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Based on record review and interview, the facility failed to provide an appropriate medical screening examination, stabilizing treatment or an appropriate transfer for one patient who presented to the emergency department's ambulance bay. A total of 78,581 patients were seen and 205 patients were transferred to other facilities in the last six months.

See A2406

Based on record review and interview, the facility failed to provide an appropriate medical screening examination, stabilizing treatment or an appropriate transfer for one patient who presented to the emergency department's ambulance bay (Patient #2). A total of 78,581 patients were seen and 205 patients were transferred to other facilities in the last six months.

Findings include:

Review of the medical record revealed Patient #2, who was unnamed, arrived to the emergency department (ED) on 01/26/24 of 6:39 PM via ambulance and was discharged one minute later at 6:40 PM.

The ED physician note dated 01/26/24 at 8:35 PM, a late entry, documented Patient #2 was in full arrest with return of spontaneous curculation that was brought in by ambulance and was diverted from another hospital due to loss of vital signs. The ambulance did not call report prior to arrival. The ED was notified that the patient may be coming by the other hospital's nursing staff at about 8:00 PM. The ambulance staff stated the patient had return of spontaneous circulation prior to arrival to the ED. The circumstances of his arrest, age or history was limited to this information. The patient was intubated, unresponsive, and being bagged by ambulance personnel. An advanced airway was in place. Return of spontaneous circulation was confirmed by ambulance personnel. The ED was free standing and had exceptionally limited resources, including oxygen for maintenance of a ventilated patient, no cardiac catheterization lab, no cardiologist, and no inpatient facility. Given the circumstances, the need for emergent percutaneous coronary intervention was warranted and recommended if available. Based on visual evaluation in the ambulance bay, the physician thought this patient would be better served by diversion to a cardiac catheterization capable facility. The ED was having prolonged transportation times for an advanced cardiovascular life support rig in this county. With the free-standing ED limitations and the patient was as stable as could be achieved at this facility, his only chance for a positive outcome was to be seen by a hospital based ED for possible cardiac catheterization and admission. The closest cardiac catheterization capable facility would be notified. The ambulance rig was agreeable to take the patient there. The patient was left in the rig and sent to the hospital based ED.

Review of the ambulance run sheet for Patient #2 revealed the ambulance was dispatched on 01/26/24 at 5:40 PM for unresponsive patient in the middle of the roadway. While en route, the ambulance crew was advised Patient #2 was now in cardiac arrest by another ambulance medic. Upon arrival cardiopulmonary resuscitation (CPR) was initiated using a Lucas device, a mechanical chest compression device. Intubation was completed. Intravenous (IV) access established. Advanced Cardiac Life Support (ACLS) protocol was started. A normal saline IV was started. Epinephrine was given. Pulse check at 6:02 PM and Patient #2 is now in ventricular tachycardia. One shock given. CPR resumed. At 6:06 PM, pulse check showed asystole. Epinephrine given. Patient #2 moved to ACLS ambulance and secured. Yellow IV placed in left humeral head. Patient #2 was placed on ventilator. Curculation 1 at 6:10 PM. Twelve lead cardiac monitoring obtained and showed atrial fibrillation with anterior wall myocardial infarction. IV saline with pressure infuser started. Transport to hospital. At 6:20 PM, Patient #2 went back into cardiac arrest. At 6:21 PM, Epinephrine given. At 6:24 PM, the rhythm check was pulseless electrical activity. At 6:25 PM, Epinephrine given. At 6:27 PM, curculation obtained. Twelve lead cardiac monitor still showed atrial fibrillation with anterior wall myocardial infarction. At 6:34 PM, Patient #2 was back in cardiac arrest. At 6:35 PM, Epinephrine given. At 6:37 PM, pulse check was asystole. At 6:41 PM, arrived at free-standing ED. As doors opened, circulation obtained. ED physician refused patient and told ambulance to go elsewhere where cath center was. At 6:43 PM, transported to another ED. Told the free-standing ED to call to let them know they were coming to them. Twelve lead cardiac monitoring showed atrial fibrillation. At 6:47 PM, Patient #2 back in cardiac arrest. Arrived at ED at 6:48 PM. Patient #2 moved to ED room and ED bed by backboard. Report given to ED staff. Care transferred to ED staff.

On 03/19/24 at 10:32 AM, one of the two named witnesses, Paramedic #1, was interviewed by phone. Paramedic #1 stated that on a recent cardiac arrest call the patient was transported without return of spontaneous circulation. Circulation was achieved so they headed toward a ST-Segment Elevation Myocardial Infarction (STEMI) facility. Circulation was lost and then obtained again, so they headed to this facility's free-standing emergency department . Circulation was lost again, and obtained as the ambulance pulled into the hospital's ambulance bay. The doctor came out and asked if there was circulation and stated they could not stay here and would have to go to another facility with a cardiac catheterization lab. The doctor lectured the ambulance staff on why they could not be there and they left to go to the next facility. They lost circulation during transport again. They arrived at the next ED and they handed off the patient and gave report. The patient did pass away a few days later. Paramedic #1 stated that this is the only time he is aware of this happening.. There were two additional staff in the ambulance at the time who witnessed this.

On 03/19/24 from 2:55 PM to 3:30 PM, the free-standing ED was toured. The free-standing ED had 10 beds, a small lab for point of care testing, and radiology services were available. At most they received 30 to 50 ambulances per month. Most patients came by private vehicle or walk in. During the tour, Staff J stated that she was present on the night of the incident but not part of the decision making. Another hospital called to inform the free-standing ED that an ambulance was being diverted to them. The ED staff was not able to talk to the ambulance directly, they just showed up. The patient had circulation on arrival. The physician made the decision to send the patient on to a cardiac catheterization lab and the patient was not brought into the ED. Staff J stated this was a "gray area" and if the squad had called ahead they would have never been on site. Staff J understands the physician did what was best for the patient, as the other ED in the area had a catheterization lab.

During an interview on 03/19/24 at 5:26 PM, Staff E stated he was not here the night of the incident, as he had just left prior to the ambulance arrival. There was an ambulance from another county that was headed to another hospital. The ambulance was diverted to this hospital due to the patient being in cardiac arrest. Circulation was obtained on arrival to the parking lot. The other hospital had called to give the ED a heads up and there was no direct communication with the ambulance. The ambulance was not on the Lucas County radio. The ambulance pulled in and the provider met the crew at the ambulance. The Lucas device was in place but not active. There was no cardiac catheterization lab at this facility. The provider directed the ambulance to the facility with a cardiac catheterization lab. The patient did not leave the ambulance. The provider "eye balled" the patient due to return of circulation. Patient #2 was added to the ED Log as "John Doe" and the electronic medical record system assigned an Alpha Numeric name. The provider put a note in the electronic medical record system.

During an interview on 03/20/24 at 1:40 PM, Staff A stated that education on Emergency Medical Treatment and Labor Act (EMTALA) was emailed to the staff and providers for review. They followed their normal quality processes which included peer review. The physician who was involved in the incident at the free-standing ED was part of a contracted group, was no longer coming to this facility, and was unavailable for interview.