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Based on interview and record review, Hospital 2 failed to meet its Recipient Hospital Responsibilities for one of four patients (Patient 1), when Hospital 1 contacted Hospital 2 on 2/19/24 to transfer Patient (Pt) 1 who was diagnosed with a dissecting aortic aneurysm and was in critical condition and Hospital 1 did not have the capability to provide the required surgical services to treat and stabilize Pt 1. Hospital 2 did not accept transfer and had the capacity and capability to provide surgical services to Pt 1. Hospital 2 did not follow its policy and procedure "Transfer of Patients - In Bound".

These failures resulted in the transfer of Pt 1 to Hospital 3 which required a ground ambulance transfer of more than three hours (approximately 220 miles), and delayed the surgical procedure needed to stabilize Pt 1's emergency medical condition (EMC) and the potential harm of injury and death. Hospital 2 was about one hour or less from Hospital 1 (approximately 43 miles).

Findings:

During a review of Patient 1's medical record from Hospital 1, the "Acute Transfer" dated 2/19/24 indicated the following:

9:25 p.m. "Received a call from [Physician 1- Emergency Department (ED)] requesting and [sic] urgent transfer for aortic dissection [medical emergency in which the inner layer of the large blood vessel branching off the heart (aorta) tears]."
9:31 p.m. "Placed a call to [Hospital 2] spoke with [Transfer Nurse 1] to request an urgent transfer for aortic dissection."
9:33 p.m. "Connected [Transfer Center Nurse 1] with [Physician 1] for report. [Transfer Center Nurse 1] will call once she is able to connect with her cardio thoracic [CT- doctor who performs surgery on the heart and lungs]."
9:40 p.m. "Called [staff at local air ambulance] for weather check to [Hospital 2 - a 43-minute ground ambulance ride from Hospital 1]."
9:42 p.m. "Received a call from [Transfer Center Nurse 1] requesting to connect [Physician 2 - Hospital 2's Cardiothoracic Surgeon] with [Hospital 1's] cardio thoracic. Connected [Physician 3 - Hospital 1's Cardiothoracic Surgeon] with [Physician 2] who refused to take the patient because he believes that [Physician 3] should be able to take care of this patient."
9:47 p.m. "Called [staff at local air ambulance] to cancel weather check to [Hospital 2] and initiate weather check to [Hospital 3]."
9:48 p.m. "Placed a call to [Hospital 2] spoke with [Transfer Center Nurse (TCN) 1] to advise that it was very inappropriate to deny the patient because [Physician 2] feels that [Physician 3] is [able] to take care of this patient. Per [TCN 1] she will run this up her chain of command."
During a review of Patient 1's transfer center documentation from Hospital 2, dated 2/19/24, the transfer center documentation indicated:
9:32 p.m. Per CM [case manager] they [Hospital 1] are requesting transfer for Cardiothoracic surgery. Pt [patient] info [information] has been faxed."
9:33 p.m. Transfer Center Nurse received a call from Physician 1 to provide report on Patient 1. "Emergency Medical Condition/Diagnosis: Acute [severe and sudden in onset] aortic dissection with hemopericardium [blood in the sac surrounding the heart] . . . They [Hospital 1] attempted pericardiocentesis [procedure done to remove fluid that has built up in the sac surrounding the heart], states 'hard to tell if it was successful', they [Hospital 1] 'removed a small amount of blood . . .They [Hospital 1] discussed with their on call Cardiothoracic surgeon who states he did not feel comfortable handling repeat pericardiocentesis or the surgery needed to correct this condition, recommended transfer. Stated he [Physician 3] did not have enough training for this acute life-threatening condition to be comfortable performing procedure, recommending transfer for HLOC [higher level of care]."
9:37 p.m. "[Transfer] Request Began."
9:39 p.m. "Call to [Physician 2]. MD [Physician 2] called, notified of pt and imaging. States they [Hospital 1] should be able to handle this at [Hospital 1], their CT can call him [Physician 2]."
9:42 p.m. Hospital 1's case manager notified of Physician 2 request to speak with Physician 3.
9:45 p.m. "Conf [conference] call facilitated with [Physician 3 and Physician 2]. [Physician 2] states they [Hospital 1] can handle this at [Hospital 1]. Per [Physician 3], he talked to the team there [Hospital 1] and they are not prepared to do it. [Physician 2] states they [Hospital 1] are affiliated with [Hospital 3], can reach out to them as well."
9:50 p.m. Case is being escalated to Hospital 2's Leadership. "Reason for Escalation: [Physician 2] states pt should be able to be managed at [Hospital 1]. In addition [Hospital 1] is affiliated with [Hospital 3], so they can try there as well."
9:59 p.m. "Call to CMO [Chief Medical Officer] on supervisor cell. CMO aware of escalation text and is in talks with requested service line."
10:07 p.m. "Per escalation text, CMO states [Physician 4- Physician 3's supervisor] is discussing with [Physician 3] now. TC [transfer center] to be updated."
10:25 p.m. "Writer called and spoke with [case manager at Hospital 1], seeking update on status of transfer. [Case Manager] states pt was accepted at [Hospital 3], however will have to go by ground as they are currently unable to fly. TC [Transfer Center] RN [registered nurse] updated.
10:31 p.m. Call to CMO on supervisor cell. Updated[.] TC spoke [with Physician 2], and per [Physician 2] if pt was accepted at [Hospital 3], to continue with transfer there and can call us back if needed. Advised pt will have to go by ground transport. CMO in agreement."
10:33 p.m. "Writer updated [Case Manager] at [Hospital 1] that since pt already accepted at [Hospital 3], to continue with transfer there and can call us [Hospital 2] back if needed."

During a review of Patient 1's "ED Note Physician" dated 2/19/24 at 7:19 p.m., the "ED Note Physician" indicated, Patient 1 had a history of an ascending aortic aneurysm (abnormal bulging and weakening in the upward part of the artery leaving the heart) brought in by ambulance for acute chest pain . . . "Patient was transferred to CT [computed tomography scan- medical imaging technique used to obtain detailed internal images of the body] in stable condition for critical CTA [computed tomography angiography - noninvasive test that uses special X-rays to focus on the coronary arteries to analyze for blockages in the heart arteries]. While waiting for CTA result, patient became hypotensive [abnormally low blood pressure]" was given IV fluids, medication to treat life-threatening low blood pressure, and transfused a unit of packed red blood cells. "CTA [results] demonstrated acute ascending aortic dissection/intramural hematoma [life-threatening aortic disease] with extension into the pulmonary [lung] arteries, with pericardial hemorrhage [bleeding around the heart]. Cardiothoracic surgery is immediately consulted; however, they recommended immediate transfer for HLOC after stabilization with pericardiocentesis . . . This patient was critically ill and at risk for deterioration requiring immediate bedside attention and intervention."

During a review of Hospital 2's list of required services, the untitled document indicated, "Services required 24/7/365 [24 hours a day, seven days a week, 365 day a year] . . . Level I and II trauma centers must have continuous availability of the surgical expertise listed below . . . Cardiothoracic surgery."

During an interview on 4/9/24 at 11:02 a.m. with Hospital 2's Vice President of Capacity Management (VPCM), VPCM stated capacity (bed space, nurses, specialty care areas, equipment, etc.) and capability (can the needed service be provided) are considered before accepting a patient transfer from another hospital. VPCM stated only the CMO can ultimately say no to a transfer request that has been escalated to leadership. VPCM stated Hospital 2 does not question the capabilities of a hospital requesting a transfer if that hospital states they are not capable of performing an emergent procedure.

During an interview on 4/10/24 at 9:21 a.m. with Physician 4 (Hospital 2), Physician 4 stated he received a call from the CMO regarding Hospital 1's transfer request for Patient 1. Physician 4 stated he then called Physician 2 and told him to accept Patient 1.

During an interview on 4/10/24 at 10:35 a.m. with TCN 1, TCN 1 stated she did not remember if word "accepted" was ever used when speaking to Hospital 1 staff.

During an interview on 4/10/24 at 12:39 p.m. with VPCM and Director of Patient Flow (DPF), VPCM and DPF both stated that capacity was not an issue for Patient 1's transfer request.

During an interview on 4/10/24 at 1:29 p.m. with Physician 2 (Hospital 2), Physician 2 stated he received a call from the transfer center regarding Hospital 1's request to transfer Patient 1 to Hospital 2. Physician 2 stated he worked at Hospital 1 for 12 years and "we" did cases like that [aortic dissection repair] all the time. Physician 2 stated he did not know Physician 3 or his capabilities. Physician 2 stated Physician 3 told him that the staff at Hospital 3 was not prepared to do the surgery Patient 1 needed. Physician 2 stated Hospital 1 has an affiliation with Hospital 3, and they should reach out to Hospital 3. Physician 2 stated he was unsure what having a hospital affiliation entailed. Physician 2 stated he did not accept Pt 1 for transfer and explained this to the transfer center. Physician 2 stated he received a call from Physician 4 to accept the transfer of Pt 1 but did not follow through with that instruction because Hospital 1 had obtained approval to send Pt 1 to Hospital 3, and therefore, he did not accept the transfer.

Record review of hospital records from Hospital 3 indicated Pt 1 was transported to the hospital by ambulance on 2/20/24. The travel time for transport from Hospital 1 was approximately 3 hours. Hospital 3's H&P Addendum for Pt 1 dated 2/20/24 at 3:36 p.m. indicated "Complaint: Type A dissection ... 73 yo male with PMH of COPD, HLD, HTN, prior Ml x 2, hx of dilated ascending aorta, after having dinner when he had sudden onset of acute CP and fainted. Per family, performed chest compressions for a few seconds before return of pulses/consciousness ... CT scan shows Type A Dissection with a pericardia! effusion s/p attempted pericardiocentesis- 5 ml pulled (while in OR found pericardia! drain did not appear to be in pericardium). He was transferred to Stanford and found to have intermural hematoma, without dissection flap. He is now s/p root with valve resuspension, ascending, and hemiarch aortic replacement ..."

Hospital 3 Discharge Summary indicated " ... Surgical Priority: Urgent ... Operation Performed: 1. Ascending aortic replacement (24mm Hemashield WDV graft) with aortic valve resuspension and aortic root remodeling; 2. Hemiarch replacement (30mm Gelweave graft) using RCP and DHCA Aortic Dissection ... [Pt 1] was transferred to [Hospital 3] for HLOC and was found to have intermural hematoma, without dissection flap, on arrival to [Hospital 3] he was taken urgently to the OR ... On POD #22 [3/13/24], patient was thought to be stable for discharge to SNF for further rehab. Family adamantly refused SNF and understand possible risk of taking patient home without facility rehab. Family willing to assume these risks given there is a large amount of help at home. Patient discharged home with HH PT/OT and home RN, HHA for continued symptom and medication management ... Discharge diagnosis: Type A aortic dissection w/ pericardia! effusion/tamponade S/p hemiarch/ascending replacement w/ supracoronary resuspension ..."

During a review of Hospital 2's P&P titled, "Transfer of Patients - In Bound," dated 10/20/23, the P&P indicated, "III Policy . . . B. [Hospital 2] will fulfill the EMTALA [Emergency Medical Treatment and Labor Act- Federal law to ensure public access to emergency services regardless of ability to pay] obligation to accept an appropriate transfer of an individual with an un-stabilized emergency medical condition who requires specialized capabilities or facilities as long as the Hospital has the capacity and capability to treat the individual."