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Based on interviews, medical record reviews and review of hospital policies and procedures, Hospital # 2, a hospital with an on call vascular surgeon, initially accepted, and minutes later, declined the transfer of PI (Patient Identifier) # 1, a patient requiring emergency vascular surgery, not available at Hospital # 1, on April 10, 2010. This affected PI # 1, one of twenty-one sampled patients.
Refer to findings in A-2411.

Based on interviews, medical record reviews and review of hospital policies and procedures, Hospital # 2, a hospital with an on call vascular surgeon, initially accepted, and minutes later, declined the transfer of PI (Patient Identifier) # 1, a patient requiring emergency vascular surgery, not available at Hospital # 1, on April 10, 2010. This affected PI # 1, one of twenty-one sampled patients.

Findings Include:

1. Medical Record Review:
PI # 1's Emergency Department Medical Record from Hospital #1/ Referring facility Includes:
Arrival Date: 4/10/2010 at 6:25 AM by ambulance. Chief Complaint: GSW (gun shot wound) to right knee
Triage and Nursing History:Onset: Thirty minutes agoPatient is triaged directly to ED Major
Nursing Assessment Includes: General: Vascular exam of right lower extremity shows "mottled and cold-unable to obtain pulses to right lower leg."Mental Status: "Alert. Oriented x 3 (person, place, day). Anxious. Fully verbal..."Skin: " Pale skin. Skin feels cool to the touch. Diaphoretic. Puncture wound noted over right anterior thigh. Has what appears to be a gun shot wound over the right anterior thigh with a total of knee with entrance and exit wounds. The right anterior thigh injury site was covered with a dry pressure dressing. Puncture wound noted over right popliteal fossa and knee with a total of posterior thigh area wounds."
6:10 AM: "...There is pain and swelling noted over the following areas: right anterior knee and right popliteal fossa and knee. Active bleeding noted over following areas: right anterior knee and right popliteal fossa and knee with a total of 2 wounds. 4x4 gauze used. Kerlix dressing applied. Ace bandage used to stabilize wound dressing."
Pulmonary: "Tachypneic. Nasal flaring. No stridor. Bilateral breath sounds clear. Respirations regular and unlabored. Mucous membranes and nail beds pink. No cough observed or reported."
Cardiac: Hypotensive. Pulse regular. No persistent tachycardia or bradycardia. No complaint of chest pain. Peripheral pulses palpable. No peripheral edema. Capillary refill less than 3 seconds."
Nursing Continuation Notes Includes:
Transferred from ambulance stretcher to bed # 12 Liters/minute O2 (Oxygen) via nasal prongsReceived verbal order to infuse two units of emergency blood. Got verbal consent to infuse emergency bloodReport called to Nurse (Hospital # 2)
"Obtained report from Employee Identifier # 2 (RN Hospital # 1 ED)...Posterior right knee continues to ooze blood from site and dressing remains intact. Right lower leg mottled and cold. EI # 3 (ED Physician at (Hospital # 1) notified. Unable to dopple pulse at this time. Pt. (patient) c/o (complains) of being cold. Warm blankets applied. EI # 3 (ED Physician at Hospital # 1 states that Hospital # 2 declined pt. after report had been called by previous RN. Pt. and family informed of change in plan. Awaiting disposition for transfer....Report called to Employee # 4 @ (at) Hospital # 3's Emergency Room. Transfer form completed. See blood administration flow sheet for 2 units being hung at this time. (Name of Ambulance Service) here to transport... "
Clinician History of Present Illness by EI # 3 ((ED Physician at (Hospital # 1/Referring Hospital) Includes:
"Pt. arrived via EMS with c/o GSW (gun shot wound) to right distal femur thigh area. Pt. is pale and diaphoretic. Pt. has two 18 gauge IV ' s - one to right AC (antecubital) and one to left hand. Exam started at 6:25 AM. History comes from patient...unknown type of gun that caused patient's injury. The patient was a victim of violent crime. History of a single gun shot wound. It is unclear from the available history how much bleeding has occurred. Wound continues to actively bleed. Has local bleeding from the right knee...Injury can be coded as occurring in home environment."
Past Medical and Surgical History Includes:COPD ( Chronic Obstructive Pulmonary Disease), Depression, Anxiety
Review of Systems (ROS) Includes:Except as noted all other ROS negative
Physical Exam Includes:
General: "On exam the patient appears shocky." Vital signs reviewed. Alert. The patient appears to be comfortable.
ENT: "...No evidence of jugular venous distention..."
Eye Exam: Pupils are reactive to light.
Pulmonary: "The chest wall is not tender to palpation. The breath sounds are normal, with good equal air movement. Currently in no acute respiratory distress... "
Circulatory: Regular rate and rhythm. No murmur. No rub. No gallop.
Abdomen: " Bowel sounds are normal...abdomen soft and nontender."
Neurologic: Oriented to person, place and time. Cranial nerves II through XII are intact. No motor deficit. No sensory deficit. Alert.
Musculoskeletal: No extremity edema.
Skin: "Dressing applied wound not explored. Exam of injury suggests that it appears to be consistent with an entrance wound located over the right anterior knee. There is a single wound over the right anterior knee consistent with a deep penetrating type of injury approximately 2 cm (centimeters) across. Will leave wound open and allow to close by primary intention. Low grade non-pulsatile oozing noted at the wound site. Skin color is normal. No rash. Dry to touch. Warm."
Lymphatic: Unable to palpate the right dorsalis pedis pulse.
Progress Notes Include:
Update: "Pt. admitted room 1. Hypotensive with some active bleeding in popliteal fossa from exit wound. IV (Intravenous) saline boluses given. Emergency release blood 2 units given to pt. D/W (discussed with) Employee # 5 (Cardiovascular Surgeon at Hospital # 1) at 0635. He came down and examined patient. He felt pt. should be transferred to Hospital # 2. Employee Identifier # 6 (On call Trauma Physician- Hospital # 2) and EI # 5 (Cardiovascular Surgeon, Hospital # 1/Referring Hospital) also spoke to him. He (On call Trauma Physician/Hospital # 2) has agreed to accept pt in transfer per EI # 5 (Cardiovascular Surgeon, Hospital # 1/Referring Hospital)."
0713: "Update note; Notified by EI # 7 (On Call Vascular Surgeon at Hospital # 2) that they (Hospital # 2) could not accept patient. EI # 5 (Cardiothoracic Surgeon, Hospital # 1/Referring Hospital) recommended I ED Physician /Jackson Hospital) call Hospital # 3...Name of Dr. (EI # 8, Vascular Surgeon/Hospital # 3), who has agreed to accept pt."
Primary Diagnosis:Victim of GW (gun shot wound)Post traumatic shockGW right anterior legAbsent dorsalis pedis pulseGun shot would to the right kneeOpen fracture of the distal femoral shaft and lateral condyleAnxiety DisorderHistory of DepressionCOPDSystolic Hypotension this visit
Results Include: 4/10/10: 6:34 AM:
RBC: 2.82 m/cumm: Normal (NL= 3.8-5.0)
Hemoglobin: 8.8 g/dl: (NL=12.0-16.0)
Hematocrit: 26.1 % (NL=37.0-47.0)
Platelet Count: 102 (NL=140-440)
X-ray of the distal femoral shaft and lateral condyle shows an acute fracture. Notes skin over the site is not intact.
Physician Orders Include:
4/10/10 - 6:50 AM: Tetanus-Diptheria Injection Dose: 0.5 mg Route:IM Intramuscular
4/10/10 - 6:50 AM: Cefazolin Dose: 2000 milligrams Route: IV (intravascular)
Disposition Includes: "To be transferred. Patient was transferred to (Hospital # 3). Patient was transferred via ambulance...Discussed transfer with (Vascular Surgeon, EI #8 at Hospital # 3) who accepted transfer. This is a certified medical emergency...Transfer form completed...Monitor, O2 (Oxygen) and IV used during transport...2 units PRBC (packed red blood cells) infusing en route..."
There is no documentation in the medical record provided by Hospital # 1 of (EI # 5/Hospital # 1), the cardiovascular surgeon's, evaluation of PI # 1 in the ED at Hospital # 1 (Referring Hospital).
History and Physical dated 4/10/2010 by EI # 8, Vascular Surgeon, Hospital # 3, Includes:
History of Present Illness:
PI # 1 is a 52 year old patient who sustained a gunshot wound to the right leg during a robbery attempt. The entrance wound is on the anterior thigh with the exit wound in the popliteal fossa. PI # 1 has no sensation or motor function in the foot. The patient was taken to the ED at (Hospital # 1) where she was evaluated by the Cardiovascular Surgeon at Hospital # 1, who was on call for the Vascular Surgery group at Hospital # 1.

The Cardiovascular (CV) Surgeon, Hospital # 1, felt PI # 1 could be "best served by transfer." The CV Surgeon, Hospital # 1, "called me EI # 8(Vascular Surgeon, Hospital # 3) personally and I have accepted the patient in transfer."

Physical Examination...
Extremities: "Gunshot wound to the right anterior distal thigh. Exit wounds on the popliteal fossa There is no active bleeding. She has a cool foot. No doppler signals. No motor or sensory function."
Impression: "Gunshot wound to the right popliteal artery with severe ischemic changes. She is to undergo emergent intervention. The risks, benefits and alternatives have been explained and accepted and she is agreeable to proceed. There is obviously a significant chance of long term morbidity and even the chance of amputation."
On April 20, 2010 beginning at 2:30 PM, the surveyor reviewed Hospital # 2's computerized ED Log beginning February 1, 2010 though April 20, 2010. PI # 1's name was not listed in the log and there was no documentation to indicate PI # 1 was accepted or expected in transfer to Hospital # 2 on, before or after April 10, 2010.
2. Hospital # 2 / Intended Recipient Hospital: Policies and Procedures:
"Title: Patient Transfer Policy Between Acute Care Facilities
Approved: 11/17/07
1. Purpose: To set forth guidelines for transferring patients into and out of the hospital in accordance with federal law and in accordance with the hospital ' s mission of research and service.
2. Philosophy: It is our belief that the hospital should care for all patients for which it has the appropriate personnel and capacity. The primary reason for the transfer of patients in and out of the hospital should therefore be medical need. It is also our belief that the hospital should adhere to any and all external federal regulations pertaining to the transfer of patients.
3. Standards:...
3.2. Federal regulation also requires that clinical services must accept appropriate transfers providing the hospital has personnel and capacity to meet the patient ' s specialized needs.
3.2.1. Specialized clinical services include, but are not limited to burn units, shock-trauma units and neonatal intensive care units.
4. Procedure:
4.1. Transfers In - Patients who require Specialized Services.
4.1.1. The hospital shall accept transfers of patients from other facilities that require specialized services not available from the requesting facility if the Hospital has current capacity to offer the specialized services and a physician is available to perform the specialized services... "

3. Staff Interviews:
Interview with Trauma Attending Physician/ EI # 6 (Hospital # 2), on April 20, 2010 at 4:00 PM:
EI # 6 says he remembers a call from a physician in an ED in Montgomery, Alabama Hospital requesting transfer of a patient with a gun shot wound to Hospital # 2. The physician says he accepted the patient for transfer to Hospital # 2, but was concerned about the "pulselessness" of the patient's leg and the length of time that would be required to transfer the patient from Hospital # 1 to Hospital # 2. EI # 6 says he discussed this concern with the ED physician at Hospital # 1 who was requesting transfer of the patient. Due to his concern, EI # 6 says he asked the ED physician at Hospital #1 about the possibility of transferring PI # 1 to a local hospital in the same town as Hospital # 1. EI # 6 says the ED Physician at Hospital # 1 said Hospital # 1 does not have an "affiliation" with the local hospital (Hospital # 3).
EI # 6 says he notified EI # 12, Hospital # 2's Vascular Surgery Fellow, about the transfer "in case" vascular surgery assistance was needed when the patient arrived at Hospital # 2. EI # 7 (On Call Vascular Surgeon at Hospital # 2) contacted EI # 6, (On call Trauma Attending Physician at Hospital # 2). EI # 6, (On call Trauma Attending Physician at Hospital # 2) says he told EI # 7, (Vascular Surgeon at Hospital # 2) that he (EI #6) "might need help" with the patient because of the location of the injury (knee). When PI # 1 failed to arrive at Hospital # 2, EI # 6 (On Call Trauma Physician at Hospital # 2) called EI # 1, (RN, ED Charge Nurse at Hospital # 2) and asked the RN to check the status of the transfer. According to EI # 6, (Trauma Physician at Hospital # 2), EI # 1's ED Charge Nurse called Hospital # 2's ED and was told the patient was transferred to another hospital "across town." EI # 6 (Hospital # 2), was reportedly told by EI # 7 (On Call Vascular Surgeon at Hospital # 2) that he EI # 7 did not refuse to accept the transfer of the patient. However, EI # 7 told EI # 6 that he (EI # 7) informed the transferring ED physician at Hospital Hospital # 1, that it would be better if PI # 1 was treated locally due to the "pulselessness" in PI # 1's leg.

Interview with Senior MIST (Medical Information Service via Telephone) Representatives, EI #'s 9 &10 at Hospital # 2, on April 21, 2010 at 9:40 AM:
EI # 9 and EI # 10 described the MIST system as a tool to, "Get MD' s (Medical Doctors) together and as a, "Communication gateway" for transfer of patients to Hospital # 2. When an incoming call requesting a specific service is received from a referring physician, the representative contacts the Hospital # 2 physician on call for the requested specialty service. The representative monitors and listens to the conversation between the physicians and documents the information in the computer. The calls are not recorded. MIST Policy and Procedures were requested by the surveyor, but the representatives said other then Hospital # 2's basic Employee Manual, departmental memos serve as "policies" and MIST training is, "More one on one."

A copy of a memo dated August 28, 2009 regarding "Policy for MIST Calls" from the Section Chief for Vascular and Endovascular Surgery, was given to the surveyor at the beginning of the interview with EI #'s 9 & 10 on April 21, 2010 at 9:40 AM:

The memo incudes:
"Effective immediately MIST CALLS for the Vascular Surgery Service should adhere to the following updated policy.
- During regular business hours: (8 AM - 5 PM) - All MIST CALLS should be directed to the office of the requested vascular surgeon. If they do not have a specific physician's name, then those calls should be directed to (office telephone number) and my office will assist them in finding the available vascular surgeon.
- After hours: ALL AFTER HOURS MIST CALLS should be directed to the attending physician on call via the UAB paging system "
"An attending Call Schedule is available on a monthly basis and is faxed to the MIST Office in addition to the usual circulation..."

A copy of a MIST CALL PATIENT REFERRAL /INTENT TO TRANSFER FORM, given to the surveyor on 4/21/2010 at 9:40 AM includes:
"This section to be completed by the MIST Operator where information is available through monitoring."
"Date: 4/10. Time of Transfer Request: 706. MIST Rep: (Name of EI # 11/ Hospital # 2). Hospital # 2's Accepting Physician (contacted at transfer): Name of EI # 7 (On Call Vascular Surgeon). Service: Trauma. Referring Physician: Name of EI # 3, ED Physician at Hospital #1. Contact #: Phone for Hospital # 1. Referring Hospital: Name of Hospital # 1. Patient Location: Emergency Room. City and State:...
Patient's Name: Name of PI # 1...Date of Birth/Symptoms/Diagnosis: 52 yo vas (vascular) prob (problem) due to assault. Time faxed 708. "

Interview with EI # 11, MIST (Medical Information Service via Telephone) Representative at Hospital # 2), on April 21, 2010 at 9:45 AM:
According to EI # 11, the initial call was received to the MIST system from EI # 3 (ED Physician at Hospital # 1) who requested to speak with the on call Vascular Surgeon at Hospital # 2.

EI # 11 said she paged EI # 7, the On Call Vascular Surgeon at Hospital # 2. EI # 7 said he was "tied up," but would return a call to Hospital # 1 (Referring Hospital) as soon as possible.

EI # 3, the ED Physician at Hospital # 1, remained on the line. EI # 3 then requested to speak with Hospital # 2's on call trauma physician. EI # 6, On Call Trauma Physician/Hospital # 2, answered the representative's page, talked with EI # 3 (ED physician at Hospital # 2), and accepted PI # 1.

At 7:28 AM, EI # 7, (Hospital # 2's On Call Vascular Surgeon,) returned a call to EI # 3, ED Physician,Hospital # 1. EI # 7 said he could not accept PI # 1. EI # 3 (ED Physician at Hospital #1), informed EI # 7 (Vascular Surgeon,Hospital # 2) that EI # 6, (Hospital # 2's Trauma Physician), already accepted PI # 1. According to EI # 11 (MIST Rep), EI # 7 (Vascular Surgeon,Hospital # 2) told EI # 3 (Referring ED Physician/Hospital # 1) that, "Name of EI # 6, Trauma Attending, Hospital # 2), could not do anything for the patient." The facility (hospital #2)failed to accept PI #1 on April 10, 2010 in need of emergency vascular surgery from hospital #1, a facility unable to provide the services needed by the patient.

The surveyor asked the representative when she (EI # 11) completed the incident report and EI # 11 said, "Today (April 21, 2010)." According to the Representative (EI #11), EI # 7 advised EI # 3 that he would call EI # 6 and inform EI # 6 that he (EI # 7, Vascular Surgeon, Hospital # 2), could not accept the patient because he was doing another procedure. EI # 7 told EI # 3 (ED Physician, Hospital #1), he (EI # 7) would call the ED physician (Hospital # 1) with a final answer, but EI #11 said she did not receive another call from EI # 7 to EI # 3 via the MIST system.

The MIST computer generated documentation of the telephone calls, dated April 10 ,2010, regarding the transfer of PI # 1 from Hospital # 1 to Hospital # 2 were given to the surveyor. This documentation notes the first call, received at 7:05 AM on April 10, 2010 by the MIST Representative, was from EI # 3 (ED Physician, Hospital # 1,) requesting contact with the on-call Vascular Surgeon at Hospital # 2. EI # 7, Vascular Surgeon's response, "I'm busy, I'll have to call you back," is documented by the representative in the comment section of the computer generated form.

A second call, on April 10, 2010 at 7:06 AM, was a request from EI # 3 (ED Physician, Hospital # 1), requesting contact with EI # 6 (On Call Trauma Physician, Hospital # 2). EI # 6 responded and accepted the transfer of PI # 1 from Hospital # 1 as indicated by the Referral Code of "0" ("Name of RN)..ref (referral) for vas (vascular) problem to ER.."

A third call, dated April 10, 2010, at 7:28 AM, from EI # 7 (Vascular Surgeon, Hospital # 2), requesting the representative to contact EI # 3, ( ED Physician, Hospital # 1). EI # 3 responded. "Follow up on (name of PI # 1)" is the only information documented in the comment section by the representative. There is no documentation on this form to indicate the decision to accept the transfer of PI # 1 was changed.

A copy of an incident report, completed April 21, 2010, by EI # 11, MIST Representative (Rep.), given to the surveyor at 9:40 AM on April 21, 2010 includes:
To: "MIST Representatives
From: Name of MIST Manager"
"Anytime the MIST process does not work according to prescribed protocols and directives, please write a detailed summary of the problem on this form..."
"Date: 4/10/2010. Time: 7:05
Incoming/Outgoing: I (Incoming)
MIST Representative: Name of EI # 11 (MIST Rep.)
Caller's Name: EI # 3 (ED Physician/Hospital # 1)
City: Location of Hospital # 1
Party Requested: Vascular Surgery
Responding Party: EI # 6, Vascular Surgery Attending/Hospital # 2
Detailed Explanation: EI # 3, ED Physician/Hospital # 1 called in and requested vas.(vascular) surg (surgery) svc.(service). EI # 7 (On Call Vascular Surgeon) answered and said he was tied up at the moment and would call EI # 3 back shortly. EI # 3 then asked me to page the trauma srv. I paged and EI # 6 (Trama Physician) ans.(answered). He accepted the patient to Hospital # 2's ER for vascular problem die to an accident. Trans (transfer) nurse was also on the line. EI # 7, On Call Vascular Surgeon/Hospital # 2, called back at 7:28 and told EI # 3 (ED Physician/Hospital # 1) that he (EI # 7) couldn't operate on the patient as he was in another operation so the patient could not be accepted because EI # 6 (Trauma Physician) could do nothing for pat. (patient). EI # 7 said he was going to call EI # 6 back and let him know the patient could not come. He (EI # 7 ) said he would call EI # 3 back with the final word on it. I never heard from him (EI # 7) again."

Interview with EI # 7, Hospital # 2, Vascular Surgeon, on April 21, 2010 at 11:30 AM:
EI # 7 said he received a page from Hospital # 2's MIST "Operator" on Saturday morning, April 10, 2010, advising him of a call from EI # 3 (ED Physician, Hospital # 1). According to EI # 7, he informed the MIST operator he was taking care of an emergency and would return a call to EI # 3 (ED Physician, Hospital # 1). "Ten to fifteen minutes later," EI # 7 says he called the MIST "operator" to request connection with EI # 3 (ED Physician, Hospital #1). According to EI # 7 (Vascular Surgeon., Hospital # 2), the operator told him he did not have to worry because EI # 6 (On Call Trauma Physician, Hospital # 2) accepted PI # 1. EI # 7 stated he then spoke with EI # 12 (Vascular Surgery Fellow. Hospital # 2) who asked if EI # 7 (Vascular Surgeon, Hospital # 2) had heard about a transfer of a patient with a vascular injury to Hospital # 2. The surgeon (EI # 7) said, "That will be a problem. EI # 6 (Trauma Physician) accepted PI # 1 to the trauma service with the plan to consult Vascular Surgery. According to EI # 7 (Vascular Surgeon), he was the only surgeon at Hospital # 2 who could perform the vascular procedure as his partners were out of town.
The on call Vascular Surgery Schedule revealed EI # 7 was on call on April 10, 2010.

Telephone Interview with EI # 3, ED Physician at Hospital # 1, on April 29, 2010 at 3:00 PM:
EI # 3 says he initially called the MIST Representative (name unknown to EI # 3) at Hospital # 2 and requested to speak to the on call vascular surgery physician. EI # 3 was informed by the representative that the vascular surgeon was busy with a case. According to EI # 3, while he was still on the MIST telephone line, he noticed PI # 1's x-ray revealed a shattered femur. Because of this fracture, EI # 3 stated he requested to speak with the on call trauma physician, EI # 6. EI # 6 (On Call Trauma Physician, Hospital # 2) accepted PI # 1. EI # 3 says he called the helicopter service to transport PI # 1 to Hospital # 2. According to EI # 3 (ER Physician), EI # 7 (On Call Vascular Surgeon, Hospital # 2, called EI #3 and was "very upset." The ED Physician (EI #3) says the Vascular Surgeon (EI # 7) told him to stop the transfer of PI # 1 from Hospital # 1 to Hospital #2.
The ED Physician says he, "Stopped everything," and contacted Hospital # 3. PI # 1 was eventually transferred to Hospital # 3, a local hospital with the capability to treat the patient The surveyor asked the ED Physician the reason he did not initially contact Hospital # 3 and EI # 3 said, "We just typically don't. We refer everything (trauma) to Hospital #2. It's just what we do."