HospitalInspections.org

Based on clinical record reviews, review of facility documentation, review of policies and interviews for one of seven sampled patients (Patient #2) who was reviewed for neonatal cardio-pulmonary resuscitation, the hospital failed to ensure that a preterm infant who delivered precipitously received resuscitative measures to include the appropriate size endotracheal tube and lifesaving medications (epinephrine) in a timely manner consistent with the recommendations of the neonatal resuscitation program (NRP) guidelines prior to the arrival of the on call neonatologist resulting in the determination of Immediate Jeopardy.

The finding includes:

Review of Patient #1's clinical record identified P #1 was admitted to the facility on 9/12/22 at 26 weeks and 6 days gestation with a history of rupture of membranes with clear fluid.

A review of the electronic fetal monitoring tracing report with the Obstetrics Director on 9/14/22 at 1:50 PM identified fetal heart rate tracing was initiated at 5:49 AM with the fetal heart rate baseline of 155-160 beats per minute (bpm) documented on the tracing at 6:03 - 6:05 AM. Further review of the fetal heart rate tracing report identified the fetal heart rate tracing was spotty with fetal heart rate baseline, variability, accelerations and declarations indeterminate between 5:54 and 6:02 AM, and between 6:06 AM and delivery of the infant at 6:31 AM.

Review of RN documentation on the fetal heart rate tracing report identified the baseline fetal heart rate was documented as 150 bpm with moderate variability at 6:00 AM and 6:15 AM.

The delivery note dated 9/12/22 identified Patient #2 a viable male fetus was delivered vertex with no nuchal cord and with thick meconium at 6:31 AM with APGAR scores of 0 at 1 minute, 0 at 5 minutes, and 1 at 10 minutes.

Review of the facility's Neo Log dated 9/12/22 identified P #2 was delivered at 6:31 AM, chest compressions were initiated at 6:33 AM with a heart rate of 0, and an endotracheal tube was placed at 6:36. The Neo Log identified P #2 had a heart rate of 58 at 6:58 AM. The neo log documentation identified an umbilical line was placed at 7:05 am with the administration of 10 milliliters of normal saline and 0.2 mils of epinephrine.

The neonatal history and physical (H&P) dated 9/12/22 at 7:59 AM identified MD #4 (neonatologist) was informed of imminent delivery of P #2 at 6:24 AM and arrived at P #2's bedside at 6:44 AM (13 minutes after delivery of infant). The H&P indicated upon arrival of MD #4 to P #2's bedside, the patient was intubated, was receiving chest compressions, had heartrate of 0 on the monitor, had purple skin and a tensely distended abdomen. The H&P further indicated an orogastric tube was placed with scant air return. The H&P identified the endotracheal tube was replaced from a 2.0 to 2.5, an umbilical line was placed at 7:05 am and 10 milliliters of normal saline was administered followed by 0.2 ml of epinephrine (32 minutes after the initiation of chest compressions) with an increase in heart rate to 92 and up to 105 at 7:15 AM. The H&P further identified P #2's heartrate then decreased, and compressions were initiated with repeated doses of epinephrine. The note identified P #2's heart rate continued to decrease, and the code was called at 7:32 AM.

An interview with MD #4 (Neonatologist) on 9/15/22 at 11:30 AM identified that when she arrived to P #2's bedside at approximately 6:44 AM, Anesthesiologist #2, Anesthesiologist #3, and MD #6 (ED-Physician) were at the patient's bedside. MD #4 indicated her main concerns were P #2's abdominal distention and obtaining intravenous access. MD #4 indicated that during a neonatal resuscitation, after the endotracheal tube is placed, the neonatal resuscitation Program (NRP) guidelines should be followed which include administration of volume, epinephrine, and supportive respiratory care. MD #4 stated that prior to securing intravenous access, epinephrine may be administered via endotracheal tube.

Interview with Anesthesiologist #2 on 9/15/22 at 12:52 PM indicated he responded to an overhead page and stated that on arrival to the infant's bedside, staff was bagging the infant and performing chest compressions. Anesthesiologist #2 indicated he was asked to intubate P #2. Anesthesiologist #2 indicated he discussed use of epinephrine with Anesthesiologist #3 but indicated the patient had no intravenous access. Anesthesiologist #2 stated he was Pediatric Advance Life support (PALS) certified and was not certified in neonatal resuscitation and according to PALS the administration of epinephrine via endotracheal tube (ETT) was not effective. Anesthesiologist #2 indicated that P #2 did not have an intravenous access and the initiation of an umbilical access was out of his scope of practice. Anesthesiologist #2 indicated he was not the lead of the Code and did not administer or request that epinephrine be administered.

An interview with Director #1 (Obstetrics) on 9/15/22 at 1:27 PM identified RN #2 was the lead staff during the resuscitation of P #2 and was NRP certified. The Director stated that the hospital had a Neonatal Resuscitation Program.

Interview with RN #2 on 9/19/22 at 10:39 AM identified Anesthesiologist #2, Anesthesiologist #3 and MD #6 (ED) all responded to the code. RN #2 indicated the infant was intubated by the Anesthesiologist #2 and stated she assumed the "Lead" role of the code until MD #4 (neonatologist) responded on site.

Although Anesthesiologist #2, Anesthesiologist #3, and MD #6 (ED) responded to the neonatal code, the personnel that responded did not have the skills in obtaining vascular access and were not knowledgeable in neonatal resuscitation. Staff did not attempt to contact the neonatologist for direction until arrival to the hospital.

Review of the facility's on call document identified the Pediatric on call Personnel (neonatology) had a 15-minute response time for call back and 45 minutes response time for in person.

Review of the Neonatal Resuscitation Program (Textbook of Neonatal Resuscitation 8th edition) indicated that a qualified team with full resuscitation skills, including endotracheal intubation, chest compressions, emergency vascular access, and medication administration, should be identified and immediately available for every resuscitation. The fully qualified team should be present at the time of birth if the need for advanced resuscitation measures is anticipated. It is not sufficient to have the team with advanced skills on call at home or in a remote area of the hospital. When resuscitation is needed, it must begin without delay.

The Program Algorithm identified that epinephrine is indicated if the baby's heart rate remains less than 60 beats/minute after 30 seconds of positive pressure ventilation and 60 seconds of chest compressions. The neonatal resuscitation program further identified intravenous or intraosseous as the preferred routes for administration of epinephrine as endotracheal epinephrine was less effective, but clinicians may choose to give a dose of epinephrine into the endotracheal tube while vascular access is being established.

The Program further provided direction for endotracheal tube size for babies of various weights and gestations ages to include for infants under 28 weeks a 2.5 ETT should be utilized.

Review of the hospital's Medical staff Bylaws 5. E. identified that Medical Staff is actively involved in the measurement, assessment, and improvement of at least the following: (p) coordination of care, treatment, and services with other practitioners and Hospital personnel.

On 9/15/22, the hospital provided an immediate plan of correction with a completion date of 9/15/22 at 5:45 PM to include: Effective immediately the emergency room provider on site will respond to a neonatal code and be the primary code lead and the ED provider will immediately contact the NRP certified provider on call to provide guidance regarding NRP practice.