
If a request is made by the Emergency physician to the on-call physician to respond to the Emergency Department, the physician on -call or his/her designee is obligated to do so".
6. "It is the responsibility of a physician who is in line for calls from the hospital regarding actual or prospective patients to notify his/her answering service or to otherwise provide notice to the medical community needing access to him/her when he/she will be inaccessible, such as in area of compromised telecommunications or beeper functionality, or to otherwise arrange back-up coverage for his/her services".
Review of the physician on-call log dated 7/31/11 through 9/3/11 revealed Physician #51 Cardiovascular Surgeon was listed on the call schedule to take calls Sunday 7/31/11 through Saturday 9/3/11 from 7am to 7am there was no back up listed on the call schedule.

During an interview on 11/8/11 at 12:35 PM in the Emergency Room (ER) with ER Physician #50, regarding the services the patient required after his initial assessment, the physician stated the patient needed Emergency Bronchoscopy to remove the foreign body.

Physician #50 further stated, immediately after viewing the X-ray he called the patient's Pulmonologist A (name given to him by the patient's wife who was present at bedside) who called back, he (Physician #50) explained the situation to Pulmonologist A who told him the patient needed a rigid bronchoscopy procedure and he did not do those, the ER physician should call the Cardiovascular Surgeon.

According to Physician #50 he made multiple calls to the Cardiovascular Surgeon listed on-call (Physician #51) but the Surgeon never responded to the calls.

Physician #50 (ER Physician) stated he then called Pulmonologist B listed on the On-Call list. According to the ER Physician (#50) when the Pulmonologist returned the call he asked Pulmonologist B to come in and see the patient. Pulmonologist B stated he did not do bronchoscopy the ER Physician should call the Cardiovascular Surgeon.

Physician #50 further stated he called Physician #54 on-call for Internal Medicine and discussed the case with him and requested that the physician admit the patient. Physician #50 stated he did not ask Physician #54 to come and see the patient and the Physician never came to the ER.

During an interview on 11/8/11 at 2:35 pm at the hospital with Pulmonologist B, he gave the following information:

He was called by the ED physician and told about the patient's condition. He could not have done anything to help the patient. He told the ER physician that the patient needed a Rigid Bronchoscopy and he was to call the Thoracic Surgeon or the ENT on Call.

The Surveyor asked Pulmonologist B if he went to the ER to see the patient, the Pulmonologist responded by saying "the patient's Attending was called first, and in his (Pulmonologist B's) opinion the call to him (Pulmonologist B) was inappropriate. He further stated he did not have the required skills, that no pulmonologist did Rigid Bronchoscopy. They were done by the Cardiologist or the ENT.

Surveyor asked Pulmonologist B if he thought he should have gone to the ER to assist with the patient, since he was listed on-call, the Pulmonologist responded by saying "should they have called the OB to see the patient because the OB was on call?"

During an interview on 11/9/11 at 12:25 pm at the facility with Physician # 54 on-call for Internal Medicine he stated the ER physician called him requesting he admit the patient.

According to Physician #54 the ER physician did not ask him to go and see the patient so he never did go to the ER. Physician #54 stated there was nothing he could have done for the patient, the person who should have responded did not answer their phone.

During a telephone interview on 11/17/11 at 9:15 am with Physician #51 Cardiovascular Surgeon who did not answer his calls, the Physician stated he was on call on the night of 8/17/11 however he did not hear his phone ring. After checking his phone about 2:30 am, he realized his answering service had called his phone several times although he did not hear it ring.

Based on record review and interview the facility's On-Call Physicians failed to come to the emergency room to provide stabilizing treatment for a patient that came to the Emergency Room (ER) in critical condition requiring emergency life saving intervention;

The facility failed to have needed emergency equipment in readiness for emergency procedure as a result, life saving emergency treatment was further delayed. Citing three (3) On-Call Physicians #s 51, 54 and Pulmonologist B that were called to the ER to provide emergency services.

Findings:

Review of clinical record for Patient #1 ( Named in a complaint ) revealed the following information:

Emergency Room (ER) Registration record dated 8/17/11 documented 55 year old Patient #1 arrived in the ER at 22:09.

Triage notes timed at 22:10 documented the patient entered the ER via EMS with history of choking during dinner at a resturant. He was intubated in the field by EMS. On arrival to the ER the patient was unconscious and was given an acuity level of 1-Critical. Recorded vital at that time was: blood pressure (B/P) 107/71, pulse 110 beats per minute and respiration 14 breath per minute. Oxygenation was 70 % on 15 liters of oxygen via ambu ventilation.

Nurses notes at 22:14 documented Patient #1 had sinus tachycardia on monitor, diminished lung sounds on the right side and diminished chest movement on the right side with respiration

Emergency Room (ER) Physician notes dated 8/17/11 at 22:10 documented the patient was seen by the ER Physician (# 50). He ordered Stat X-ray at 22:14. The report at 22:34 documented impression as follows:

Opacification of the right hemithorax with shifting of the trachea to the right suggests atelectasis. Obstruction of the right main stem bronchus by foreign body is a consideration as it is not visualized.

The ER physician gave his clinical impression as Cardiopulmonary Arrest and Aspiration.

Review of ER nurses notes dated 8/17/11 through 8/18/11 revealed the patient was on contineous monitoring.The vital signs were fluctuating and was unstable at times.
On 8/17/11 at 23: 07 the B/P was 134/78, pulse 116 bpm, respiration 18 , oxygen saturation 54%.
At 23:27 Oxygen saturation dropped to 40%.
At 23:58 critical arterial blood gas results of pH 7.1 was called to the ED physician. Arterial temperature was 37.0 degrees centigrade.

Review of vital sign documented on 8/18/11 at 00:28 revealed blood pressure (B/P) had dropped to 62/43, pulse 101, respiration 12 and oxygen saturation at 44%.
Review of ER Nurses notes dated 8/18/11 at 0:35 revealed documentation that Physician #55 was at bedside with bronchoscope to remove foreign object from airway. Patient extubated and re-intubated to remove partial meat pieces.
At 1:55 B/P was 101/60, pulse 109, respiration 24 and oxygen saturation at 70%.( Physician #55 had been treating the patient with flexible bronchoscope).
Review of the ER telephone communication logs dated 8/17/11 revealed the ER staff made the first call at 23:37 to physician #55, (who was not on call) however he responded to a call at 23:45 and came in to see the patient at midnight, aproximately two (2) hours after the patient first arrived in the ER.

Review of procedure notes dated 8/18/2011 revealed documentation by Physician #55 that he was called at approximately 23:37 and he arrived in the ER at about midnight. The patient had a blood gas of 7.1 with blood pressure in the 60s, saturation in the 30s, heart rate in the 120s and still a gcs of 3. His pupils were dilated and sluggishly reactive and the patient was on no pressors.

The operating room was not available and after discussion with family a decision was made to proceed immediately with flexible bronchoscopy which was delayed by the absence of a complete flexible scope. Initial inspection through the ET tube revealed a significant amount of blood suggesting traumatic intubation. In addition there was near complete obstruction of the trachea, with complete obstruction of the right main stem by foreign body much like a cork in a bottle.

The OR was ready and the patient was transported to the OR after arresting twice necessitating CPR. However the intended Rigid Bronchoscopy was not performed as the complete scope could not be located.

EMCO was considered but according to the perfusionist this was not immediately available. An attempt at performing rigid bronchoscopy combined with using the flexible scope for ilumination was unsuccesful. The patient arrested and was pronounced dead at 03:46.

During an interview on 11/8/11 at 12:35 PM in the ER with Physician #50 regarding the services the patient required after his initial assessment the physician stated the patient needed Emergency Bronchoscopy to remove the foreign body.

According to Physician #50 Multiple calls were made to the cardiovascular Surgeon on-call with no response. Two pulmonologists were also called who did not come and see the patient and a Cardiovascular Surgeon who said he did not take calls for the hospital.

During an interview on 11/8/11 at 11:15 am in a conference room at the facility with Physician #55 (not on-call) he stated he was called shortly before midnight to see the Patient #1. He arived in the ER around midnight and evaluated the patient. He realized a Rigid Bronchoscopy was required, however at that time an Operating Room was not available so he had to attempt a Flexible Bronchoscopy, which delayed the treatment.
According to Physician #55 the procedure was further delayed because the bronchoscope did not have all the required parts available.

Physician #55 further stated that at 2:00 am (8/18/11) the Operating Room (OR) became available and the patient was taken to the OR for a Rigid Bronchoscopy, however there was a delay in performing the procedure because parts of the bronchoscope could not be located.
According to physician #55 the patient was profoundly acidotic, hypothermic and hypotensive and those conditions were not addressed. According to Physician #55, attempts to remove the food particle without the rigid scope was unsuccesful and the patient expired.

During an interview on 11/8/11 at the facility at 11:40 am with the Risk Manager she stated an investigation was conducted in the matter and one of the findings was there was a confusion as to where the rigid bronchoscope was kept, and that parts of the scopes were packaged in separate packaging.