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Based on medical record reviews, it was determined the facility failed to order laboratory blood tests to determine a patient's cardiac status, and to provide the critical results of laboratory blood tests to the emergency department physician, in a timely manner. This was found in MR #1.
Findings include:
A stat Troponin test was not ordered in a timely manner in keeping with current standards of practice. MR #1 is a fifty-three year old patient who presented to the ED at 11:42 AM on 11/22/09 with complaints of shortness of breath, increased anxiety and chest pressure according to the triage notes. The patient also had nausea and vomiting for 1-2 days and the symptoms had worsened that morning according to the physician's notes. The patient's previous medical history was significant for high cholesterol. Vital signs included a pulse of 72 and B/P of 142/72. Oxygen saturation was 100%, respirations were normal and his chest was clear. The EKG at 11:51 AM showed normal sinus rhythm and subsequent monitoring was continuous.
Labs were ordered at 12:01 PM and the specimens were collected at 12:08 PM and received in the lab at 12:22 PM. The Troponin blood test was added to the lab request at 1:37 PM. The initial Troponin result was completed at 1:54 PM, showed a critical value, and therefore was immediately repeated. After the stat Troponin result (0.96) was verified by the lab, it was reported to the ED physician at 2:16 PM. The result showed the Troponin level was 0.96 which is a panic (critical) value, as the normal range was 0.00-0.09 NG/ML. CK was 523 whereas the normal range is 35-232 U/L.
A review of the facility's tracking data of lab test for Troponin revealed the median result for the August 2011 "order to result" timeframe was 45 minutes.
According to the facility's policy titled, "STAT Procedures" which was dated 6/12/06, "all stat requests are to be done timely." Included in the list for stat specimens was the test for Troponin. The facility's laboratory policy titled, "Critical Value Result Reporting", last revised 10/28/09, states that "all critical values are to be confirmed by repeat analysis."
In the interview, conducted on 10/25/11 at approximately 11:00 AM with the Administrative Director of the Laboratory, he stated that "all ED orders are carried out as stat requests." He also stated that all lab results with critical values are repeated, to ensure accuracy.
Documentation in the medical record at 2:35 PM revealed the patient had a decreased sensation of chest pressure. At this point, plans were in place to transfer the patient to a higher level of care facility and the patient's condition was listed as stable. The transfer reason was listed as Acute Coronary Syndrome.
Based on the patient's cardiac-type symptoms when he first presented to the ED, a Troponin blood test should have been ordered immediately as per the standard of practice. In addition, there was a further delay in notifying the ED physician of the critical value of the Troponin level until after the test was repeated and verified. These factors both contributed to the patient's delay in being transferred to another hospital in a timely manner.

Based on record review and interview, it was evident that the emergency department (ED)failed to integrate services with surgical services to ensure that the provision of safe care meets standards of practice.

Findings include:

Review of MR#2 on 10/25/11 found that the patient with a history of dissection of the aorta who presented to the ED on 7/31/11 at 8:45AM with sudden onset of severe abdominal pain was not provided with an organized plan of care to address his critical care needs. When the ED attending called for a surgical consultation to assess the patient for an acute abdomen and a CT (completed at 9:50AM) which demonstrated a colon perforation with abscess, that surgeon did not see the patient for approximately 2 hours after receiving the first call from the ED attending. There was no evidence that the surgeon on call reviewed the CT or its interpretation until 11:58 AM. Interview with the ED attending on 10/25/11 found that the attending did not recall if he informed the surgeon on call that the report included an abscess, as well as, microperforation.

Based on record review and interview, it was evident that the facility failed to formulate and implement a policy and procedure to ensure that specialty consults are available for onsite assessments of emergency patients.

Findings include:

Review of MR#2 on 10/26/11 found that the patient whose CAT scan demonstrated a perforated colon with abscess was not provided with a surgical consultation from the time of arrival at 0845 hours until 1230 hours. The diagnosis on the face sheet was "acute abdomen." The surgery consult arrived at 1230 hours at which time the patient was in septic shock and being intubated.

At interview with the ED attending by phone on 10/25/11, it was stated that he felt that the patient required emergent operative intervention.

Review of the Medical Staff Bylaws on 10/26/11 found that consults are to arrive in the ED in a "timely manner."