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Based on review of clinical records, review of hospital policies, review of hospital documentation and interviews with hospital personnel for one (Patient #27) of ten patients admitted to the Emergency Department (ED), documentation and interviews failed to reflect that emergency services were coordinated and communicated to ensure appropriate and safe emergency patient care. The findings include:

1a. Patient #27 was admitted to the hospital ED on 10/5/13 at 8:36 PM after several failed suicide attempts over a two week period. Review of the clinical record identified that the patient reported the attempts had included carbon monoxide poisoning in car approximately one week prior to admission (PTA), as well as ingestion of Klonopin three days PTA, extra strength Tylenol and Motrin ingestion one day PTA, followed by heroin and cocaine. Patient #27's clinical record documented the reason for admission as Acetaminophen poisoning and acute liver injury. Review of the clinical record and interview with PA #2 on 10/22/13 at 10:45 AM identified that upon initial examination, Patient #27 was alert, oriented and was exasperated with the failed suicide attempts. The patient received intravenous (IV) fluids and Zofran and Protonix IV for nausea and vomiting. PA #2 identified that evaluation of Patient #27 included laboratory blood collection requests on 10/5/13 timed 9:17 PM for the following: carboxyhemoglobin, complete blood cell count (CBC) with differential, chemistry 13 panel, magnesium, serum osmolality, urine drug screen, alcohol, salicylate, acetaminophen level and acetaminophen level every 4 hours (q4h). Review of the ED clinical record and interview with the Laboratory Director, Director #2 on 10/21/13 at 11 AM identified that the acetaminophen level q4h request was auto-canceled by the electronic medical record software because the order recognized it as a duplicate order. Although the electronic medical record reflected that on 10/5/13 at 9:19 PM the acetaminophen level was canceled and not completed q4h as ordered, PA #2 identfied that he/she was not aware of the cancellation of the blood work.

1b. The blood collection requests were obtained on 10/5/13 at 10:18 PM. Liver and kidney function tests were completed on 10/5/13 at 10:29 PM: The alanine transaminase (ALT) = 739 Units/Liter (U/L) (reference range 12-78) and aspartate aminotransferase (AST) = 620 U/L (reference range 15-37), the blood, urea, nitrogen (BUN) = 23 (reference range 7-18) and creatinine = 2.0 (reference range 0.6-1.3). Review of the clinical record and interview with Director #2 identified that the initial acetaminophen result was completed and noted on the lab computer (Meditech) as 66 micrograms (mcg)/milliliter (ml) on 10/5/13 at 10:32 PM. Although, the results were completed on 10/5/13, the completed lab results were not interfaced between Meditech and the ED computer (Allscripts) until 10/6/13 at 8 AM (because of the pending alcohol level). Director #2 identified that lab test results, although completed, were not sent and interfaced between Meditech and Allscripts until all values were completed. Director #2 identified that the completed lab results were available for review by the ED physicians via Meditech as of 10/5/13 at 10:29 PM.

1c. The acetaminophen result of 66 mcg/ml was not identified as a critical result as per hospital policy. Although, review of the Receiving and Reporting Critical Test Results and Values Policy identified that a critical result/value must be reported to the practitioner within one hour of receipt, the acetaminophen critical value noted on the policy was >150 mcg/ml, so it was not communicated to the practitioner. The patient's liver function and kidney function results were not identified as critical values as per policy. Director #2 identified that abnormal ED lab results not identified as critical were not called to the practitioner. Review of Order Record documentation and interview with Director #2 identified that all ED lab values were completed as "STAT" and it was the expectation that the physicians would view them in the computer system. Interview with the ED Chairman, MD #7 on 10/22/13 at 2 PM identified that it was the expectation that the ordering physician and/or covering physicians to review laboratory results in the computer system.

1d. Review of the clinical record identfied that on 10/5/13 at 9:28 PM a psychiatric consult was ordered and identified that Patient #27 was not yet medically cleared for disposition. Interview with the supervising physician (for PA #2), MD #12 on 10/22/13 at 9:50 AM identified that he/she evaluated the patient, but did not recall PA #2 communicating lab values and/or reviewing the laboratory results before leaving on 12/6/13 at midnight. MD #12 indicated that although he/she recalls reporting off to MD #11, MD #12 could not recall the hand off report in detail. Interview with the MD #11 on 10/22/13 at 11:15 AM identified that he/she recalled the transfer of care of Patient #27 and that he/she "assumed/recalled" MD #12 signed the patient over as medically cleared and that Patient #27 was waiting to be seen by psychiatry. MD #11 indicated that he/she did not recall PA #2 reporting off any patient information and was not aware of any pending lab results.

1e. Review of the ED Record and interview with RN #1 on 10/23/13 at 10:30 AM identified that Patient #27 was asking for something for a toothache on 10/6/13 at 11:16 AM and at that time, RN #1 advised the patient of abnormal liver and kidney function tests. RN #1 indicated that he/she was told in report that Patient #27 was medically cleared and waiting for psychiatric evaluation. RN #1 did not discuss lab values with a physician because he/she assumed that the physicians were aware of the lab results because the patient had been medically cleared.

1f. Patient #27 remained in the ED on 10/6/13 and 10/7/13 with stable vital signs, alert and oriented, and on q 1 hour suicide assessment/reassessment checks. Review of the clinical record and review of hospital documentation identified that Patient #27 was cared for by ED physicians, MD #12, MD #11, MD #10 and MD #9. During Patient #27's admission to the emergency department, all MD's believed that the patient was medically cleared and waiting for psychiatric evaluation (completed on 10/6/13 at 3:52 PM) followed by psychiatric placement. Although the lab results were now available on Allscripts, the ED physicians did not review the patient's lab results.

1g. Review of the ED record, review of hospital documentation and interview with ED physician, MD #8 on 10/22/13 at 3:00 PM identified that MD #8 received hand off report from MD #9 on 10/7/13 at 3:00 PM. MD #8 hovered over the laboratory computer icon during the report and viewed the patient's elevated lab levels that were completed on 10/5/13. MD #8 noted that they had not been repeated. MD #8 ordered repeat blood work on 10/7/13 at 4:01 PM. Review of the ED record and interview with MD #8 identified that Poison Control and the toxicologist were consulted. Review of the completed results at 5:20 PM identified ALT 6922, AST 5418, and acetaminophen <2. Review of the ED record and interview with MD #8 identified that the patient was treated with IV fluids, Acetadote 20% 8200 mg IV at 8:59 PM and transferred to a tertiary care center on 12/8/13 at 12:08 AM.

1h. Review of Patient #27's tertiary acute care Discharge Summary identified that the patient was admitted on 12/8/13 with acute liver failure in the setting of a Tylenol overdose, and was discharged to a psychiatric hospital on 12/10/13. Review of the Summary identified that Patient #27 was placed on a maintenance dose of N-acetylcysteine of 5800 mg in 5% Dexrose drip at 62 ml per hour and completed the drip over 15 hours. The patient's AST decreased from 5400 to 4207 and ALT from 6900 to 6097. The patient was scheduled for return follow-up with Gastroenterology. The patient was given discharge instructions that included calling 911 whenever experiencing suicidal ideation, to avoid Tylenol, non-steroidal anti-infalmmatory drugs (NSAIDs), any recreational drug use and alcohol which can further damage the liver.