HospitalInspections.org

Based on interview and record review, it was determined that for 1 of 20 sampled patients the hospital failed to provide stabilizing treatment, within the hospital's capabilities, when the patient presented to the hospital with an identified emergency medical condition (EMC). Specifically, the hospital transferred a 28 day-old critically ill infant despite having the available resources and capabilities onsite to treat the patient. The infant's medical condition showed signs of destabilization prior to departing the emergency department (ED) and while in flight to the receiving sister hospital. Additionally, the hospital had a neonatologist onsite that was not contacted to provide the necessary stabilizing treatment prior to the transfer. (Patient identifier: 1)

Findings include:

Review of patient 1's medical record revealed patient 1 was a 28 day-old infant admitted to the ED via ambulance from a local medical clinic, on 2/14/2020.. The emergency medical personnel documented vital signs of pulse 150 to 152, respirations 22 to 30 and an oxygen saturation of 92% on oxygen at 10-15 liters via "Blow-By".

Upon arrival to the hospital, patient 1 had a "Decreased LOC (level of consciousness), low blood sugar and respiratory issues." Patient 1's initial vital signs at 9:26 AM were documented as pulse 147, respirations 22 and an oxygen saturation of 100% on oxygen via blow-by. The ED physician documented that patient 1, " ...does not look good, minimal responsiveness, lethargic. ...No drainage or bleeding from ears or nose. ...No obvious distress retractions but has very shallow breathing and coarse rhonchi. IO (intraosseous) in the right tibia but looks like it is infiltrated. Patient is lethargic and rather floppy. ..."

Blood cultures were drawn at 9:40 AM and a nasal wash was completed at 10:30 AM to complete a respiratory panel which included influenza A and B as well as respiratory syncytial virus (RSV).

The ED physician documented, "The NICU (neonatal intensive care unit) nurse was able to get an (sic) scalp vein in on the 1st attempt." Patient 1 received multiple boluses of dextrose as well as Ceftriaxone 100 milligrams/kilogram IV (intravenous).

A NICU respiratory therapist assisted in the care of patient 1 to help maintain patient 1's airway and oxygenation. Patient 1 was "slowly getting more tired" and was intubated after the third attempt by the NICU respiratory therapist and the ED physician.

The ED physician further documented that a pediatric hospitalist assisted with the resuscitative efforts and arranged for patient 1 to be transferred to the pediatric intensive care unit (PICU) of an affiliated hospital C, approximately 67.8 miles away. The pediatric hospitalist began making arrangements for the transfer at 10:20 AM. The ED physician documented, "Looks like patient have (sic) sepsis, pneumonia and sign (sic) of little bit of septic shock with hyperglycemia probably from using up off (sic) her glycogen stores and also now fact in the liver. ...Patient transferred down to [affiliated hospital C] at the PICU. Life Flight newborn team came up to fly the patient down. ..."

On 3/31/2020 at 3:57 PM, an interview was conducted with the Chief Operating Officer (COO) who was present while patient 1 was in the ED on 2/14/2020. The COO was asked what he remembered occurring during patient 1's ED visit and eventual transfer. The COO communicated that "On February 14th a distressed 28 day old baby was brought into our ER (Emergency Room). Immediately, many caregivers sprang into action to save this baby's life and also prepare for transfer to a PICU (Pediatric Intensive Care Unit). I happened to be doing my daily rounding in the ER when I came across the situation. I watched for roughly ten minutes at which time the Pediatric Hospitalist [Physician 1] had our ER (Emergency Room) clerk call [children's specialty hospital B which provides the highest level of care for newborns and children in Utah]. She asked to get in touch with one of their Pediatric Intensivists at [children's specialty hospital B]. I was standing right next to [Physician 1] when she was speaking with someone at [children's specialty hospital B]; it was not the doctor at this point. Once she hung up the phone, I said something on the lines of this, [Physician 1] I don't want to challenge your judgement as a medical provider in this situation, but is this a patient that Ogden Regional Medical Center's [affiliated hospital C] can manage? Knowing that she wants to support our [name of corporation] Children's Services and that [affiliated hospital C] has a PICU, she immediately said, 'Oh my gosh. You are right. They can go to [affiliated hospital C]. I totally spaced even thinking of them.' One thing to realize is that [Physician 1] is used to sending PICU patients to [children's specialty hospital B] because there was no other option for her. Also while in practice, she was not willing to send her patients to [affiliated hospital C] PICU due to the length of travel. I can assure you that this provider is confident in her decision making and there was in no way an opportunity for me to push her to send to [affiliated hospital C] or force her. I simply asked the question and she responded positively to send the patient to [affiliated hospital C]. After our very brief conversation, [Physician 1] called [affiliated hospital C] to converse with the provider that was on for the day. After some time, the [children's specialty hospital B] provider called back and [Physician 1] notified the provider that she would be sending the patient to [affiliated hospital C]. I did not hear [Physician 1] speak to the provider at [children's specialty hospital B]; rather I was told by [Physician 1] that this is what she told the provider from [children's specialty hospital B]."

An interview was conducted on 4/1/2020 at 12:04 PM, with physician 1, a hospitalist on duty that provided care to patient 1 in the ED on 2/14/2020. The surveyor asked why the infant (patient 1) was not appropriate for her hospital and why patient 1 needed to be transferred to another hospital. The physician stated patient 1 was too old, at one month, for the hospital's NICU. She also stated patient 1 was never a patient of the NICU and was not considered "clean", meaning she was infectious and coming from outside the hospital, which could potentially infect the fragile newborns in the NICU. Physician 1 further stated the hospital's NICU is for clean patient's coming from the hospital and not from the community. The physician stated she was more appropriate for a PICU, which the receiving hospital (affiliated hospital C) had and Ogden Regional Medical Center (ORMC) did not have. The physician was asked if she felt pressured by administration to send patient 1 to sister hospital C versus children's specialty hospital B, in which she replied, "No, not at all." She stated that she had been a physician in the community for 30 years and there was always only the children's specialty hospital B as an option. She stated she had only been in the hospitalist position for a few months and she did not remember that ORMC's affiliated hospital C was even an option, and had she remembered, that would have been her first choice for patient 1. She stated the receiving hospital (affiliated hospital C) had a PICU with a pediatric intensivist and was more than capable of providing care for patient 1.

Physician 1, a pediatric hospitalist that cared for patient 1 in the ED on 2/14/2020, was re-interviewed on 6/22/2020 at 11:56 AM. Physician 1 was asked what the process was for consulting with a neonatologist for neonates that were admitted to the ED. Physician 1 stated ORMC's policy was to stabilize the patient and transfer the infant to another hospital for a higher level of care. Physician 1 stated ORMC did not admit patients to it's NICU due to a "contamination process", meaning that the patient had been cared for at home prior to being seen in the ED. Physician 1 stated, "In retrospect and rethinking everything, a neonatologist would see the baby in the ER." Physician 1 stated that the pediatric unit had an isolation room that could have been set up to accommodate patient 1's critical condition and that ORMC had the capability of caring for patient 1. Physician 1 was asked if the hospital policy could have been changed to admit patient 1 into the NICU. Physician 1 stated, "Yes." Physician 1 further stated that she had a conversation with the on-call neonatologist after patient 1 had been transferred to the affiliated hospital C. Physician 1 stated the on-call neonatologist would have seen patient 1 in the ED and participated in the resuscitation efforts. Physician 1 was asked what the medical need was that prompted the change from the children's specialty hospital B to affiliated hospital C that was more than 30 miles away. Physician 1 stated the distance and flight time was not considered. Physician 1 stated that she initially placed a call to the children's specialty hospital B, was put on "hold" before the call was "dropped." Physician 1 stated that a call was then placed to the affiliated hospital C at which time she reviewed patient 1's condition with an intensivist at the affiliated hospital. She stated the medical reason was to conduct a timely transfer and that affiliated hospital C could provide a more effortless and timely set-up for transfer. Physician 1 was further asked what the protocol was when a patient had a decline in stability just prior the aircraft departing the hospital. Physician 1 stated, "I don't know. I have never participated in a situation where it was a no go."

On 4/28/2020 at 4:09 PM, an interview was conducted with the Pediatric Registered Nurse (RN) who provided care to patient 1 on 2/14/2020. The RN stated that she worked in the NICU. The RN stated that infants were not admitted to the NICU after they had been discharged from ORMC. She stated that they had a pediatric unit but the unit did not have the capability to take care of children on ventilators. The RN stated patient 1 was not appropriate for the pediatric unit and needed more care than they could provide. The RN stated, "... Everyone there, including the two doctors and multiple ED nurses, communicated very well. After we had intervened with all the Pediatric Advanced Life Support (PALS) protocols and gathered all necessary information including testing, labs, ABG's (arterial blood gases) and all of that, it was asked if anyone could think of anything else we didn't cover and if we had missed anything. It was also asked if anyone else had any other ideas before the transfer. As far as supporting her respiratory wise, that is where she needed to be".

On 4/28/2020 at 4:56 PM, an interview was conducted with the Quality Director (QD) at ORMC. The QD stated that the hospital did not have a PICU. The QD stated, "We didn't have the higher level of care the little one needed, we stabilized and transferred this patient as soon as possible".

An interview was conducted with the hospital neonatologist, who was on-call on 2/14/2020, at 12:56 PM. The neonatologist stated that he was at ORMC, "seeing babies in the NICU" at the time patient 1 was treated in the ED. The neonatologist stated that there was not an official process for consulting with a neonatologist when an infant was admitted to the ED. The neonatologist stated he would be happy to consult and participate in resuscitative efforts for any baby or children up to two years of age. The neonatologist stated that had he been involved in the care of patient 1, he would have "brought the baby back to the NICU". The neonatologist said that policies could have been changed depending on the circumstances. The neonatologist stated, "If the baby was that sick, I probably would have kept the baby here."

A review of the ORMC Neonatal Admission and Discharge criteria documented, " ...3. Neonates that are ill and require intensive nursing care will be considered candidates for admission. These include neonates with: A. Cardiovascular disorders. ...L. Infections - congenital, perinatal, bacterial and viral. ...U. Respiratory disorders: acute. ..." Additionally, neonates with cardiac or respiratory monitoring, high risk for sepsis and persistent hypoglycemia (low blood sugars) would also meet the admission criteria, according to hospital admission criteria, to the NICU. Patient one was identified as having these conditions.

In the medical record, the ED physician documented that patient 1 was stable for transfer; certifying that the benefits outweighed the risk of the transfer. The ED physician did not document what the medical need was or why patient 1 was to be transferred for a "higher level of care" despite having a NICU with the capability of treating patient 1's medical condition. Patient 1's vital signs, obtained between 10:50 AM to 11:15 AM, just prior to being loaded onto the aircraft for transport to affiliated hospital C, was noted as - blood pressure 99/49; respirations 39; pulse 175 and pulse oximetry of 100% while on a ventilator.

The life flight crew documented a dispatch time to ORMC at 10:36 AM with an arrival time at 10:54 AM. At 11:04 AM, patient 1's vital signs were documented as pulse 168; blood pressure 75/36 with respirations of 55. It was noted that the NICU respiratory therapist was "hand-bagging" patient 1. At 11:10 AM, patient 1 was placed on a transport ventilator with synchronized intermittent mechanical ventilation, volume control rate of 28 beats per minute, fraction of inspired oxygen (Fi02) 100, tidal volume 22 ml, positive end-expiratory pressure (PEEP) of 5 cm (centimeters). At 11:13 AM, patient 1's glucose decreased from 101 to 67. Eight ml's of D25 (Dextrose 25%) was administered by the ED staff. At 11:15 AM, patient 1 required a Fi02 of 70% to keep the oxygenation in the mid 90's. A member of the air ambulance crew made contact with a physician at children's specialty hospital B while in the ED to discuss patient 1's ventilator settings prior to transport. Patient 1's PEEP was increased to 7 with orders for an additional bolus of fluid as well as orders to administer epinephrine drops and hydrocortisone if needed. Despite the decompensation in patient 1's condition, patient 1 was transferred to the aircraft with vital signs of pulse 171, blood pressure 77/41 and respirations of 37 at 11:30 AM. Patient 1 received additional fluids during the transport. At 12:12 PM, patient 1 arrived at the receiving affiliated hospital C and was admitted to the Pediatric Intensive Care Unit (PICU) at 12:14 PM.

The receiving physician at affiliated hospital C documented that patient 1 had "bloody ETT (endotracheal tube) secretions" in flight. On arrival, patient 1 had oxygen saturations in the 80's before being placed on the hospital ventilator with a PEEP of 8. Patient 1's oxygenation continued to decline into the 60's at which time a copious amount of bright red blood was observed from the ETT. Patient 1's PEEP was increased to 10 then to 12. Patient 1's heart rate "started trending down to the 50s with the o2 sats to 0. CPR (cardiopulmonary resuscitation) was initiated. Resuscitation efforts continued for 1 hour and 45 minutes at which time CPR was discontinued and patient 1 was declared deceased.

An entrance conference was conducted with the quality director (QD) on 6/22/2020 at 9:45 AM. The QD stated that the NICU had an isolation room, and the NICU had a capacity of 17. The QD stated the NICU census on 2/14/2020 was 15 with the isolation room being occupied for an unknown reason. The QD stated that the NICU only admitted babies that were born at ORMC and had not been discharged. The QD stated that admitting patient 1 to the NICU was "never a consideration." The QD stated that pediatric patients could be admitted to the pediatric unit if the patient was not on a ventilator and did not require intensive care. The name of the on-call neonatologist was obtained from the QD.

A telephone interview was conducted with the nursing director (ND) over the NICU and pediatric unit on 6/22/2020 at 10:16 AM. The ND was asked if a community infant was ever admitted to the NICU. The ND stated, "No. We have not because they are dirty." The ND was asked if the hospital was capable of caring for a vented neonate on the pediatric unit or the NICU. The ND stated that an isolation room could have been set up and that there was trained staff that could have cared for patient 1. The ND further stated that it would have taken "10 minutes to set up." The ND was asked if there had been a review of the hospital's policies since patient 1 had passed away. The ND stated that the ED was to notify the NICU staff when a critical infant was admitted to the ED.

A telephone interview was conducted with the patient safety director (PSD) on 6/22/2020 at 10:35 AM. The PSD was asked about the investigation into the death of patient 1. The PSD stated that it was determined the patient 1 was appropriately transferred to affiliated hospital C and that the corporate physician over all of the pediatric units reviewed the medical records for patient 1. The PSD stated that the corporate physician discussed with ED physicians about affiliated hospital C's capabilities but that a peer review was not conducted. The PSD stated that the flight to affiliated hospital C was 52 nautical miles which equaled 28 minutes as opposed to 24 nautical miles and 14 minutes flight time to the children's specialty hospital C. The PSD stated that a review of the hospital policies had not been considered.

A telephone interview was conducted with the ED physician that cared for patient 1 on 2/14/2020. The ED physician was asked what the process was for consulting with a neonatologist. The ED physician stated that once an infant was discharged from a hospital the infant was considered "dirty". The ED physician stated that neonatologists were for newborn babies and preemies and that a consultation with a neonatologist would not occur for infants that were 28 days old. The ED physician stated, "That is not what we do. A baby this old would go to a PICU not a NICU." The ED physician stated patient 1 was stable enough to fly and that patient 1 was "critical" and had "completely used all of her reserves up."

On 6/22/2020, the QD was asked for the hospitals policy and procedure for when a neonatologist would be consulted for ED cases. The QD responded, "We do not have a policy in place for this, but we plan to discuss this at length."