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Based on review of hospital Emergency Medical Treatment and Active Labor Act (EMTALA) policies and procedures, observation and interviews, it was determined that the Level 1 Trauma Center Hospital failed to comply with their policy to provide triage and a medical screening examination to all patients who are in need of emergency treatment that can not be provided by an initial treating hospital.

On the evening of 12/11/09 the Transferring Hospital Emergency Department (ED) physician attempted to arrange the transfer of a patient (Patient #1) with a ruptured globe to the care of the on call Ophthalmology Resident and Attending for the Emergency Department at Level 1 Trauma Center Hospital.

There was an ophthalmologist on call on December 11, 2009 for the Transferring Hospital, and this physician was paged. He did not answer the pages so the Transferring Hospital ED physician called the Level 1 Trauma Center Hospital with a residency program. He talked to the ophthalmology resident physician and documented that the resident said they do not cover for this hospital (the Transferring Hospital).

At 4:00 a.m. the Transferring Hospital ED physician called the on-call ophthalmologist at home and the on-call ophthalmologist advised the Transferring Hospital ED physician that ruptured globes go to the Level 1 Trauma Center Hospital per pre-arrangement - according to the VP Medical Affairs.

At 4:22 a.m., the Transferring Hospital ED physician again called the ophthalmology resident at the Level 1 Trauma Center Hospital and she advised him that this is NOT true - they do not have an agreement - and she would not take the patient. The ophthalmology resident told the Transferring Hospital ED physician to call another (alternate) hospital (Nearby Alternate Hospital) which she said is closer to them than the Level 1 Trauma Center Hospital. The Transferring Hospital ED physician then called Nearby Alternate Hospital Transfer Center and spoke with a Registered Nurse (RN) to attempt to transfer Patient #1 to Nearby Alternate Hospital. All calls with the Nearby Alternate Hospital Transfer Center are recorded.

The Findings Included:

REVIEWED at Level 1 Trauma Center Hospital:
1. The Emergency Log.
2. Twenty (20) Emergency Department medical records from July to December 2009 - chosen by the surveyors from the Emergency Log. The patient record of the transfer in question was in this sample.
3. Nurse staffing schedules for the Emergency Department for December 2009 and January 2010.
4. Emergency Department Physician schedules for July - December 2009.
5. Attending physician on-call schedules for July-December 2009.
6. Personnel files of
7. Medical Staff Credentialing files of
8. Hospital EMTALA policies and procedures.
9. Quality documents for the ED for 2009.
10. Medical Staff By-Laws.
11. Bed Tower log for patient's transferred in as a direct admission.
12. Medical Executive Committee Minutes for January-December 2009.

INTERVIEWED at Level 1 Trauma Center Hospital:
1. Vice President of Medical Affairs
2. Emergency Department Medical Director
3. Chairperson of Ophthalmology Department
4. Attending Ophthalmologist on-call the night of December 11, 2009
5. Ophthalmology Resident on-call the night of December 11, 2009
6. ED Team Coordinator
7. Bed Tower Director and Manager
8. Patient Safety Specialist/Accreditation Operations Manager

OBSERVED at Level 1 Trauma Center Hospital:
1. Emergency Department - 40 bed ED with a 5 bed fast track unit. This is a Level 1 Trauma/Burn Center.

This Level 1 Trauma Center hospital is a 534 bed hospital in the center of a busy city and is a referral center for many outlying hospitals. It has a residency program for the Eastern Virginia Medical School. The ophthalmology residency program, which is involved in the complaint, has six (6) resident physicians.

The complaint investigation stemmed from a previous investigation - which alleged that the Transferring Hospital could have handled treating a patient with a severe eye injury. The Transferring Hospital no longer did eye surgeries and had no eye equipment for their on-call ophthalmologist to use.

INTERVIEWED at Transferring Hospital:
1. Emergency Department Attending Physician on the evening of 12/11/09
2. Administrator

REVIEWED at Nearby Alternate Hospital:
1. The taped conversations with the Transfer Center Nurse and ED physician for Transferring Hospital

INTERVIEWED at Nearby Alternate Hospital:
1. Director of Patient Care Operations
2. Director of Med Surg.
3. Chief Nursing Officer
4. Emergency Department Nurse Manager
5. Director Customer Relations Management (Transfer Center Director)
6. CSA (Registration clerk)
7. Medical Director of the Emergency Department
8. Orthopedic Surgeon on Call 8/31/09
9. Orthopedic Trauma Specialist
10. Senior Vice President/Administrator
11. Director of Human Resources
12. Vice President Trauma and Emergency Services
13. Emergency Department Physician on duty 8/31/09


A 43 year old male (Patient #1) presented ambulatory to the Transferring Hospital's on-site Emergency Department at 1:46 a.m. on December 11, 2009, with the chief complaint of a fall with eye trauma and multiple facial lacerations. The Patient #1 was seen by the Transferring Hospital ED physician, medicated for pain and nausea, and taken to x-ray at 2:14 a.m. for a CT scan without contrast of the eye orbit, plus a chest x-ray. The patient returned to the ED from x-ray at 2:55 a.m. and the Transferring Hospital ED physician saw him again measuring his eye pressure with a Tonopin (a pen that measures eye pressure). By 3:14 a.m., the physician determined that the patient had hyphema (blood in the front area of the eye) and a rupture of the eye globe with partial intraocular tissue loss. This hospital only has periodic on-call ophthalmology coverage, as they only have two ophthalmologists on the medical staff.

There was an ophthalmologist on call on December 11, 2009 for Transferring Hospital, and this physician was paged. He did not answer the pages so the Transferring Hospital ED physician called the Level 1 Trauma Center Hospital, which has a residency program. He talked to the ophthalmology resident physician and documented that the resident said they do not cover for the Transferring hospital.

At 4:00 a.m. the Transferring Hospital ED physician called the on-call ophthalmologist at home and the on-call ophthalmologist advised the Transferring Hospital ED physician that ruptured globes go to the Level 1 Trauma Center Hospital per pre-arrangement - according to the VP Medical Affairs.

At 4:22 a.m., the Transferring Hospital ED physician again called the ophthalmology resident at the Level 1 Trauma Center and she advised him that this is NOT true - they do not have an agreement - and she would not take the patient. The ophthalmology resident told the Transferring Hospital ED physician to call another (alternate) hospital (Nearby Alternate Hospital) which she said is closer to them than the Level 1 Trauma Center Hospital. The Transferring Hospital ED physician then called Nearby Alternate Hospital's Transfer Center and spoke with a Registered Nurse (RN) to attempt to transfer Patient #1 to Nearby Alternate Hospital. All calls with the Nearby Alternate Hospital's Transfer Center are recorded.

The Transferring Hospital ED physician stated, "She (the Nearby Alternate Hospital Transfer Center RN) was going to connect him to the ED physician there (Nearby Alternate Hospital), but inquired about the patient's insurance first, and then told the doctor that since the patient had Optima HMO, he (Patient #1) would be out of his insurance network, he would probably end up with a large bill at their hospital.

The Transferring Hospital ED physician told the Nearby Alternate Transfer Center RN that their on-call ophthalmologist did not have the ability to operate on the patient at their hospital because they do not have the equipment needed, and Level 1 Trauma Center Hospital refused to accept the patient from them. She then said she would let the Transferring Hospital ED physician talk to their Nearby Alternate ED physician and he said okay. In the meantime, the Transferring Hospital ED physician said he found a protocol for transferring patients to Level 1 Trauma Center Hospital and he told the Nearby Alternate Transfer Center RN he would try that first. The call then ended.

The Transferring Hospital ED physician hung up from that call, called the on-call Administrator at his hospital (Transferring Hospital) at 4:45 a.m., and discussed the transfer difficulty with her. The on-call administrator recommended transferring the patient to the Level 1 Trauma Center ED. The Transferring Hospital ED physician then talked to an ED physician at Level 1 Trauma Center Hospital who accepted the patient. The patient was transferred at 6:15 a.m. by Medical Transport. The patient was medicated for pain and nausea to keep him comfortable during the wait.

On January 20, 2010 at 3:10 p.m., the surveyors interviewed the Transferring Hospital ED physician who initially treated the patient with the ruptured globe eye injury on December 11, 2009. The Transferring Hospital ED physician said it took three phone calls to the Level 1 Trauma Center and at least 1 1/2 to 2 hours to get the patient accepted for transfer. However, he said, the patient needed to get to an operating room. The Transferring Hospital ED physician confirmed the events listed above.

Review of the patient's medical record at Level 1 Trauma Center Hospital revealed that the patient arrived at the Level 1 Trauma Center Hospital at 6:50 a.m. Ophthalmology was notified at 8:05 a.m., and saw the patient at 8:20 a.m. The patient was prepared for surgery and was taken to surgery at 9:25 a.m.

Interview #1:
On 1/26/10 the Level 1 Trauma Center Hospital ED Medical Director was interviewed regarding the transfer of a patient from one hospital to their hospital. He stated, "If the calling physician doesn't know the system that physician will call the specialist on call instead of the ED attending." "If a physician calls and asks to speak with the ophthalmologist on call they will speak with the resident on call." We (Level 1 Trauma Center Hospital) prefer the physician from another hospital ED call and speak with our (Level 1 Trauma Center Hospital) ED attending regarding a transfer." "We will always accept the transfer."

Interview #2:
The Chairperson for Ophthalmology (CoO) was interviewed on 1/28/10 and provided the following information. The CoO stated, "I have been the chairperson for 1 year and hold the position for 2 years." "Since my residency I have had 16 years in ophthalmology."

The CoO was asked about patients being transferred for ophthalmology emergencies from another hospital to the Level 1 Trauma Center Hospital and she stated, "The ED physician should call the ophthalmologist on call for that hospital (transferring hospital). The ophthalmologist on call for that hospital (the Transferring Hospital) should come to the ED of that hospital and see the patient before determining if a transfer is needed." "What has been occurring is if there is no ophthalmologist on call or the ophthalmologist on call doesn't want to come into the ED they will send to (Name of Level 1 Trauma Center Hospital) because we have a resident on call." The CoO explained, "An attending is required to be on call with a resident."

The CoO explained, "Each department sets their own on call rules."

The CoO was asked to explain what equipment was necessary to close a ruptured globe. The CoO stated, "If the hospital had an operating room and is capable of performing cataract surgery they can close a ruptured globe." "You need an operating microscope, ophthalmic needle holders, forceps and sutures; what you would find on a cataract tray."
"If the patient has a retinal detachment the specialist can treat that the next day or up to 24 hours. If the patient has an orbital fracture that can wait to be treated for up to 2 weeks." "A resident can not perform surgery without the attending present."

"The transfer from (Name of Transferring Hospital) was an inappropriate transfer."

Interview #3:
The Ophthalmology resident (OR) on call for Level 1 Trauma Center Hospital 12/11/09 was interviewed on 1/28/10 and provided the following information. The OR stated she had completed one year of a medical residency/internship and had been in the ophthalmology residency program for 1 and 1/2 years.

The OR was asked to describe the events of 12/11/09 involving Patient #1 as she remembered them. The OR stated, "I received a call from the ED physician at (Name of Transferring Hospital) on 12/11/09 at about 3-4 A.M. He asked if we (Level 1 Trauma Center Hospital) was on call for them (Transferring Hospital)." She stated she told the Transferring Hospital ED physician, "No we are not on call for you. If you have no ophthalmology coverage call (Name of Nearby Alternate Hospital) they have coverage and they are closer to you." She then stated, "The (Transferring Hospital) ED physician stated he had called the ophthalmologist on call for them and the ophthalmologist on call said we (Level 1 Trauma Center Hospital ) was to cover." The OR stated, "He (Transferring Hospital ED physician) said this (the case, Patient #1) is a ruptured globe, do you cover for a ruptured globe? I understand there is an arrangement with (Name of Level 1 Trauma center Hospital)." The OR stated she told the (Transferring Hospital) ED physician, "No, there is no arrangement."

The OR stated, "He (the Transferring Hospital ED physician) never asked me to take the patient and I never refused to take the patient." "We (residents) can't accept or decline a patient."

The OR was asked what equipment was necessary to close a ruptured globe and she stated, "You need less equipment to care for a ruptured globe than to care for a cataract." "Ruptured globes are best closed immediately, even 30 minutes can make a big difference."

The OR provided the name of the Attending Ophthalmologist on-call the night of December 11, 2009 with her and described the Attending as a general ophthalmologist.

Interview #4:
On 1/28/10 the Vice President of Medical Affairs (VPMA) (at Level 1 Trauma Center Hospital) was interviewed regarding the transfer of Patient #1 and provided the following information.

The VPMA was asked who the Attending Ophthalmologist on-call the night of December 11, 2009 was and he provided the name of the physician. The VPMA stated, "Residents can't give advice or consult." He stated, "A resident has a medical license and can accept a patient." He was asked who was the last deciding factor in accepting a patient for transfer or not and stated, "The ED attending is the final straw. They don't have to get permission from anyone to accept the patient."

Interview #5:
On 1/28/10 the Attending Ophthalmologist (AO) on-call for the Level 1 Trauma Center Hospital the night of December 11, 2009 was interviewed by telephone and provided the following information.

The AO was asked to describe her experience as an Ophthalmologist and stated, "I have been out of my residency for approximately 2 and 1/2 years and have treated approximately 15 ruptured globes."

The AO was asked if she recalled the events of 12/11/09 involving Patient #1 and stated, "Yes." The AO explained, "I was the attending on call and was called about 8ish in the morning by the resident." "(Name of Resident) told me she had been called early in the morning by (Name of Transferring Hospital) about transferring a ruptured globe." "She (Resident on call) said it was appropriate to transfer the patient to (Name of Nearby Alternate Hospital). I'm not sure who she was telling." "I didn't hear any more about the patient (Patient #1) until he arrived in the ED at (Name of Level 1 Trauma Center Hospital)."

The AO stated she spoke with the VPMA and he explained the events of the evening.

The AO was asked what equipment was needed to care for a patient with a ruptured globe and she stated, "It is similar to what is needed for cataract surgery. You can care for a ruptured globe if you can care for a cataract."

The AO was asked to describe her professional on relationship with a resident on call. The AO stated, "They (resident) can accept a patient from a referring hospital but I want to be called immediately and told about the case." "I am ok with them (residents) saying to the referring hospital to go to the nearest hospital that can treat the emergency."

During the investigation another occurence was identified of Level I Trauma Center (this hospital) failure to accept a transfer. The findings follow:

On 8/31/09 at 1:07 A.M. Patient #3 presented to the (hospital identified as the Nearby Alternate Hospital) ED following a MVA (Motor Vehicle Accident). The x-rays obtained on 8/31/09 indicated Patient #3 had 1. an acetabular fracture on the right and 2. dislocation of the femoral head due to the fracture. The Nearby Alternate Hospital ED physician recommended admitting Patient #3 and called the orthopedic surgeon on call (Orthopedic Surgeon (OS). The Orthopedic Surgeon reviewed the x-rays of Patient #3 online and refused to admit Patient #3 to Nearby Alternate Hospital.

The OS was interviewed by telephone on 1/26/10 and provided a written statement of events dated September 1, 2009. The OS stated, "I was uncomfortable in caring for the complexity of the trauma and recommend the patient (Patient #3) be transferred to Name of Hospital (Level 1 Trauma Center Hospital). He (Patient #3) needed an orthopedist who specializes in trauma." OS stated, "I never came into see him (Patient #3) because I didn't think it was necessary after reviewing his films." The OS stated, "The General Surgeon on Call for that evening was willing to admit the patient (Patient #3) to Nearby Alternate Hospital but wanted a Orthopedic Surgeon who was going to handle the case to back him up. The General Surgeon saw the patient (Patient #8) in the Nearby Alternate Hospital ED."

OS stated, "I spoke with (Name of Physician at Level 1 Trauma Center Hospital who treats orthopedic trauma patients) who agreed to take the patient (Patient #3) but then said Nearby Alternate Hospital had hired a trauma orthopaedist and he would call him." "Dr. (Name of Physician at Level 1 Trauma Center Hospital, who treats orthopedic trauma patients) called back saying the trauma orthopaedist at Name of Nearby Alternate Hospital would take the case." "I received a call from the Name (of general surgeon on call for Nearby Alternate Hospital) who said trauma orthopaedist was not on call and he would see the patient tomorrow (9/1/09)." "I was not comfortable with that and did not feel the patient could wait so I recommended the patient be transferred to another hospital."

On 1/26/10 the Nearby Alternate Hospital Orthopedic Trauma Specialist (OTS) was interviewed via telephone and stated he had dictated a concern which was given to the medical director. The OTS stated, "Most orthopedics could manage the dislocation as an emergency and then a Orthopedic Trauma Specialist could come in 2-4 days later and do the definitive surgery from the posterior wall fracture standpoint." The OTS stated, "I received a call from the Orthopedic Trauma Specialist at (Name of Level 1 Trauma Center Hospital) asking why they wanted to transfer patient (Patient #3) and why he was not being managed at our hospital (Nearby Alternate Hospital)." "I called (Name of Doctor OS) and he stated he was not comfortable stabilizing the hip." "I told (Name of Doctor OS) I would help if he would handle the initial injury." "I was not on call on 8/31/09 and I did not agree to accept the patient (Patient #3)."

A review of Patient #3's clinical record revealed the following occurred on 8/31/09:
? 1:07 A.M. arrived at Nearby Alternate Hospital ED
? 2:35 A.M. x-rays obtained and preliminary results
? 4:42 A.M. OS reviews record on line and determines he can not treat Patient #3
? 5:46 A.M. Level 1 Trauma Center Hospital initially accepts Patient #3
? 6:14 A.M. Level 1 Trauma Center Hospital refuses Patient #3 until discusses case with Orthopedic Trauma Specialist
? 1:55 P.M. Helicopter arrives to transport Patient #3 to a fourth hospital
There were no additional notes in Patient #3's clinical record that addressed the transfer of Patient #3 to another facility.

A review of OS's "Order of events written on September 1, 2009 revealed the following:
? 6:45 A.M. Level 1 Trauma Center Hospital ED physician want OS to discuss case with Orthopedic Trauma Specialist
? 7:10 A.M. Orthopedic Trauma Specialist from Level 1 Trauma Center Hospital wanted to discuss case with Orthopedic Trauma Specialist from Nearby Alternate Hospital
? 7:45 A.M. OS discussed case with Orthopedic Trauma Specialist at Level 1 Trauma Center Hospital and relayed Nearby Alternate Hospital would keep Patient #3 and Orthopedic Trauma Specialist at Nearby Alternate Hospital would consult on case with the General Surgeon on call for 8/31/09
? 9:30 A.M. Orthopedic Trauma Specialist at Nearby Alternate Hospital declines to come to Nearby Alternate Hospital because not on call; recommends transferring to Level 1 Trauma Center Hospital
? 11:30 A.M. General Surgeon reported Level 1 Trauma Center Hospital Orthopedic Trauma Specialist refuses to accept Patient #3
Discussed Patient #3 with a fourth hospital who agreed to accept Patient #3