HospitalInspections.org

Based on review of documentation and interviews, it was determined that:
1.) Hospital staff failed to recognize that Patient #1's condition had changed from stable to unstable between the time frame that a decision was made to transfer Patient #1 to a Tertiary care Center, arrangements were made to identifiy bed availability and the actual transfer to Hospital #2 on 8/10/11.

2.) Hospital staff failed to provide medical treatment within the Hospital's capacity (intubation, the insertion of a tube into the airway to provide mechanical ventilation) to minimize the risk of transfer to 1 (Patient #1) of 2 unstable patients (Patients #1 and #6) in a sample of 24 Emergency Department (ED) patients transferred during the time period from 9/4 to12/26/11.

3.) The Hospital failed to ensure that a qualified physician signed certification indicating that based upon the information available at the time of Patient #1's 8/10/11 transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at Hospital #2 outweighed the increased risks.

4.) The Hospital failed to ensure that the physician certification related to the transfer of Patient #6 on 10/10/11 included a summary of the risks upon which the transfer decision was based.

Findings include:

For sections 1 through 3.) ED Triage documentation indicated that Patient #1 presented to the ED on 8/9/11 at 7:31 P.M. with complaints of shortness of breath (SOB) and a non-productive cough. Patient #1 was triaged to Express Care (an area within the ED for non-urgent patients).

Express Care documentation dated 8/9/11 indicated that Patient #1 was observed to be in respiratory distress at 7:55 P.M. and his/her vital signs were: temperature (T) = 98 degrees Fahrenheit (normal = 97.8-98.8), heart rate (HR) = 126 beats/minute (normal = 60-90), respirations (R) = 22 breaths/minute (normal = 12-22) and oxygen saturation level (SpO2, a measurement that gives indication of the oxygen content of the blood) = 79% (normal = 97-100%) on room air. Patient #1 was immediately placed on nasal cannula oxygen at 4 liters/minute and evaluated by a Physician Assistant (PA #1). PA #1 placed Patient #1 on a non-rebreathing (NRB) face mask (an oxygen administration device with a reservoir bag that is used to deliver high concentrations of oxygen) at 5 liters/minute and transferred Patient #1 to the Main ED.

Patient #1's Main ED 8/9/11 Triage Assessment indicated that Patient #1 was accompanied by his/her Mother and Patient #1's medical history was significant for primary pulmonary hypertension (PPH, a serious illness in which tiny arteries in the lungs become narrowed, blocked or destroyed making it harder for blood to flow through the lungs) diagnosed when he/she was a child. Patient #1's breathing was labored and he/she was unable to speak in full sentences. Vital signs obtain between 8:05 and 8:07 P.M. were: HR = 123, R = 22, blood pressure (B/P) = 127/68 (normal = 100-130/60-80) and SpO2 = 87% on a NRB face mask at 5 liters/minute.

ED Physician documentation dated 8/9/11 indicated that ED Physician #1 evaluated Patient #1 at 8:18 P.M. Patient #1 indicated that his/her symptoms of Shortness Of Breath [SOB] and a dry cough that began the preceding day. Patient #1 indicated that he/she had a history of PPH and had been started on a continuous infusion of Remodulin (a medication that dilates blood vessels in the lungs and throughout the body) 2 weeks earlier. His/her PPH was treated by a physician at Hospital #2 (Physician #3). Patient #1 was in moderate respiratory distress, but was able to speak in full sentences. He/she had normal breath sounds. ED Physician #1 ordered blood testing including arterial blood gases (ABGs, blood testing performed on blood obtained from an artery that gives indication of the levels of oxygen and carbon dioxide in the blood), an intermittent infusion device (IID, a device that inserted into a vein for periodic administration of intravenous fluid and/or medication) and a portable chest x-ray.

The Respiratory Therapist (RT) who obtained the ABGs from Patient #1 on 8/9/11 at 8:50 P.M. (RT #1) was interviewed by telephone on 1/5/12 at 12:40 P.M. RT #1 said that the ABG results indicated that Patient #1's oxygen level was below normal. RT #1 said that she started to use different oxygen delivery devices on Patient #1 to increase his/her oxygen level.

Review of the Physician Orders dated 8/9/11 indicated there was no order for oxygen or an oxygen delivery device.

Documentation completed by ED Registered Nurse (RN) #1 on 8/9/11 at 9:19 P.M. indicated that Patient #1 was placed on a HiOx NRB face mask (a type of NRB face mask). Patient #1's SpO2 was 94%.

ED Physician #1 was interviewed by telephone on 1/4/12 at 2:00 P.M. He said that Patient #1's respiratory status improved with the administration of oxygen delivered by a NRB face mask and Patient #1 was conversing in full sentences.

ED Physician #1 said that he discussed Hospital admission with Patient #1 and Patient #1's Mother. ED Physician #1 said that Patient #1 and the Mother indicated that they wanted to go to Hospital #2 and Physician #3 for continued care. ED Physician #1 reported contacting Physician #3 to discuss Patient #1's clinical status and the Patient's desire to be transferred to Hospital #2. ED Physician #1 said that Physician #3 agreed with Patient #1's transfer. ED Physician #1 said that he then spoke with the ED Transfer Physician at Hospital #2. He said that the ED Transfer Physician indicated that Hospital #2 did not have an available bed and that they would call when one became available.

ED Physician #1 said that Patient #1's chest x-ray indicated possible bilateral pneumonia.

ED Physician and Nursing documentation dated 8/9/11 indicated that ED Physician #1 inserted a central line (an intravenous catheter inserted into the central vascular system) into Patient #1 at 9:36 P.M.

An Authorization To Transfer Form completed by ED Physician #1 at 9:45 P.M. on 8/9/11 indicated that Patient #1 had been stabilized such that, within reasonable medical probability, no material deterioration of his/her condition was likely to result from or occur during the transfer. Other documentation on the Form indicated the reason for transfer was "Medical benefits outweigh risks", the benefit of transfer included "Continuity of care", the risks of transfer included, but were not limited to "Deterioration in condition or possible death" and "Transportation risk" and the means of support was to be an advanced life support (ALS) ground ambulance provided by Ambulance Company #1.

Documentation completed by ED RN #1 on 8/9/11 at 10:35 P.M. indicated that Patient #1 had labored breathing, but with reduced work of breathing. Patient #1's SpO2 was 94%. Additional vital signs obtained at 10:40 PM were: HR = 113, R = 22 and B/P = 110/75.

Physician Orders dated 8/9/11 at 10:45 P.M. indicated that ED Physician #1 ordered 2 intravenous (IV) antibiotics for Patient #1 (Ceftriaxone and Azithromycin).

ED Physician #1 said that he gave a verbal report regarding Patient #1 to ED Physician #2 sometime between 10:30 and 11:00 P.M. on 8/9/11 and left the ED. ED Physician #1 said Patient #1 was still receiving oxygen by a NRB face mask and was conversing in full sentences.

ED Physician #2 was interviewed in person on 1/4/12 at 11:05 A.M. ED Physician #2 said that ED Physician #1 indicated Patient #1 had PPH and SOB and espressed the desire to go to Hospital #2 because his/her doctor was affiliated with Hospital #2. ED Physician #2 said that ED Physician #1 had arranged the transfer for Patient #1, but the transfer was pending based on Hospital #2's bed availability. Hospital #2 was to call the ED when a bed became available.

Documentation completed by ED RN #1 indicated that the IV Ceftriaxone infusion was initiated at 10:57 P.M.

RT #1 said she saw Patient #1 for the last time around 11:00 P.M. on 8/9/11. She said Patient #1 was comfortable and had a SpO2 of 89-91% on high-flow Aquanox oxygen (humidified oxygen delivered by nasal cannula).

ED Nursing documentation dated 8/9/11 at 11:10 P.M. indicated that Patient #1's vital signs were: HR = 110, R = 22, B/P = 114/79 and SpO2 = 85% on high-flow Aquanox oxygen.

Review of the Physician Orders dated 8/9/11 to 8/10/11 indicated there were no orders for low Aquanox or humidified oxygen written.

ED RN #1 was interviewed in person on 1/4/12 at 2:45 P.M. ED RN #1 said that RT #1 changed Patient#1's oxygen delivery device from a HiOx NRB face mask to high-flow Aquanox by nasal cannula.

The RN who relieved ED RN #1 (ED RN #2) was interviewed in person on 1/4/12 at 11:35 A.M. ED RN #2 said that ED RN #1 gave a verbal report regarding Patient #1 around 11:15 P.M. on 8/9/11. He said that Patient #1 had PPH and SOB and was awaiting transfer to Hospital #2. ED RN #2 said that Patient #1 was very ill and had SpO2s of 88-90%.

ED Physician #2 said that on 8/9/11 between 11:00 and 11:30 P.M. Hospital #2 notified the ED of bed availability for Patient #1. ED Physician #2 reported going to Patient #1's bedside and noting that Patient #1 was dyspneic (had labored/difficult breathing) with abnormal vital signs. ED Physician #2 said that he introduced himself to Patient #1 and Patient #1's Mother, told them of the Hospital #2 bed availability and asked if they still wanted the transfer. ED Physician #2 said that Patient #1 and the Mother indicated that they wanted the transfer and that Patient #1 wanted to be cared for by Physician #3. ED Physician #2 said that he told Patient #1 and the Mother that Patient #1 could decompensate during the transfer. He said Patient #1 and the Mother acknowledged that Patient #1 could decompensate during the transfer but they still wanted the transfer. ED Physician #2 did not conduct a full assessment on Patient #1. ED Physician #2 did not document the transfer discussion with Patient #1/Patient #1's Mother or any other information related to Patient #1.

ED RN #2 said that when the ED was notified of the availability of a Hospital #2 bed for Patient #1 on the evening of 8/9/11, ED Physician #2 told Patient #1 and Patient #1's Mother of the bed availability and confirmed they still wanted the transfer. An Ambulance Company, #1 ALS ambulance, was summoned for Patient #1's transfer.

Documentation completed by ED RN #2 on 8/9/11 indicated that the IV Azithromycin infusion was initiated at 11:44 P.M. Staff from the ALS ambulance summoned for Patient #1's transfer arrived in the ED at 11:49 P.M. ED RN #2 gave a verbal report regarding Patient #1 to Hospital #2 at 11:50 P.M.

Documentation on the Authorization To Transfer Form completed by ED Physician #1 at 9:45 P.M. on 8/9/11 indicated that Patient #1 signed the Transfer Request Consent section for stable patients on the Form at 11:55 P.M. ED Physician #2 did not update the Form or sign a certification indicating that, based upon the information available at the time of transfer, the medical benefits reasonably expected from the provision of appropriate medical treatment at Hospital #2 outweighed the increased risks to Patient #1.

ED RN #2 said that he thought Patient #1 left the ED with the ALS Ambulance Crew, but around 12:10 AM on 8/10/11, he noticed Patient #1 and the Ambulance Crew were still in the ED. ED RN #2 reported asking the Ambulance Crew when they were leaving the ED. ED RN #2 said that the Ambulance Crew indicated that they did not have enough oxygen for the transfer and that they were waiting for more oxygen to be delivered. ED RN #2 said that he considered calling for another ambulance for Patient #1, but the Ambulance Company #1 Ambulance Crew indicated that oxygen was on the way and would be there very soon.

ED Nursing documentation dated 8/10/11 at 12:10 A.M. indicated that Patient #1's vital signs were: HR = 127, R = 48, B/P = 100/70 and SpO2 = 84% on high-flow Aquanox oxygen at 35 liters/minute.

Documentation completed by ED RN #2 on 8/10/11 at 12:10 A.M. indicated that Patient #1 was hyperventilating at times, his/her SpO2 was 88-90% and ED Physician #2 was aware of the transfer delay.

ED Nursing documentation dated 8/10/11 at 12:25 A.M. indicated that Patient #1's vital signs were: HR = 128, R = 48, B/P = 100/62 and SpO2 = 84% on high-flow Aquanox oxygen at 35 liters/minute.

Physician Orders dated 8/10/11 indicated that ED Physician #2 ordered 1000 mls of IV normal saline to run wide open (very fast) at 12:30 A.M. Documentation completed by ED RN #2 on 8/10/11 indicated the normal saline infusion was initiated at 12:30 A.M. through the central line.

ED RN #2 said that the ALS Ambulance Crew had questions/concerns regarding Patient #1's transfer and he referred them to ED Physician #2.

ED Physician #2 said that the ALS Ambulance Crew asked him about Patient #1's SOB and B/P. He said that he told the Ambulance Crew that Patient #1 had been SOB and that Patient #1's B/P was a little low, but he/she had received additional fluid.

Documentation completed by ED RN #2 on 8/10/11 at 12:34 P.M. indicated that Patient #1 complained of nausea, so ED Physician #2 ordered medication (IV Zofran) and the medication was administered. Patient #1 wanted to eat, but was advised not to because of his/her nausea, SOB and the impending ambulance ride. Ambulance personnel were speaking with ED Physician #2.

ED RN #2 said that the ALS Ambulance Crew had questions/concerns regarding Patient #1's oxygen and he summoned a RT to speak with them.

The RT who spoke with the ALS Ambulance Crew (RT #2) was interviewed by telephone on 1/5/12 at 11:15 A.M. He said that the Ambulance Crew had questions/concerns about the HiOx NRB face mask they were going to use for Patient #1's transfer. RT #2 said that he told the Ambulance Crew that the HiOx NRB face mask was "just a fancy NRB face mask" and attached the mask to the ambulance oxygen tank. RT #2 said that he never saw Patient
#1.

Nursing documentation completed on 8/10/11 indicated that Patient #1 left the ED with the ALS Ambulance Crew at 12:41 A.M. Patient #1's vital signs were: T = 98, HR = 128, R = 48, B/P = 100/62 and SpO2=90% on high-flow Aquanox oxygen.

ED Physician #2 said that he was concerned about Patient #1's transfer to Hospital #2, but did not think Patient #1's life was in danger. ED Physician #2 said that his concern was about Patient #1's respiratory status. He said that it was possible that Patient #1's respiratory status would deteriorate during the ambulance ride, but Patient #1 was being transported by ALS personnel who could intubate and start mechanical ventilation if needed.

ED RN #2 said that Patient #2 was ill, but he thought Patient #1 was stable for transfer. He also said that Patient #1 was insistent about going to Hospital #2 and was aware of the transportation risks.

Documentation completed by ED RN #2 on 8/10/11 at 12:41 A.M. indicated that Patient #1 was transferred in unstable condition.

ED RN #2 said that later during the morning of 8/10/11, he received a telephone call from an ED physician at Hospital #3 (ED Physician #4). ED RN #2 said that ED Physician #4 indicated that Patient #1 had a medical problem during his/her transport to Hospital #2 and Patient #1 was diverted to Hospital #3 and expired.

Documentation indicated ED RN #2 communicated information related to Patient #1's demise and a Hospital Internal Investigation including a TapRooT (a type of root cause analysis) was conducted. The Hospital Internal Investigation determined that: 1.) ED Physician #2 and ED RN #2 saw a very different Patient #1 than did ED Physician #1 and ED RN #1. 2.) ED Physician #2 did not recognize that Patient #1 was much sicker than the patient ED Physician #1 arranged a transfer for, 3.) ED Physician #2 did not formally and/or fully reassess Patient #1 at any point, despite noting that Patient #1 was dyspneic with an SpO2 in the 80s, ordering 1000 mls of IV normal saline wide open and IV Zofran and questions posed by ambulance personnel, 4.) Patient #1's deterioration appeared to begin when he/she was changed from a HiOx NRB face mask to high-flow humidified oxygen by nasal cannula, 5.) ED Physician #2 did not order, nor was he aware of the change in Patient #1's oxygen delivery system, 6.) Patient #1 was unstable at the time of his/her transfer, 7.) ED Physician #2 did not re-consider the appropriateness of Patient #1's transfer, 8.) the term "decompensate" was not a term that would convey the extreme danger of the transfer situation to a lay person, 9.) Patient #1's increased respiratory rate accompanied by a decreased SpO2 suggested the need for intubation and 10.) Patient #1 should have been intubated prior to his/her transfer. The Hospital Internal Investigation also identified issues related to Patient #1's Triage Assessment and vital sign monitoring, RT practice related to the changing of oxygen delivery systems in the ED without physician orders, RT documentation in the ED electronic medical record, ED Physician #2's (lack of) documentation and documentation on Authorization To Transfer Forms.

A review of the Corrective Action Plan related to the Hospital Internal Investigation of Patient #1's 8/9-8/10/11 ED care and transfer indicated it called for: 1.) mandatory physician bedside hand-off rounds/reports for all patients with a pending acute care facility transfer (with the exception of stable psychiatric patients awaiting an inpatient bed), 2.) mandatory nursing bedside hand-off rounds/reports for all patients with a pending acute care facility transfer (with the exception of stable psychiatric patients awaiting an inpatient bed), 3.) mandatory physician and nursing reassessments prior to all transfers, 4.) education of ED physicians and staff and RT staff regarding the need for physician orders for all oxygen therapy/oxygen therapy devices, 5.) designation of an area within the ED electronic medical record for RTs to document oxygen interventions, assessments and reassessments, 6.) education of ED nursing staff regarding triage assessment and vital sign monitoring and 7.) quarterly ED physician discussions related to Authorization To Transfer Forms.

Documentation related to the Hospital Internal Investigation indicated that ED Physician #2 participated in the Investigation and was aware of his assessment and documentation failures.

A review of the Corrective Action Plan implementation indicated that the Plan was fully implemented except for the quarterly ED physician discussions related to Authorization To Transfer Forms. The Authorization To Transfer Form discussions were scheduled to begin in January 2012.

ED Education records indicated that the ED physicians and staff received EMTALA education in 2010 and 2011. The Hospital is beginning work on building a "Just Culture" (a framework based on creating an open, fair and just culture, creating a learning culture, designing safe systems and managing behavioral choices).

4.) Patient #6's ED Record indicated that Patient #6 was transferred to Hospital #4 in unstable condition on 10/10/11. Patient #6 was transported by air ambulance for neurosurgical services not available at the Hospital. The physician certification related to Patient #6's transfer did not include a summary of the risks upon which the transfer decision was based.