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Based on record review and interview, the facility failed to follow the provider's agreement to comply with special responsibilities of Medicare hospitals in emergency cases. Specifically, the facility failed to accept, in a timely manner, an appropriate transfer requiring specialized capabilities for 1 patient (#31), out of 3 transferred patients reviewed. This failed practice delayed care and had the potential to place the patient at risk for complications and delayed recovery.

Findings:

Patient #31

Record review on 9/6/24 and 9/9-11/24 revealed Patient #31 presented to the Alaska Regional Hospital (ARH) emergency department (ED) on 8/29/24 at 7:20 pm by ambulance with two lacerations, estimated at 4-inches in length each, to the front (anterior) on his/her neck.

During an interview on 9/9/24 at 1:20 PM, ARH ED Physician #8 stated at the time Patient #31 presented to the facility, there was no Ear, Nose, and Throat (ENT) specialty available within the hospital. Because of the extent of the trauma, ARH ED Physician #8 initiated a request, through the transfer center call line, for an expedited transfer to Providence Alaska Medical Center (PAMC) for treatment as they had ENT specialty available. ARH ED Physician #8 further stated he/she completed a chest x-ray and CT angiogram (CTA - medical imaging that uses x-rays and special dye to create detailed pictures of blood vessels and tissues of the body), and at the time of contacting the transfer center call line, the CTA imaging results were not back yet.

ARH ED Physician #8 further stated there was resistance from PAMC's ENT physician to accept the transfer, requested imaging results and photos prior to making a decision, and then questioned ARH's ability to handle the case themselves. Due to this interaction, ARH ED Physician #8 included hospital administration, and after the administration talked with PAMC the transfer was accepted.

Review of the transfer center call line's audio recordings of the phone calls between ARH and PAMC, dated 8/29/24 and provided by ARH, revealed ARH ED Physician #8 was connected with PAMC ED Physician #16 who stated he/she would accept the patient assuming PAMC ENT Physician #24 was in agreement.

Further review revealed:

1. ARH ED Physician #8 was able to talk directly to PAMC ENT Physician #24. ARH ED Physician #8 gave a report on the extent of the injury, expressed concerns that this wound was deep enough to expose subcutaneous fat layers and he/she had concerns it may have gone deeper into neck structures, declared ARH did not have the capabilities to treat this injury, and requested transfer to PAMC for treatment.

2. PAMC ENT Physician #24 stated, "basically it is just a cut to the neck" and asked if surgery was available at ARH. ARH ED Physician #8 stated ARH did have general surgery but felt this wound may require ENT specialty if surgical repair was necessary. PAMC ENT Physician #24 asked how deep the cuts were, ARH ED Physician #8 offered to send pictures if it was needed to gain approval, PAMC ENT Physician #24 requested the pictures. After reviewing the pictures, PAMC ENT Physician #24 stated he/she couldn't tell how deep the cuts were, and ARH ED Physician #8 stated he/she did not feel comfortable exploring the wound which could cause more damage.

3. PAMC ENT Physician #24 requested the CTA imaging results be forwarded for his/her review prior to accepting the transfer. ARH ED Physician stated he/she would send the imaging to PAMC.

Review of PAMC's documentation of the timeline for the phone conversations between the physicians, dated 8/29/24, revealed the following timeline:

- 8:00 pm: First call from ARH to transfer center requesting transfer for Patient #31 to PAMC.

- 8:03 pm: PAMC ED Physician #16 agreed to accept Patient #31 to the ED assuming PAMC ENT Physician #24 was agreeable.

- 8:13 pm: ARH ED Physician #8 was connected with PAMC ENT Physician #24, photos of wounds sent, CTA imaging requested.

- 8:26 pm: The CTA imaging for Patient #31 was available for PAMC ENT Physician #24 to review.

- 8:40 pm: PAMC ENT Physician #24 notified the transfer center he/she was reviewing the imaging.

- 9:26 pm: Review of documentation revealed: ". . . Providers connected at this time. Disagreement as to if patient requires transfer to ENT. [ARH ED Physician #8] uncomfortable closing neck wound therefore requesting transfer. [PAMC ENT Physician #24] aware patient will be transferring to the ER [Emergency Room] . . ."

- 9:32 pm: PAMC ED Physician #16 accepted Patient #31 for transfer. (1 hour and 32 minutes after initial request for transfer)

During an interview on 9/11/24 at 12:28 pm, the Medical Director state it was the expectation of the facility to ask two questions when ED to ED transfers is requested due to specialty needs: 1. Do we have the capability to treat the patient? and 2) Do we have the capacity, or room, to accept the patient? The Medical Director stated if the answer is yes to both, then we should be accepting patients with every transfer request.

When asked about the incident with Patient #31 and PAMC ENT Physician #24 delay in accepting the transfer, the Medical Director stated it wasn't PAMC ENT Physician #24's job to determine if ARH had the capability to handle Patient #31's needs, it was his/her job to accept the transfer and treat the patient. The Medical Director further stated PAMC ENT Physician #24 should not have waited for the imaging before accepting Patient #31's transfer.

Review of the facility's policy "Emergency Medical Treatment and Labor Act (EMTALA)," effective 4/2024, revealed: ". . . Transferring requirements. If the hospital does not have the capability to treat the condition, and "appropriate" transfer of the patient to another hospital must happen consistent with EMTALA regulations. A hospital with specialized capabilities is obligated to accept transfers from hospitals who lack the capability to treat unstable emergency medical conditions . . . Receiving hospital requirements. The receiving facility must have adequate space, equipment, and qualified personnel to treat the individual before agreeing to accept the transfer, the receiving facility is obligated to provide appropriate medical treatment . . ."

Review of PAMC ENT Physician #24's "Reappointment Application for Medical Staff [and] Allied Health Professionals," dated12/4/22, revealed: "I have had an opportunity to read and will abide by the Hospital and Medical Staff Bylaws, rules and regulations, policies and procedures provided . . . I agree to provide for continuous care of my patients and may be required to take Emergency Room Call in my specialty . . ."
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Based on record review and interview, the facility failed to accept, in a timely manner, an appropriate transfer requiring specialized capabilities for 1 patient (#31), out of 3 transferred patients reviewed. This failed practice delayed care and had the potential to place the patient at risk for complications and delayed recovery.

Findings:

Patient #31

Record review on 9/6/24 and 9/9-11/24 revealed Patient #31 presented to the Alaska Regional Hospital (ARH) emergency department (ED) on 8/29/24 at 7:20 pm by ambulance with two lacerations, estimated at 4-inches in length each, to the front (anterior) on his/her neck.

During an interview on 9/9/24 at 1:20 PM, ARH ED Physician #8 stated at the time Patient #31 presented to the facility, there was no Ear, Nose, and Throat (ENT) specialty available within the hospital. Because of the extent of the trauma, ARH ED Physician #8 initiated a request, through the transfer center call line, for an expedited transfer to Providence Alaska Medical Center (PAMC) for treatment as they had ENT specialty available. ARH ED Physician #8 further stated he/she completed a chest x-ray and CT angiogram (CTA - medical imaging that uses x-rays and special dye to create detailed pictures of blood vessels and tissues of the body), and at the time of contacting the transfer center call line, the CTA imaging results were not back yet.

ARH ED Physician #8 further stated there was resistance from PAMC's ENT physician to accept the transfer, requested imaging results and photos prior to making a decision, and then questioned ARH's ability to handle the case themselves. Due to this interaction, ARH ED Physician #8 included hospital administration, and after the administration talked with PAMC the transfer was accepted.

Review of the transfer center call line's audio recordings of the phone calls between ARH and PAMC, dated 8/29/24 and provided by ARH, revealed ARH ED Physician #8 was connected with PAMC ED Physician #16 who stated he/she would accept the patient assuming PAMC ENT Physician #24 was in agreement.

Further review revealed:

1. ARH ED Physician #8 was able to talk directly to PAMC ENT Physician #24. ARH ED Physician #8 gave a report on the extent of the injury, expressed concerns that this wound was deep enough to expose subcutaneous fat layers and he/she had concerns it may have gone deeper into neck structures, declared ARH did not have the capabilities to treat this injury, and requested transfer to PAMC for treatment.

2. PAMC ENT Physician #24 stated, "basically it is just a cut to the neck" and asked if surgery was available at ARH. ARH ED Physician #8 stated ARH did have general surgery but felt this wound may require ENT specialty if surgical repair was necessary. PAMC ENT Physician #24 asked how deep the cuts were, ARH ED Physician #8 offered to send pictures if it was needed to gain approval, PAMC ENT Physician #24 requested the pictures. After reviewing the pictures, PAMC ENT Physician #24 stated he/she couldn't tell how deep the cuts were, and ARH ED Physician #8 stated he/she did not feel comfortable exploring the wound which could cause more damage.

3. PAMC ENT Physician #24 requested the CTA imaging results be forwarded for his/her review prior to accepting the transfer. ARH ED Physician stated he/she would send the imaging to PAMC.

Review of PAMC's documentation of the timeline for the phone conversations between the physicians, dated 8/29/24, revealed the following timeline:

- 8:00 pm: First call from ARH to transfer center requesting transfer for Patient #31 to PAMC.

- 8:03 pm: PAMC ED Physician #16 agreed to accept Patient #31 to the ED assuming PAMC ENT Physician #24 was agreeable.

- 8:13 pm: ARH ED Physician #8 was connected with PAMC ENT Physician #24, photos of wounds sent, CTA imaging requested.

- 8:26 pm: The CTA imaging for Patient #31 was available for PAMC ENT Physician #24 to review.

- 8:40 pm: PAMC ENT Physician #24 notified the transfer center he/she was reviewing the imaging.

- 9:26 pm: Review of documentation revealed: ". . . Providers connected at this time. Disagreement as to if patient requires transfer to ENT. [ARH ED Physician #8] uncomfortable closing neck wound therefore requesting transfer. [PAMC ENT Physician #24] aware patient will be transferring to the ER [Emergency Room] . . ."

- 9:32 pm: PAMC ED Physician #16 accepted Patient #31 for transfer. (1 hour and 32 minutes after initial request for transfer)

Review of Patient #31's ARH ED note, dated 8/29/24, revealed: ". . . Trauma alert called. CT angiogram of the neck performed. Chest x-ray performed and negative for any acute abnormality . . . exams performed in the ER . . . I eventually was able to speak with ENT, [PAMC ENT Physician #24], regarding the case however they wanted further testing before accepting the admission which I feel delayed care . . ."

Review of Patient #31's PAMC ED notes, dated 8/29/24 revealed Patient #31 arrived in their ED at 11:34 pm, and the PAMC ED Physician #52 assumed care.

Review of Patient #31's PAMC ED Physician #52's note, dated 8/29/24, revealed: ". . . Two lacerations to the anterior neck approximately 8 centimeters in length [3.15 inches] each . . . ENT made aware of patient's arrival; [PAMC ENT Physician #24] came to evaluate the patient at bedside and kindly agreed to repair the wounds . . ."

During an interview on 9/11/24 at 12:28 pm, the Medical Director state it was the expectation of the facility to ask two questions when ED to ED transfers is requested due to specialty needs: 1. Do we have the capability to treat the patient? and 2) Do we have the capacity, or room, to accept the patient? The Medical Director stated if the answer is yes to both, then we should be accepting patients with every transfer request.

When asked about the incident with Patient #31 and PAMC ENT Physician #24 delay in accepting the transfer, the Medical Director stated it wasn't PAMC ENT Physician #24's job to determine if ARH had the capability to handle Patient #31's needs, it was his/her job to accept the transfer and treat the patient. The Medical Director further stated PAMC ENT Physician #24 should not have waited for the imaging before accepting Patient #31's transfer.

During an interview on 9/11/24 at 3:13 PM, PAMC ED Physician #52 stated when he/she initially examined Patient #31's lacerations, he/she wasn't sure if he/she would have been comfortable closing the wound and was grateful PAMC ENT Physician #24 completed the closure.

During an interview on 9/11/24 at 3:18 PM, PAMC ENT Physician #24 stated after he/she reviewed Patient #31's CTA imaging, he/she felt the laceration was a single skin layer cut and he/she didn't understand why ARH couldn't close up the lacerations. PAMC ENT Physician #24 further stated he/she felt the transfer was inappropriate but after talking with ARH's administration agreed to accept the transfer.

Review of PAMC ENT Physician #24's note, dated 8/30/24, revealed: ". . . Outside imaging did not demonstrate any violation of the platysma [neck muscles] or injury to any neurovascular structures of the head neck. The team there did not feel comfortable suturing up the lacerations and [he/she] was transferred in by ambulance . . . There were repaired in the emergency department without trouble . . . Lacerations were then closed . . . total length of closure was just over 30 cm [11.8 inches] . . ."

Review of the facility's policy "Emergency Medical Treatment and Labor Act (EMTALA)," effective 4/2024, revealed: ". . . Transferring requirements. If the hospital does not have the capability to treat the condition, and "appropriate" transfer of the patient to another hospital must happen consistent with EMTALA regulations. A hospital with specialized capabilities is obligated to accept transfers from hospitals who lack the capability to treat unstable emergency medical conditions . . . Receiving hospital requirements. The receiving facility must have adequate space, equipment, and qualified personnel to treat the individual before agreeing to accept the transfer, the receiving facility is obligated to provide appropriate medical treatment . . ."

Review of PAMC ENT Physician #24's "Reappointment Application for Medical Staff [and] Allied Health Professionals," dated12/4/22, revealed: "I have had an opportunity to read and will abide by the Hospital and Medical Staff Bylaws, rules and regulations, policies and procedures provided . . . I agree to provide for continuous care of my patients and may be required to take Emergency Room Call in my specialty . . ."
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