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Based on staff interviews, clinical record and document reviews from the Transferring Hospital (TH) and the Receiving Hospital (RH), the Transferring Hospital's noncompliance with the requirements under EMTALA presented when the hospital failed to receive prior acceptance from the Receiving Hospital for the transfer of Patient 101 [A 2409].

Based on staff interviews, document and clinical record reviews from the Transferring Hospital (TH) and the Receiving Hospital (RH), the TH failed to make an appropriate patient transfer for 1 of 20 patients (Patient 101) when the TH's Emergency Department's (ED) Physician A was still on the phone with the RH's ED Physician B discussing the possibility of Patient 101's transfer when the ambulance arrived at the RH with the patient.

Findings:

Based on the TH's ED "Provider Notes" (Physician Notes) dated 10/7/14 and the "ED Adult and Pediatric Smart Form" (Nurse Notes) dated 10/6/14, indicated Patient 101, a 39 year old male walked into the main entrance of the TH's ED on 10/6/14 at 10:25 p.m. with the chief complaint of being assaulted by two individuals with a knife, resulting in a stab wound to the left flank at the level of the lower ribs.

During an interview on 10/14/14 at 3:40 p.m. the TH's ED Charge Nurse (TH's ED Nurse G) stated, "...as Patient 101 came through the front door I went to greet him. He had blood on him. He had been stabbed. I alerted everyone in the department of the trauma..." TH's ED Nurse G also stated Physician A was at the bedside and had started one of the two IVs (Intravenous lines- the infusion of liquid substances directly into the vein). Vital signs were taken and the wound was covered. Document review of the "Emergency Department Adult and Pediatric Nursing Notes" (undated), indicated the patient was roomed (assigned an ED bed) at 10:30 p.m.

During phone interviews on 10/14/14 at 12:45 p.m. and 10/16/14 at 3:20 p.m., Physician A stated he had a conversation with Physician C (his colleague) after he had examined Patient 101. "We discussed what the best approach would include. My impression was to get him (Patient 101) over there [RH -Level II Trauma Center] as soon as possible."

During an interview on 10/14/14 at 3:40 p.m. with subsequent document review, TH's ED Nurse G stated Physician A indicated that this was a "trauma" and the patient was to be sent to the RH. She also stated that she had initiated the call with EMS (Emergency Medical Services - ambulance) 911. The time reported on the ambulance 10/6/14 "trip report" indicated - "Call Received: 10:29 p.m." "Dispatched (ambulance sent) and Enroute: (ambulance on the way to the TH) 10:31 p.m." [The ambulance trip report provides a detailed description of the patient's symptoms and physical findings at the time of transport, including functional status, safety issues, and special precautions or monitoring performed.]

Review of the Emergency Medical Services (ambulance) "trip report" dated 10/6/14 indicated, "RN (TH's ED Staff G) states she was on the phone with the [RH] and they want to speak with the sending M.D." The M.D. (Physician A) got on the phone with the RH and the TH's ED Staff G said to EMS, "Just go to the [RH]." The time reported on the ambulance "trip report" indicated - "At PT [patient] Side: 10:38 p.m." "Transport (ambulance start time from the TH to the RH), 10:47 p.m." "Arrival, 10:55" [at the RH].

During an interview on 10/15/14 at 7:30 a.m., with document review, the RH's ED Staff H stated she received a call from the TH's ED Staff G. TH's ED Staff G spoke with her about a patient they had in the ED that they were going to "re-triage." RH's ED Staff H stated she informed TH's ED Staff G she was not aware of what "re-triage" meant and had not heard of the term before.

RH's ED Staff H asked the TH's ED Staff G if she had spoken with the Transfer Center (a means for hospital to hospital to facilitate communication for patient transfers) or if there had been a physician to physician conversation. TH's ED Staff G said, "No" they did not need to do that, since they were doing a "re-triage" of the patient.

While still on the phone with the TH, RH's ED Staff H stated an ED Physician [Physician B] was standing near her and she asked Physician B to speak with Physician A from the TH. RH's ED Staff H stated Physicians A and B had a conversation. RH's ED Staff H also stated that while Physician B was still speaking with Physician A "the radio went off" and she [RH's ED Staff H] heard the message from the ambulance service, "stab wound on the way."

When queried on how the transfer would have usually occurred, RH's ED Staff H stated the TH would have called the Transfer Center. She stated the Transfer Center has recorded lines, the "Transfer Form" would be completed (with details of the patient), and the Transfer Center would be responsible for TH physician to RH physician communication.

During a phone interview on 10/14/14 at 4:10 p.m., TH's Physician C offered information on the history of the Transfer Center, stating it was designed as a mechanism of getting a patient to a higher level of care. Physician C went on to describe the process of the Transfer Center as the primary contact who contacts the RH. When asked how long it usually takes to utilize the Transfer Center Physician C stated, "A reasonable time." When asked if she uses the Transfer Center Physician C stated, "I usually use them."

During a phone interview on 10/14/14 at 4:10 p.m., TH's Physician C stated that Physician A appeared "visually upset" after speaking with RH's Physician B and stated to her he [Physician A] was having "a hard time". Physician C stated during the course of Physician A and B's conversation, she [Physician C] conversed with RH's Physician B whom she had had interactions with on previous occasions. Physician B told her [Physician C] that he did not like the way the transfer was going. Physician C told Physician B that "... this is reasonable." Physician B stated he "identified EMTALA as an issue" [regarding this particular transfer]. Physician C stated at that point she gave the phone back to Physician A since he was the "examining physician".

During the phone interviews on 10/14/14 at 12:45 p.m. and 10/16/14 at 3:20 p.m., Physician A stated the RH's Physician B was "upset" because he [Physician B] wanted the TH to go through the Transfer Center. Physician A stated they tried to go through the Transfer Center, however when they called the Transfer Center, the Transfer Center said the physician to physician contact and the call to EMS had already occurred. Physician A stated the Transfer Center told him, "There was no need for the Transfer Center." When queried if he used the Transfer Center Physician A stated, "...sometimes it takes 20 -30 minutes, sometimes longer to get physician to physician [communication]." When asked if he had used the "Re-triage Guidelines" he stated, "Never." When queried what he did after speaking with Physician B and Physician C he stated he "released the patient." Physician A stated he did not remember at what point the patient left.

During an interview on 10/15/14 at 11 a.m., Physician B stated on the date of the incident, as he walked down the hall RH's ED Staff H, who was on the phone, called to him and said the TH's ED nurse told her they were transferring a patient. RH's ED Staff H stated the nurse indicated it was a "911 Re-Triage" and did not know what that meant. Physician B stated RH's ED Staff H gave the phone to him and TH's Physician A was on the phone by then. Physician B stated that he had asked Physician A why he had not called the Transfer Center and Physician B stated Physician A said because this was a "911 Re-Triage". Physician B stated they were still talking when the patient arrived.

During the same interview, Physician B stated, "I would have accepted the patient. I might have liked him [Physician A] to have an x-ray to see if he [Patient 101] had a pneumothorax, but I would have taken the patient." Physician B also indicated that once Physician A had described the wound he told Physician A there was "no need for urgency' and believed the treatment of the patient was within the capabilities of the TH. In addition, he told Physician A this could be an EMTALA.

During an interview on 10/16/14 at 3 p.m., the TH's ED Director, Physician I stated, that in the spirit of working together [TH and RH], "everything was done appropriately." However, there was a need for "area improvement" related to emergency calls and the Transfer Center.

During a group discussion and document review on 10/14/14 at 8:30 a.m., RH's Physicians D and E corroborated that the Transfer Center should be used; however that did not preclude physicians from calling other physicians regarding transfers. Physician E stated the "North Coast Trauma Re-Triage and Transfer Procedure" was created in 8/2012. The expectation was that it would be posted in every emergency room [Sonoma and Mendocino Counties].

During an interview with concurrent document review, on 10/16/14 at 3:20 p.m., Physician A stated he chose to send Patient 101 based on the "North Coast Trauma Re-Triage and Transfer Procedure" which indicated "Patients who have a high likelihood for emergent life-or limb-saving surgery or other intervention within 2 hours."

The "North Coast Trauma Re-Triage and Transfer Procedure" (undated) indicates, "Goal: Appropriate regional trauma patients shall be re-triaged and transferred immediately to Hospital B (Level II Trauma Center) by direct ED to ED communication through the Transfer Center." This document went on to indicate under "Emergency Level Re-Triage: These are patients whose needs are generally known immediately or soon after initial arrival, based on clinical findings. Avoid any unnecessary studies (e.g. CT scans). Request ambulance for transport (use 911 when appropriate / available)." Under the subtitle: Provider Judgement- "Patients who have a high likelihood for emergent life-or limb-saving surgery or other intervention within 2 hours."

Review on 10/16/16 of the RH's "ED Report" for Patient 101, dated 10/6/14, indicated under "Medical Decision Making / Course", "Patient with stab wound to the left flank. Denies other injuries. Differential diagnosis includes pneumothorax (an abnormal collection of air or gas in the space that separates the lung from the chest wall), hemopericardium (blood in the pericardial sac of the heart), bowel laceration (tear, cut, or gash of the bowel), renal laceration (tear, cut, or gash of the kidney), intraperitoneal hematoma (bleeding in the membrane that lines the walls of the abdominal cavity). CXR (chest x-ray) does not reveal hemo or pneumothorax (blood or air accumulate in the pleural [lung] cavity). CT (Computed Tomography Scan is a technology that uses computer-processed x-rays to produce tomographic images (virtual 'slices') of specific areas of the body) of the abdomen shows some blood in the peritoneum near the colon. It is still possible that there is a colon injury. Patient will be admitted by trauma for serial exams and serial hemoglobins, and further monitoring..."

Review of Patient 101's TH's "Transfer Certification and Patient Consent to Transfer" dated 10/6/14, under Section 1, "Patient Condition/Physician Certification" 'E' should have indicated the Receiving Hospital's Physician and Phone number. This section was not completed by Physician A.

During a document review on 10/20/14 of the "Reciprocal Transfer Agreement" between the TH and RH dated 5/27/13 indicated under 2.1: "A physician at the Transferring Facility shall determine and document that the patient is appropriate for transfer in accordance with all applicable federal and state laws and regulations regarding transfer as well as with applicable requirements of the Transferring Facility's transfer policies."

Section 2.2 indicated: "A physician or personnel at the Transferring Facility shall telephonically notify a physician at the Receiving Facility and obtain consent to transfer and confirmation that the patient meets the Receiving Facility's admissions criteria relating to appropriate bed, personnel and equipment, and that the Receiving Facility has the capability to treat the patient."

Within the same document 2.8 read- "Receiving Facility agrees to accept and provide appropriate medical treatment to each patient for whom a physician at Receiving Facility and Transferring Facility have consented and confirmed acceptance of transfer."

During a review of the TH's clinical policy and procedure titled, "EMTALA: Provision of Emergency Services and Care and Patient Transfer" dated 10/2012, indicated, VII. Transfer of Patients Out of the Hospital with an Emergency Medical Condition, (B...2) Requirements for Transfer- "The receiving hospital has available space and qualified personnel for treatment of the patient; and the receiving hospital and physician has agreed to accept the patient and provide appropriate medical treatment."

Clarification was requested from the Level II Trauma Center (RH) with regards to the current use of the "Re-Triage" Guidelines by contracted hospitals. The response via an email review on 10/20/14 from Administrative Staff F, dated 10/20/14, indicated: "The North Coast Re-Triage and Transfer Procedure was developed as a departmental guideline by the 'receiving hospital' Trauma Services based on the American College of Surgeons recommendations for rapid triage of trauma patients who present at non-trauma facilities. This process was endorsed by the EMS agency in collaboration with local Emergency Departments. We will convene the appropriate stakeholders to determine whether to incorporate this guideline into our existing policies."