HospitalInspections.org

Based on review of medical records, medical staff by-laws, policies, Governing Body and Medical Staff meeting minutes, quality documents, and interviews, it was determined that a patient who presented to the Emergency Department (ED) with an emergent situation, was transferred to another hospital for treatment when the on-call surgeon failed to come to see the patient within the time frame of 30 minutes as established by this hospital's Medical Staff Rules and Regulations.

The findings include:

1. The Medical Staff Rules and Regulations as revised June 2011 read, "7. On-Call Physician Responsibilities: An on-call physician or dentist is responsible for treating and/or making disposition decisions with respect to each patient referred to him. Any disagreements in disposition decisions between physicians requires the on-call physician to be physically present to examine the patient before the on-call physician order will be followed. An on-call physician or dentist is to be present in the Hospital within thirty (30) minutes of receiving a request to appear. The on-call physician shall examine, treat, transfer, or discharge the patient, admit the patient directly to the Hospital by telephone or in person for further examination or treatment, or refer the patient to another physician for care after having obtained such other physician's agreement to provide proper care to the patient."

2. Review of the patient's medical record revealed that on October 16, 2011, at 1300, a 45 year old male patient presented to the Emergency Department with complaints of rectal pain and a low fecal impaction consisting of a mass of chewed unshelled sunflower seeds. The patient;s pain level at triage was listed as 8 out of 10. The patient was treated by the ED physician (#1) with three kinds of enemas without success and he was medicated for pain with Morphine. A flat and upright of the abdomen x-ray was done as well as lab work. The ED physician noted that the patient was hemodynamically stable.

3. At 16:23 the ED physicians' shift changed and a new ED physician (#2) was assigned. This physician examined the patient and found that the patient's belly remained soft and there was no evidence of perforation. The patient was again medicated with Morphine.

4. At 1623 (4:23 PM) ED physician #2 discussed the case with a gastroenterologist, who declined the case because he felt it was a surgical issue. ED physician #2 then discussed the case with the surgeon on call who declined to see the patient because he said he was not a colorectal surgeon and this was out of his scope. ED physician #2 then called the ED at another hospital and a physician there accepted the patient.

5. At 1650 the attending ED nurse documented that she spoke with the patient's wife and told her the patient would be transferred to another hospital. Transport ambulance was called and at 1731 a report was called to a nurse at the receiving hospital. At 1751, the patient was leaving the ED by stretcher, when he was stopped by ED physician #2, saying to bring the patient back in as he was going to be evaluated by the on-call surgeon.

6. At 1759, ED physician #2, documented multiple phone calls. He documented that he had called and discussed with the on-call surgeon, who declined to see the patient, that the attending surgeon at the receiving hospital had called and requested to speak to him to verify that he indeed was unable to perform the needed procedure for this patient. The attending surgeon at the receiving hospital said that if that were true, he was ready to accept the patient. At 1821 ED physician #2 documented in the record that the on-call surgeon still had not paged the attending surgeon at the receiving hospital. The attending surgeon at the receiving hospital then told physician #2 to go ahead and transport the patient.

7. The patient was again medicated with morphine and was transferred by a second transport team to the the accepting hospital at 1915 on October 16, 2011.

8. During a 03/21/2012 1615 interview with the ED physician #2, he said that the on-call general surgeon declined the patient in no uncertain terms. He said the hospital he called to accept the patient had no colorectal surgeon on staff - and the accepting physician was a general surgeon. He said the patient was not that sick but was in a lot of pain. He said he discussed with the on-call general surgeon the request by the surgeon at the receiving hospital to call him, and after that expected the on-call surgeon to respond to the receiving surgeon. He said that about 20 minutes after the patient left - the on-call surgeon came in to the ED to see the patient. That was approximately 3 hours since the original call to him by ED physician #2. ED physician #2 said the receiving hospital surgeon, "Sedated the patient and removed it (the impaction)."

9. Review of the medical record from the receiving hospital reveals that the patient was admitted 10/16/11 at approximately 2000. He had a history & physical done, a pre-anesthesia evaluation, then underwent exam under anesthesia, manual rectal disimpaction, proctoscopy and flexible sigmoidoscopy. The procedure was done with minimal blood loss, but with friable mucosa due to the trauma. The post-op diagnosis was fecal impaction from sunflower bezoar. The patient was kept in short stay/observation until 10/18/2012.

10. During a 03/21/2012 1600 interview with the Vice President of Medical Affairs, he said he was called by the attending surgeon at the receiving hospital on Sunday, October 16, 2012 and said he wanted to talk to the general surgeon who was on call to verify that he could not do the needed procedure for the patient. The VP Medical Affairs said he called and reported it to the Chief of Surgery on Sunday evening, and on Monday, October 17, 2011, reported the issue to the President/Administrator.

11. In a 03/22/2012 10:30 am interview with the President/Administrator, he said he talked to the Vice President Medical Affairs on Monday, October 17, 2012, then called the Chief of Surgery at the receiving hospital to see how the patient was. He said he called the patient's wife the day after the patient was discharged from the hospital and told her about his concern for the patient and family. He said he told her that the situation would go through the peer review process, and said he informed her that peer review is a confidential process. The President reported to the surveyors that the on-call physicians did go through the peer review process starting October 20, 2011 at the Emergency Department Committee Meeting. The situation then had peer review by a like surgeon - then on to M&M (Mortality & Morbidity), Medical Staff and Medical Executive Committees. A new policy, "Inter-hospital Transfer of Patients" was distributed on January 13, 2012. The Peer Review action plan was final as of March 1, 2012, and continues for follow-up in four months.

12. The credential files and delineation of privileges (DOP) was reviewed for the general surgeon who declined care for this patient. His DOP had been reviewed for current competencies in 2011, and his DOP included 1. Diseases and injuries of the rectum, 2. colonoscopy, and 3. Diseases/injuries of the stomach, small bowel, colon, rectum, liver, pancreas, gall bladder and spleen.