HospitalInspections.org

Based on review of medical records, hospital policies, procedures, and protocols, interviews with key staff, on January 28-29, 2010 and February 1, 2010, and review of accepted Emergency Medicine standards, it was determined that the hospital failed to provide stabilizing treatment that was within the hospital's capacity and capability to provide. These findings present an Immediate Jeopardy to the health and safety of patients served by the Emergency Department at Inland Hospital.

Findings include:

1. The medical record of Patient A was reviewed for the Emergency Department visit that occurred on January 16, 2010 at 0418. The 'ED triage/assessment form' indicated that the patient's vital signs upon arrival were pulse (P): 163, blood pressure (BP): 86/69, and oxygen saturation of 100% on four (4) liters of oxygen. Additionally, there was documented evidence in the medical record that Patient A had "...prior coronary artery bypass surgery and prior aortic valve replacement, also with chronic systolic heart failure, who underwent implant of a dual chamber ICD in 2007..." It was also documented that [Patient A] had an " ...upgrade of his/her ICD to a cardiac resynchronization therapy defibrillator..." in March 2009.

2. The 'Emergency Physician Record' indicated, that ED Physician A had interpreted the patient's cardiac rhythm as SVT (super ventricular tachycardia) with aberrancy from the electrocardiogram (EKG) performed at 0419.

3. A review of Inland Hospital Policy: EMTALA-Emergency Treatment & Transfer, indicated, "...Any person with an Emergency Medical Condition identified by the screening exam receives stabilizing treatment within the capability of Inland Hospital and the on-call Medical Staff...All physicians on the Active Medical Staff must take ED call...This includes prompt availability for consult by telephone, to attend a patient in the ED as needed to complete an emergency medical screening exam, to stabilize the patient, and to admit a patient from the ED..."

4. ED Physician A documented on the 'Emergency Physician Record,' " D/W [discussed with] pt + family potential cardioversion vs. meds. Opted for initial medication approach." The clinical impression section, revealed a diagnoses of A-fib, hypotension, SVT with aberrancy and pulmonary edema.

5. The medical record documented that the patient had received two doses of Digoxin, a continuous Neosynephrine drip of 20 mcg/minute to 80 mcg/minute, and a dose of Diltiazem. In spite of these increasing doses of a vasopressor (Neosynephrine), the patient's blood pressure remained low and heart rate remained elevated. The medical record documented that the patient's blood pressure remained in the 70's to 90's systolic and 50's to 60's diastolic. Additionally, there was documentation of a blood pressure of 38/25 at 0605. The patient's heart rate was documented as remaining in the 160's throughout the ED visit.

6. A repeat EKG was performed at 0730 and continued to show that the patient was in ventricular tachycardia.

7. Sheehy's Manual of Emergency Care, Sixth Edition (2005) Emergency Nurses Association (Mosby, Inc), Chapter 10, "Rhythm Recognition and Electrocardiogram Interpretation" page 159, stated, "...If rapid VT [ventricular tachycardia] does not self-terminate, it may deteriorate to ventricular fibrillation... " and pages 160-161, stated, "...Ventricular fibrillation (VF) produces no effective cardiac output; death occurs if this rhythm persists more than 4 to 6 minutes. Ventricular fibrillation often follows ventricular tachycardia..."

8. Emergency Medicine, A Comprehensive Study Guide, Sixth Edition (2004) American College of Emergency Physicians (McGraw-Hill, Medical Publishing Division), Section 3, "Disturbances of Cardiac Rhythm and Conduction" page 191, stated, "...Ventricular tachycardia cannot be differentiated from SVT with aberrancy on the basis of clinical symptoms, blood pressure, or heart rate. Patients who are unstable should be cardioverted..."

9. A review of credentialing files on January 29, 2010, revealed that both ED Physicians A and B were qualified and privileged to perform cardioversion.

10. At 0740, there was documentation in the 'detail sheet' by nursing that '[Hospitalist A] here/ [Cardiologist A] paged.' The nursing documentation also indicated that the patient was to be admitted to ICU [intensive care unit].

11. During an interview with [Cardiologist A] on January 28, 2010 at 1420, [Cardiologist A] stated, "We're on call 24/7...There is never a time when cardiology isn't covered...Response time is thirty (30) minutes when an ER doc says to come right now...We would treat the unstable arrhythmia here and then transfer to a tertiary care center."

12. A review of the Hospital's Medical Staff Rules and Regulations revealed, "Responsibilities of On-Call, Attending or Designated Physicians to the Hospital Emergency Department...The physician overall shall respond in person to the ED when specifically requested to do so by any Medical Staff member..."

13. During an interview with [Hospitalist A], on January 29, 2010 at 1100, [Hospitalist A] stated, "I was called to admit the patient to ICU. I talked with [Cardiologist A] and asked [him/her] to come in after my initial evaluation of the patient. I went back to the patient to complete assessment. [Cardiologist A] called again and said it would be better to transfer because they [the patient] have their own cardiologist...The daughter agreed to the transfer...the patient and the daughter did not ask for the transfer. [Cardiologist A] initiated the transfer. [Cardiologist A] felt the patient would be better served at [receiving hospital]."

14. During an interview with [Cardiologist A] on January 28, 2010 at 1420, [Cardiologist A] indicated, "Yes, I was on-call on January 16, 2010. I received a call from the ED physician. We discussed the case [Patient A]. I was told the patient was in atrial fibrillation. I was ready to go to the hospital to the see the patient and admit the patient to ICU. I went to my computer [at home] and looked at the patient ' s record. I realized that [Cardiologist B] was the cardiologist of record. I asked the Hospitalist to find out from the patient if s/he had been seen by [Cardiologist B] in the past month. That was my cut-off. I had been accused of stealing [Cardiologist B's] patients, so I asked the Hospitalist to call [Cardiologist B] and I didn't hear anything else."

15. In a progress note, dated 1/16/10 (time unknown), [ED Physician B] documented, 'Pt seen by [Hospitalist A] + D/W [Cardiologist A]. Recommended that patient be sent to [receiving hospital] to be seen by [Cardiologist B] who is the patient's cardiologist. I discussed pt [with] [Cardiologist B] who accepted the patient."

16. At 0910, the medical record documented the patient's P: 164 and BP: 88/57. Neosynephrine 80 mcg IV continued per the nursing documentation.

17. In spite of having multiple physicians, including a cardiologist, available and qualified to perform cardioversion, the medical record stated that the patient was transferred to [receiving hospital] at 0930.

18. The transfer form was completed on January 16, 2010 at 0830 by [ED Physician B]. The transfer form indicated under patient condition, "The patient may be at risk for deterioration from or during transport." Under Reason for Transfer, it was documented 'For equipment or services not available at this facility: + to be cared for by his private cardiologist." Under benefits and risks of transfer, it was documented that the risks of transfer were hypotension, and cardiac or respiratory arrest. Note: the box for "None Stable for Transfer" was not checked.

19. During an interview with [Cardiologist B] on January 26, 2010 at 0930, it was revealed that a patient had been transferred to [receiving hospital]. [Cardiologist B] stated, "I had three of my patients sent to me over that weekend. [Cardiologist A] refused to go to the hospital and see the patients. The worst was [Patient A]. S/He was in SVT and I had to cardiovert her/him at [receiving hospital] with 50 joules."

20. During an interview with the VP of Medical Affairs on February 1, 2010 at 1410, s/he indicated, "The patient was medically unstable when we transferred. It says so right on the transfer form. Yes, we had the capacity and capability to treat and stabilize the patient here [Inland Hospital]."