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Based on review of medical records, the transfer call log sheet, facility policies and procedures, Medical Staff Bylaws/Rules and Regulations, credential files, facility data, transfer center recordings, Emergency Department (ED) physician schedule, and on-call schedule, and physician and staff interviews, it was determined that the facility lacked an effective system to ensure that individuals from a referring hospital were accepted as an appropriate transfer who required the specialized capabilities or facilities if the receiving hospital had the capacity to treat the individual. This affected one (1) of twenty-one (21) sampled patients (#16). Refer to findings in A-2411.

Based on review of medical records, the transfer call log sheet, facility policies and procedures, Medical Staff Bylaws/Rules and Regulations, credential files, facility data, transfer center recordings, Emergency Department (ED) physician schedule, and on-call schedule, and physician and staff interviews, it was determined that the facility lacked an effective system to ensure that individuals from a referring hospital were accepted as an appropriate transfer who required the specialized capabilities or facilities if the receiving hospital had the capacity to treat the individual. This affected one (1) of twenty-one (21) sampled patients (#16).

Findings were:

A review of the Medical Staff Bylaws/Rules and Regulations revealed that the active medical staff were to provide specialty coverage for the Emergency Department (ED) per Department policy. The on-call physicians were to come in if requested by the ED physician.

A review of the ED physician's contract required that all ED physicians were to comply with the applicable provisions of the Emergency Medical Treatment and Active Labor Act (EMTALA). The contract indicated that the professional conduct of the ED physicians was subject to the bylaws of the facility, the bylaws of the Medical Staff, and the facility's values, code of conduct, policies, rules, programs, and regulations.

A review of facility policy entitled "Athens Regional Medical Center EMTALA Policy", last revised August 2004, indicated that if the hospital provides a service to the public then the same service should be available by on-call coverage in the ED. The facility must have a list of physicians on-call for duty if evaluation and stabilization treatment by a specialty service are necessary. The policy revealed that the on-call specialty physicians have the option of either being contacted directly by out-lying hospitals about a request to accept an appropriate transfer or the specialty physician can have these requests referred to the ED physician on duty at the time of the call. If the on-call physician opts to refer these requests to the on-duty emergency physician, the hospital operator will forward the call to the ED. The emergency physician will speak to the personnel at the out-lying hospital and will accept appropriate transfers. If there is a question about the appropriateness of the transfer, the emergency physician may consult with the on-call physician by phone if necessary.

A review of facility policy entitled "Referrals - Patient Transfer", last revised August 2007, indicated that the emergency physicians may accept transfers of emergency department patients from other hospitals on behalf of those members of the medical staff who have specifically requested that they do so. Requests for patient transfers to the facility are to be forwarded to the Transfer Call Center.

A review of facility policy entitled " Medical (Physician) Coverage for the Emergency Department", last revised July 2007, indicated that medical staff coverage on-call lists will be maintained in the unit secretary's work area of the nurses station and will be posted in both Pod A and Pod B secretarial areas and in the attending physician and ED physician dictation rooms. The policy further revealed that emergency physicians are provided by means of a contract with the ED Medical Director and Athens Regional Medical Center.

A review of the "Georgia Emergency Medical Specialists" Orientation Handbook, the training guide for orientation of new ED physicians, indicated that the Transfer Call Center (TCC) was located in the ED and staffed by registered nurses. The TCC maintains a database with the transfer "preferences" of the medical staff. Many physicians have requested that the emergency physicians accept ED transfers on their behalf, so many calls are referred to the ED physicians. The TCC nurse will take the call and contact an ED physician to speak with the transferring physician. The call is recorded and the TCC nurse listens to the entire conversation. The Handbook also indicated that the ED physicians are obligated to accept an incoming transfer if: (1) the patient is an ED patient, (2) the patient has an "emergency medical condition, (3) the transferring facility is unable to provide the level of care the patient needs to stabilize the condition, and (4) this facility is able to provide the level of care the patient needs and has an appropriate bed. The training material revealed that if the ED physician is unsure if these requirements are met he/she should err on the side of caution and accept the patient.

A review of patient #16's medical record from the transferring facility revealed that the patient presented to the facility's emergency department (ED) via emergency medical system (EMS) ambulance on 4/22/2012, with a chief complaint of pain in the back and pain and numbness in the right leg. Diagnostic studies (ultrasound and CT scan) were performed and identified a massive aortic abdominal aneurysm (AAA - a swelling or bulging of the body's largest blood vessel, the aorta, in the abdominal area which can become life threatening if a rupture occurs). The studies also indicated that the patient's aneurysm had ruptured. Further documentation by the ED physician at the referring hospital revealed in part, " The patient appears to be cold, acutely ill appearing, and there is word from EMS that he spent the last 10 days in a tent in a campground. . . . Medical Decision Making: I (ED physician at referring hospital) felt the patient immediately needed to be transferred for definitive care, specifically surgery, but we needed a CT scan (specialized x-ray). .. Immediately I went to CT with him Blood pressure waxed and waned, sometimes going down to the 80 ' s and 90 ' s which required fluid boluses (rapid infusion of intravenous fluid), otherwise I would cut the fluid off so that we would not over resuscitate him causing him to bleed more." The radiologist confirmed that the patient had a massive ruptured AAA with significant bleeding and no blood flow to the iliacs arteries (arteries below the umbilicus that branch off the aorta to the left and right) or femoral arteries (vessels that supply blood to the legs). Additionally, the ED physician documented in part, " at 2:17 p.m., radiologist called me stating that there was evidence of COPD (Chronic obstructive Lung Disease- this disease limits airflow to and from the lungs causing shortness of breath) from the CT scan, coronary artery disease and left kidney appeared to be quite abnormal, and there was bleeding towards and around it . . . At 2:19 p.m. we also attempted to contact Athens Regional Medical ...at 2:28 p.m.- I was given the phone with the vascular surgeon on call on 4/22/2012 (at Athens Regional Medical), the vascular surgeon stated that despite the patient's (#16) need for the immediate transfer and their ability to take the patient, he felt that this was too far, and other hospitals in the . . . area should accept him, I (ED at transferring hospital ) did discuss with him that we had contacted multiple other hospitals, had other pages in place. . . but the vascular surgeon stated he will not accept the patient, and that I needed to call elsewhere." The facility failed to accept an appropriate transfer of an individual (#16) who required the specialized vascular capabilities to treat patient #16 with an identified emergency medical condition on 4/22/2012. Patient #16 was finally accepted at another acute care facility transported via helicopter and taken emergently to surgery.
A review of the "Transfers In" Call Log Sheet for 04/22/12 revealed that the facility's transfer center received a transfer request for patient #16. The transfer center documented four (4) calls related to the requested transfer of the patient to this facility. The transfer request was from an ED department at an acute care facility in Cummings, Georgia. The patient had a ruptured AAA and the referring facility was requesting transfer for a higher level of care with the services of a vascular surgeon. An intensive care unit (ICU) bed placement was anticipated. The Log Sheet documentation revealed the following summary of the calls:

2:23 p.m. - Telephone call from (TCF) the transfer center at ED in Cummings, GA. They are in need of a vascular surgeon for a patient with a ruptured AAA.

2:25 p.m. - Telephone call to (TCT) the MD Dictation area. ED physician/credential file #2 answered. He/she asked why they were calling us, as there were many hospital much closer. Conference call established. Referring ED physician advised that he/she had tried four (4) other facilities. ED physician/credential file #2 advised referring physician that it would be better to find a closer facility. ED physician/credential file #2 asked transfer center staff to contact the vascular surgeon.

2:29 p.m. - TCT the facility operator to page the vascular surgeon/credential file #1. Case explained by transfer center staff to the vascular surgeon who reported he/she would speak to this facility's ED physician/credential file #2.

2:45 p.m. - TCF this facility's ED physician/credential file #2 advising that the vascular surgeon/credential file #1 would like to speak to the referring ED physician if he/she calls back.

The Transfer Log Sheet listed the transfer request as "refused/other" because the ED physician/credential file #2 advised that it would be better to transfer the patient some where closer.

After the Transfer Log Sheet was reviewed, the transfer call center audiotape recordings were played of the four (4) calls that were recorded related to patient #16. The recordings including the following information related to the calls:

Call #1 at 2:23 p.m. - A call was received from the transfer center of the referring ED facility requesting a transfer of a patient (patient #16) with a ruptured AAA. A call back number was obtained and the referring facility was advised that a physician would be contacted and a return call made.

Call #2 at 2:25 p.m. - A call was made from this facility's transfer center to this facility's ED physician/credential file #2 to inform him/her of the requested transfer of a AAA patient from the referring facility. The ED physician/credential file #2 asked where Cummings (the location of the referring facility) was located and were they the closest facility to them. The transfer center staff was not sure if they were the closest or if other facilities had been contacted. The ED physician/credential file #2 agreed to talk to the referring physician and was connected to him/her. The referring physician explained that they were about 40 miles from this facility and acknowledged that Atlanta was closer to their facility but he/she listed (5) other facilities that had been contacted and the patient had not yet been accepted anywhere. He/she listed two (2) additional facilities that were being contacted in an attempt to find placement. The ED physician/credential file #2 commented that there are a ton of hospitals in Atlanta and he/she was surprised they can't find anyone to take the patient. During the conversation, the referring physician put the ED physician on hold to take another call. During that time this facility's ED physician/credential file #2 asked his/her call center staff to call the vascular person on call and notify them that the Cummings facility wanted to transfer a AAA patient that did not have a vascular surgeon on board. He/she wanted to let the vascular surgeon know what's going on and comments that it is so far to send a ruptured AAA. The referring doctor returned to the phone. The ED physician/credential file #2 explained that it did not seem like a good idea to transfer a patient with a ruptured AAA this far. He/she gave a specific recommendation of another facility to try first which was in Atlanta and was a Level 1 trauma center with vascular surgery service. The ED physician/credential file #2 stated that that he/she would have their guys talk to their vascular surgeon in the meantime and see what they could figure out and again mentioned that it seemed like a long way to send a ruptured AAA. The call stopped between the doctors. The ED physician/credential file #2 then asked the transfer center staff to contact the on-call vascular surgeon/credential file #2 and review the situation. He/she commented that he/she was not sure if the vascular surgery physician would want them to accept a ruptured AAA from that far away.

Call #3 at 2:29 p.m. - The transfer center staff contacted the on-call vascular surgeon/credential file #1 to advise him/her that the ED physician/credential file #2 wanted the vascular surgeon's involvement before acceptance. The information was reviewed regarding a requested transfer from Cummings of a patient with a AAA and that they were having a difficult time finding a transfer placement. The surgeon/credential file #1 questioned why they were trying to transfer here when there were about 50 hospitals 15 or 20 minutes from them. The transfer staff responded that the referring doctor had tried several other facilities but that no place was available. The surgeon/credential file #1 reported that he/she had never had a referral from that facility and that he/she didn't feel comfortable taking the referral from that far away but he/she wanted to speak more with this facility's ED physician/credential file #2 and would call him/her to discuss further. The call ended and there was no recording made of the discussion between the ED physician and the vascular surgeon at this facility.

Call #4 at 2:45 p.m.- The ED physician/credential file #2 contacted the transfer call center. He advised the transfer center staff that he/she had talked a long time with the vascular surgeon and that the vascular surgeon wanted to speak directly to the referring ED physician if he/she calls back.

A review of the facility's Specialty Referral List, updated April 13, 2012, indicated that an ED referral of a patient requiring the services of a vascular specialist were to be referred to the ED physician.

An interview was conducted at 5:00 p.m. on 11/13/12 in the administrative conference room with the transfer call center nurse who received the transfer call request on patient #16. The interviewee reported that when he/she first received the transfer request he/she initially started to page the vascular surgeon on call but remembered that their policy was for the ED doctors to accept the ED to ED transfers for vascular surgery patients. The interviewee informed the ED physician regarding the referring facility's request for the patient's transfer, connected the ED physicians at the two (2) facilities to discuss the case, and was later asked by his/her ED physician to connect the referring physician directly to the vascular surgeon on call if the referring physician called back.

An interview was conducted at 4:40 p.m. on 11/13/12 in the administrative conference room with the ED physician/credential file #2 who was involved with the transfer request call from the referring facility. The interview and a written statement received from the physician after the interview revealed the following information. The physician received a call through the transfer call center from a physician in Cummings, GA. requesting to transfer a patient with a ruptured AAA. He/she had never received a transfer request previously from the facility. The facility was 1.5 hours away and it seemed that there were closer facilities around Atlanta to transfer this critically ill patient. The referring physician was questioned regarding what other facilities had been contacted and then suggestions were made of other closer facilities to try that would have vascular surgery services. The referring physician was told that this facility's ED physician/credential file #2 would discuss the case with the vascular surgeon in the meantime, and advised him/her to call back if he/she could not find a closer facility. It was made clear that it seemed strange to transfer a critically ill patient 1.5 hours, bypassing multiple larger facilities, to get to this facility. This facility's ED physician then contacted this facility's vascular surgeon who agreed with the assessment that there should be many closer facilities with vascular surgery services. The vascular surgeon agreed to speak with the referring physician directly if he/she called back and the transfer call center was notified to connect the referring physician to the vascular surgeon if a call back was received. The interviewee reported they never received a call back from the referring physician.

An interview was conducted at 4:15 p.m. on 11/13/12 in the administrative conference room with the vascular surgeon/credential file #1 who was on call for vascular surgery services on 04/22/12 when a transfer request was made for patient #16. The interview and a written statement received from the physician after the interview revealed the following information. The surgeon has been at the facility for 15 years and has not received a transfer call from this facility before. He/she spoke with the facility's transfer center and was advised of the transfer request for a patient with a AAA. He/she was uncomfortable that an attempt was being made to transfer an unstable patient 1.5 hours past seven (7) hospitals that had similar services. These concerns were expressed to this facility's transfer center staff and he/she called this facility's ED physician/credential file #2 directly to discuss the case. He/she was informed that ED physician #2 had advised the referring physician of closer facilities with similar services. The vascular surgeon concurred that it seemed unrealistic to expect an unstable ruptured AAA to be able to survive a transfer to Athens. If a closer facility did not accept the patient, the vascular surgeon advised ED physician #2 that they could accept the patient and the surgeon understood this information was communicated to the transfer call center and the referring facility. If the referring physician called back, he/she was to be connected directly to the vascular surgeon. The referring physician never called back and the vascular surgeon never had any direct contact with the referring physician or referring facility's transfer call center. The interviewee reported that the hospital policy regarding vascular surgery is that all calls go to the ED physician and they are authorized to accept patients on behalf of the vascular surgeons at all times. The vascular surgeon indicated that they do not turn down transfers and it is hospital policy is to take all transfer requests. He/she felt that ED physician #2 was correct to suggest closer facilities for a patient with this condition. The vascular surgeon reported that although he/she did not think a transfer to this facility would have been in the best interest of the patient due to the seriousness of his/her condition and the distance need to travel, the facility would have accepted the patient if the facility had called back advising that a closer accepting facility was not found.

A review of the Emergency Physician Schedule for April 2012 confirmed that the ED physician/credential file #2 was scheduled to work from 8:00 a.m. to 4:00 p.m. on 04/22/12.

A review of the ED Service Call Roster indicated that physician/credential file #1 was assigned on-call responsibility for vascular services on 04/22/12. A review of the credential files for the vascular surgeon/credential file #1 indicated that he/she had been granted privileges for emergency surgeries related to aortic aneurysms.

Review of the credential files for the vascular surgeon/credential file #1, the ED physician/credential file #2, and the ED Medical Director/credential file #3 revealed appropriate licensure and credentialing. The ED physician and ED Medical Director were both board certified in emergency medicine. The vascular surgeon was board certified in surgery and vascular medicine.

An interview was conducted with the Director of Accreditation at 9:30 a.m. on 11/15/12 in the administrative conference room. The interviewee reported that the facility has a total capacity of 359 patients. There are 36 adult intensive care unit (ICU) beds with 12 designated as cardiac beds and 24 designated as general medical-surgical beds. Vascular surgery patients are routinely assigned to the medical-surgical ICU beds. The interviewee confirmed that on 04/22/12 neither the facility nor the ICU units were at full capacity with a total facility census of 265 patients and a total ICU census of 28 patients. The facility had the capacity to provide the specialized vascular services needed for patient #16 on 4/22/2012.