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Based on review of the facility policy, call center documentation, ambulance run report, medical record (MR), Obstetrician triage daily assignments, and interviews, it was determined Baptist Medical Center East (BMC-E, Hospital A) failed to ensure the on-call Obstetrician accepted Patient Identifier (PI) # 1, a 37 week pregnant patient in active labor, when contacted by the transferring hospital (Hospital B) which had no labor and delivery (L&D) services, when BMC-E had the capability and capacity to treat the patient. This deficient practice affected 1 of 1 emergency transfer requests, who were appropriate for transfer to the facility and, which BMC-E had the capability and capacity to treat.

Findings include:

Refer to A2411 for findings.

Based on review of the facility policy, call center documentation, ambulance run report, medical record (MR), Obstetrician triage daily assignments, and interviews, it was determined Baptist Medical Center East (BMC-E, Hospital A) failed to ensure the on-call Obstetrician accepted Patient Identifier (PI) # 1, a 37 week pregnant patient in active labor, when contacted by the transferring hospital (Hospital B) which had no labor and delivery (L&D) services, when BMC-E had the capability and capacity to treat the patient.

This deficient practice affected 1 of 1 emergency transfer requests, who were appropriate for transfer to the facility and, which BMC-E had the capability and capacity to treat. There was no documentation provided of other incoming transfer requests for transfer to BMC-E from April 2019 through October 2019. This did affect PI # 1, and had the potential to affect all pregnant patients with a request for transfer to BMC-E Obstetric services.

Findings include:

Baptist Health Patient Care Policy and Procedure
Emergency Department
Title: Patient Management Screening, Stabilization Transfer, Consultation and Referral
Review Dates: 12/17

Policy
To ensure that all patients are evaluated, and/or stabilized for transfer to another facility or discharged to home, in a safe, efficient manner consistent with EMTALA guidelines. This policy is adapted from EMTALA and applies to Health Care Providers, nursing staff, and hospital.

Emergency Medical Condition:
An individual has an emergency medical condition if his/her medical condition is marked by acute symptoms or sufficient severity, including severe pain, or the absence of immediate medical attention could reasonable (reasonably) be expected to result in:
Placing the person's health in serious jeopardy, Serious impairment of body function; or Serious dysfunction of any body organ or part.

SPECIAL NOTE REGARDING PREGNANT WOMEN:
Women in active pre-term labor or other conditions that pose a threat to the health or safety to the mother and fetus will be presumed to have an emergency medical condition. ALL EMTALA guidelines apply to labor and delivery.

Hospital B (transferring hospital) documentation:

PI # 1 presented to Hospital B's emergency department (ED) via ambulance on 7/10/19 at 12:34 AM with a chief complaint of labor pains. The ED physician, evaluated the patient at 12:37 AM and documented that PI # 1's water was not broken, the initial pelvic exam did not show any blood or fluid. The baby's head could be felt at the pelvic inlet. It was not visible at the introitus. The ED physician was uncertain of how far dilated PI # 1 was. PI # 1 was scheduled for elective C-section (cesarean section) on 07/23/19, which would make the patient about 37 weeks. PI # 1 had a previous low transverse C-section. The ED physician further documented, he/she spoke with PI #1's primary OB physician and they "both felt it might be more expedient (to) send her to Montgomery given the frequency of the contractions." The ED physician then spoke with the On-call OB at BMC-E in Montgomery who advised since PI # 1 had an obstetrician which was negligible distance away (from BMC-E), that PI # 1 should be transferred to (hospital C, receiving hospital). PI # 1's primary OB physician at hospital C (receiving hospital) had agreed to accept the patient if BMC-E would not.

The ED physician performed a second manual examination prior to the transfer of PI # 1 to Hospital C, receiving hospital, and documented the membranes felt intact and bulging, palpation of the baby's head was about 5 cm (centimeter) up from introitus. PI # 1 had "no bleeding or gush of fluid but had passed probably a mucus plug by her/his history. Fetal heart tones 140....pre contractions about...4 minutes apart. Mucus plug passed ....in moderate acute distress in active labor ...manual pelvic exam shows initially some dilatation ..."

Review of the MR revealed a Patient Transfer Form and Physician Certification dated 7/10/19 for ambulance transport, "...condition... active labor", and a hospital to hospital transfer to (Hospital C, receiving hospital).

Review of the ED Nursing Documentation dated 7/10/19 at 1:40 AM, revealed "pt (patient) in active labor, pelvic exam x 2 with last being just before departure, see MD note, iv (intravenous) [line] intact. OB kit with transporter. belongings with transporter. vital stable. pt agreeable and desires transfer where Epidural and or c-section can be provided. paperwork given to ems (emergency medical service) transport. water has not broken although pt has stated that she lost some mucus, occasional sensation of having BM (bowel movement)/void per pt..but has not voided or had BM thus far, report called. MD and transporter aware of all these findings."

Review of the ED Provider Note dated 7/10/19 at 1:54 AM, revealed the following Plan:
Additional Treatments: Normal Saline
Disposition: Transferred
Reason for Transfer: Services not available
Receiving Facility: (Hospital C, receiving hospital identified)
Receiving Physician: On-Call OB physician and Primary OB physician identified
Mode of Transportation ALS (Advanced Life Support)
Evaluation Notes
"Patient was in active labor and contractions were every 3-4 minutes. She had not ruptured her membranes not bleeding. Fetal heart tones 140. Attempts to get her accepted at BMC-E ... were not successful. She was transferred by EMS (emergency medical service) to (On-Call OB physician) at hospital C.


Hospital A, BMC-E, documentation :

Review of the BMC-E Call Center Documentation dated 7/10/19 at 12:59 AM revealed a call was received from Hospital B (transferring hospital) ED physician with a request for the On-Call OB physician. BMC-E On-Call OB physician responded to the call from hospital B at 12:59 AM. There was no documentation of what the call was about or what the response was.

Review of the OB Triage Daily Assignments from 7/10/19 at 12:30 AM through 7/10/19 at 3:00 AM revealed BMC-E had 3 of the 14 Labor and Delivery (L&D) beds occupied, leaving 11 L&D bed's available for an incoming transfer.

There was no documentation the L&D was on diversion or of the reason BMC-E did not accept the transfer of PI # 1.

Ambulance Run Report documentation:

Review of the ambulance run report dated 7/12/19 revealed the following documentation:
EMS (Emergency Medical Service) arrived at hospital B (transferring hospital) on 7/10/19 at 01:38 AM to receive PI # 1 for "immediate transport to (hospital C, receiving hospital) and left hospital B at 01:42 AM. Patient diagnosed with... Normal delivery childbirth. Patient being transferred to specialized OB services, N/A (not available) at Hospital B. "...Patient transfer refused by closer facilities due to patient's primary OB physician at transfer location. Upon arrival EMS found...contractions 2-3 minutes apart...Patient starts active labor during transport. Patient's amniotic bag ruptures and contractions continue. Patient has normal delivery during transport. Cord is clamped and cut. Patient has minimal bleeding post delivery following fundus massage...OB-childbirth - EMS personnel present at 7/10/19 2:18 AM...Patient was left in care of hospital C."

Further review of the ambulance run report revealed PI # 1 arrived at hospital C via EMS at 2:34 AM.


Hospital C (receiving hospital) documentation:

Review of the History and Physical dated 7/10/19 at 03:23 AM revealed hospital C's On-Call OB documented PI # 1 presented to hospital C in a transfer from hospital B (transferring hospital) having delivered en route. Hospital C's On-Call OB documented PI # 1 began having contractions around 9:30 PM that evening and went to hospital B ED. PI # 1 had a history of previous C/S (c-section) for fetal distress with an unknown uterine incision. The ED physician at hospital B (transferring hospital) deemed the patient was in labor, called hospital C's (receiving hospital) Labor and Delivery, and spoke with PI # 1's primary OB "who recommended she be transported to the nearest hospital with OB services. On-Call OB at BMC-E refused transfer. Hospital C's On-Call OB then documented he/she was called "and echoed the recommendations of the primary OB physician but did agree that if there was no accepting hospital in Montgomery that we would care for her here." PI # 1 "delivered about 15 min (minute) prior to arrival at hospital C, receiving hospital. Per EMS report she had SROM (spontaneous rupture of membranes) in en route. Fluid was bloody. Delivery soon thereafter without dystocia (difficult birth) or cord. Baby had good color, cry, and heart rate."

Review of the Hospital C's Discharge/Transfer Summary dated 7/12/19 revealed the discharge diagnosis IUP (intrauterine pregnancy) 37 plus weeks, vaginal delivery-VBAC (Vaginal Birth After Caesarean), in ambulance during transport, prior LTCS (Lower segment Caesarean section). VBAC enroute to the hospital of a 6 lb (pound) 11 ozs (ounce) ...


Interviews:

An interview was conducted on 10/7/19 at 10:43 AM with PI # 1 who verbalized the reason she/he went to hospital B (transferring hospital) was that while at work she went into labor and the ambulance took her there. PI # 1 verbalized she was seen by the physician in the ED who said she was in labor. PI # 1 voiced since there was no OB services at the hospital and the ED physician recommend to send her to hospital C or Montgomery, whomever would accept me." PI # 1 verbalized hospital B (transferring hospital) sent her to hospital C (receiving hospital). PI # 1 verbalized she did not have a preference/choice of where she was transferred on 10/7/19.

An interview was conducted on 10/9/19 at 11:21 AM with EI # 4, ED physician at Hospital B (transferring hospital), who stated PI # 1 came to into hospital B after being at work in the area. EI # 4 stated, PI # 1 "went into labor but didn't seek attention. We did a Medical Screen Exam (MSE) and pelvic exam. The babies head was not visible...I wasn't sure she would be able to deliver safely after C-Section. I felt going down I 65 was faster. I felt Montgomery was 15 min closer." EI # 4 verbalized he did speak with EI # 1, (On-Call OB physician at BMC-E (hospital A) to request a transfer of PI # 1 to BMC-E (hospital A). EI # 4 stated, EI # 1 said "she has a doctor you just need to send her there."

An interview was conducted on 10/9/19 at 1:21 PM with EI # 5, Paramedic, who performed the transfer of PI # 1 and delivery of the baby during the transfer. EI # 5 stated, "The fire department brought the patient in to the ER (Emergency Room). The ER staff said they might have OB patient going out. So, we just hung out. Her contractions were about 5-10 mins apart. MD talked with patient about where OB was, the patient said hospital C's (receiving hospital) location. They called hospital C. My understanding, (hospital C) thought Montgomery was closer due to the hospital C's location being rural roads. The doctor (ED) called BMC-E... They didn't want the patient, from my understanding. So, the doctor called hospital C back. It would have been the same amount of time for any of those facilities."

EI # 5 was then asked if he/she knew or was told the reason for not transferring to BMC-E. EI # 5 stated, "I wasn't in on the conversations. So, I don't know what the deal was. I was standing there when the doctor was talking to them. The ER doctor was basically begging one to take the patient, I think it was (another hospital identified) but I'm not 100%. I don't know what they said but the patient wasn't accepted."

An interview was conducted on 10/10/19 at 12:30 PM with EI # 1, OB on-call for BMC-E (hospital A) who stated, "ED physician call(ed) had a pre-term labor previous C-Section which was 34 weeks. I asked who the primary OB was. I asked why have you not called them. He/She (EI # 4, ED physician for hospital B, transferring hospital) brought up that he called PI # 1's Primary OB first and the primary OB said if I wouldn't take the patient then the primary OB would. He (EI # 4) brought up there was about a 10 min difference between here and her (PI # 1) doctor. It's almost equal distance, so if she (PI # 1) has a doctor that can perform the services then she needs to see that doctor. So, continuity of care with primary doctor. I don't know if PI # 1's primary OB or EI # 4 was suggesting the patient come here. I don't know that...I don't recall if EI # 4 told me if she was dilated or not. It wasn't suggested she was in advanced labor...I just told EI # 4 it would be better for her to go to her primary doctor. I denied transfer because I though it would be better for her (PI# 1) to go to her primary doctor..."

An interview was conducted on 10/10/19 at 1:40 PM with EI # 3, On-Call OB for Hospital C (receiving hospital) who was on-call and admitted PI # 1 to Hospital C. EI # 3 stated, PI # 1 "was not accepted at another facility. PI # 1's primary OB had recommended transfer to the nearest facility, Montgomery. She (PI # 1) was in labor, it was closer. She (PI # 1) had a vaginal delivery enroute. I met her (PI # 1) at the hospital here, she had her baby in her arms." EI # 3 was asked if he recalled what the reason for the transfer to hospital C (receiving hospital) was. EI # 3 stated, "She wasn't accepted there because she had another OB provider."

An interview was conducted on 10/10/19 at 2:30 PM with EI # 2, Primary OB Provider, who verbalized she/he was not on call on 7/10/19 but was called by mistake. EI # 2 stated the following information was provided to her about PI # 1, "She might be in early labor, in pain, not bleeding, sent there from her work. She was not near delivery. I wanted to transfer her... I told them to transfer to nearest facility. I called hospital C's (receiving hospital) L&D (labor and delivery) nurse and told her to fax prenatal records to hospital A (transferring hospital). EI # 4, ED physician at hospital B, and I had a conversation about (the) need to be transferred vs. monitored. They couldn't monitor the baby." EI # 2 then verbalized she told hospital # 1's ED physician to send PI # 1 to nearest facility. EI # 2 then verbalized that hospital C (receiving hospital) was not nearest due to rural travel.

EI # 2 was then asked if she received any additional call about PI # 1. EI # 2 stated, "No, the next call was to (EI # 3, On-Call OB at hospital C, receiving hospital), he/she was actually on call OB at hospital C and took the second call after Montgomery facilities didn't accept the transfer..." EI # 2 was asked when did you find out your patient wasn't transferred to the nearest Montgomery facility? EI # 2 stated, "the next day on rounds. I saw the baby name on census. I thought it was a done deal, she'd go to Montgomery. End of the conversation. When I saw EI # 3 the next day, I asked what happened. EI # 3, said she delivered enroute VBAC, vaginal delivery in ambulance. The ED physician at Hospital B (transferring hospital) called (EI # 3) , said he couldn't send her to Montgomery, so (EI # 3) accepted the transfer to hospital C (receiving hospital), she couldn't stay in hospital B (transferring hospital). They couldn't monitor her baby.