HospitalInspections.org

Based on a review of the
- UAB (University of Alabama in Birmingham- Main Hospital ) ED (Emergency Department) Communication Control Log
- Ambulance report
- UAB Activity Log (Electronic Central Log)
- ED (Emergency Department) Medical Record
- EMTALA (Emergency Medical Treatment and Labor Act) Policies and Procedures
- ED Census (7/28/16) and interviews, the hospital failed to:

1). Assess Patient Identifier (PI # 1's) and PI # 2's condition on arrival to the ED to ensure both patients were appropriately prioritized, based on presenting signs and symptoms, to be seen by the physician and

2). Initiate a Medical Screening Evaluation (MSE) on arrival for:

- PI # 1, a patient with a history of subdural hematomas who was transported via ambulance to the ED with a chief complaint of increased muscle twitching, increased drooling and slurred speech on 7/28/16 and

- PI # 2, a patient with an ankle fracture transported via ambulance to the ED for orthopedic services not available at the sending hospital.

The Medical Screening Examination was not provided for PI # 1 until 6:52 PM, almost six hours after the patient's arrival. PI # 1 was triaged three hours and 57 minutes after arrival and was assessed to be a Level III based on the Emergency Severity Index (ESI), but did not receive nursing/and or medical attention within 60 minutes per ED policy.

A Medical Screening Examination was not provided for PI # 2 until 19:32, two hours and seventeen minutes after the patient's arrival. PI # 2 was triaged 53 minutes after arrival and was assessed as a Level III based on the ESI, but did not receive receive nursing and/or medical attention within 60 minutes per ED policy.

The patients were not triaged upon arrival to the ED. As a result, the ESI level at the time of arrival could not be determined because a triage assessment and vital signs were not obtained. Therefore, the medical screening examinations were delayed for PI # 1 and PI # 2.

This deficient practice affected PI # 1 and P # 2, two of 24 sampled patients, but has the potential to affect all patients who present to the ED for evaluation of a medical condition.

1). UAB ED's Communication Control Log dated 7/28/16: (PI # 1):

A review of the log containing phone reports from EMS (Emergency Medical Services) personnel regarding incoming patients via ambulance to the ED revealed a call was documented at 4:20 PM regarding a 67 year old male (identified by ED Manager as PI # 1). Blood Pressure (BP): 95/55, Heart Rate (HR) : 100, Respirations: 20 and Oxygen Saturation: 98% on Room Air.
Initial Patient Information: COPD (Chronic Obstructive Pulmonary Disease), 3 Liters per Minute Home Oxygen, Dyspnea (shortness of breath) and CP (? Chest Pain - not spelled out). Estimated time of arrival: 7 - 8 minutes.

2). Ambulance Report (received with complaint prior to survey):

Date of Service: 7/28/16

12:13 PM: Arrived on scene (PI # 1's home). Patient sitting upright in chair. No specific complaint by patient. Per family, the patient is drooling more than usual and his left arm is twitching more frequently over the past couple of days. History of inoperable intracranial brain tumor? Alert and oriented x 4.

12:15: Airway: Patent; normal respirations.

Circulation: Radial pulses normal.

General weakness.

12:25: Oxygen @ 2 Liters per mask.

12:27: IV (intravenous) access initiated.

12:29: Cardiac Monitor initiated.

Transport Priority: Emergency.

Time of Arrival to UAB ED: 1:58 PM

Condition on arrival: Improved. "After RN (Registered Nurse) check in, instructed to position against the wall for available room."

14:57: Blood Pressure 92/48, Pulse 86 (regular and strong), Respirations 17 (normal and regular). Alert.
Comments: "1st hour after arrival to ER (Emergency Room). No VS (vital signs) taken by ER staff. Pt. (patient / PI # 1) on EMS (Emergency Medical Services) stretcher, against the wall."

15:57: BP 90/42, Pulse 86 (strong and regular), Respirations 17 (Normal). Comments: "2nd hour after arrival. No VS (vital signs) taken by ER staff... Pt. (patient) is c/o (complaining) of Left foot pain secondary to gout."

16:57: BP 96/50, Pulse 90 (strong and regular), Respirations 17 (Normal). Comments: "3rd hour after arrival. No VS (vital signs) taken by ER staff...
EMS patient still on the wall..."

17:44: BP 94/52, Pulse 90 (strong and regular), Respirations 17 (Normal).
Comments: "4th hour after arrival. VS are taken by ER RN (Registered Nurse). Rm. (room) assigned...approximate 30 minutes before it will be available. Patient Identifier (PI) # 1 told RN his foot "hurts bad and overall pain from lying on stretcher."

3). UAB Activity Log (Electronic Central Log):

According to documentation on the ED Log, PI # 1 arrived at 2:03 PM on 7/28/16.


4). ED Medical Record Review (Patient Identifier) PI # 1:

Arrival Date/ Time: 7/28/16 at 2:03 PM

Order for BMP (Lab - Basic Metabolic Profile): 5:51 PM. Entered in computer system by ED physician. (Entry verified by ED Manager, Employee Identifier (EI) # 1).

Triage: 5:50 PM.
Acuity Level 111 (patient generally needs medical/nursing attention within 60 minutes and two resources - see Emergency Severity Index Policy and Procedure).

Primary Nursing Assessment: 5:50 PM

Chief Complaint: Sent for evaluation of muscle twitching all over that has worsened since diagnosis of "intracranial hematoma" three months ago status post fall.
Neurological: Awake, alert. Baseline tremor, slow to communicate.
Respirations: Unlabored.
Vital Signs: Blood Pressure: 91/54, Pulse: 73, Temperature: 97.5. Respirations: 18 breaths per minute.
Oxygen Saturation: 95%. Room Air

Nursing Assessment of PI # 1: 7/28/16
6:44 PM: Patient to exam room via ambulance. Patient alert and hooked up to bedside monitor.
Vital Signs:
Blood Pressure: 107/62, Pulse: 92, Temperature: 98.6, Respirations: 18.
Oxygen: Nasal Cannula 5 L (Liters) per minute.

ED Physician Note:
Time Seen: 7/28/16 at 6:52 PM
Arrival Mode: Ambulance
Source: Patient
History limitation: Clinical condition
Chief Complaint: "Sent for evaluation of muscle twitching all over that has worsened since diagnosis of intracranial."

History of Present Illness:
67 year old male with history of seizure disorder, chronic subdural hematomas (SDH), Deep Vein Thrombosis-not on anticoagulation (medications that work to prevent blood clotting (www.wikipedia.org), Hypertension, Alcoholic cirrhosis, recent falls who presents with altered mental status and increased twitching. Recently discharged from UAB on 6/1/16 for Altered Mental Status thought to be "multifactoral." A fall on "4/27" caused bilateral subdural hematomas (collection of blood outside the brain, www.webmd.com) with extension and subsequent left frontal and temporal intraparenchymal hematomas (a blood clot that develops in the brain, www.reference.com) that was subsequently complicated by seizures, but improved on Vimpat and Keppra (anti-seizure medications). The patient was discharged to a skilled nursing facility, but was readmitted for hypotension (low blood pressure), bradycardia (slower than normal heart rate, www.mayoclinic.org) and hyperkalemia (high potassium) due to Acute Kidney Injury.

On readmission, PI # 1 was placed in the Medical Intensive Care Unit and intubated (insertion of a breathing tube into the trachea for mechanical ventilation, www.medicinenet.com). The patient was subsequently transferred to the floor and discharged.

He has an intermittent productive cough, but denies shortness of breath. EMS states they were called because the patient has had increased "twitching" after his recent SDH (Subdural Hematomas). The patient's family is not available for further history and the patient cannot give further comments about these symptoms

Review of Symptoms:
Constitutional: Weakness and fatigue...
Respiratory: Cough and sputum production....
Cardiovascular: No chest pain.
Gastrointestinal: No abdominal pain, no nausea and or vomiting.
Genitourinary: No dysuria (uncomfortable or painful urination, www.study.com), no hematuria (blood in urine).
Neurological: No headaches, no dizziness.

Medical History:
Active Problems:
- Diabetes
- Hypertension
- Lung Nodule
- Non-occlusive thrombus left leg
- Peptic Ulcer Disease

Physical Examination:
Vital Signs:
BP: 91/54, Pulse: 73, Temperature: 97.5, Respirations: 18.
General: No acute distress, ill-appearing, not alert.
Cardiovascular: 1+ edema to mid-shin.
Respiratory: Scattered rhonchi, no wheezing or rales.
Neurological: Somnolent, but arousable, follows commands, oriented to self and situation only...

Medical Decision Making:
Documents reviewed: EMS run report, prior records.

Differential Diagnoses and Rationale:...presents with possible increased confusion over baseline as well as persistent twitching. Differential diagnosis includes encephalopathy due to Hepatic Encephalopathy, Metabolic Derangement, Infectious Process, Non-conclusive seizure, or change in Chronic Subdural hematoma. Will obtain labs to rule out metabolic causes, infectious workup and head CT (Computerized tomography scan; combines a series of X-ray images taken from different angles and uses computer processing to create cross-sectional images of the bones, blood vessels and soft tissues inside the head, www.mayoclinic.org).

Electrocardiogram: 7/28/16 7:43 PM: First degree AV Block...(stable from previous).

Lab Results: 7/28/16 7:43 PM: (Hospital Lab References not documented)

Potassium: 5.4 mmol/L (Hi) (Range 3.5-5.1 mmol/L, millimole per liter (unit used in medicine to measure the concentration of substances in the blood, emedicine.medscape.com).

BUN (Blood Urea Nitrogen): 70 milligrams per dL, (deciLiter) Hi. (reveals information about kidney and liver function. Measures the amount of urea nitrogen in blood, www.mayoclinic.org/tests-procedures/blood-urea).

Creatinine: 3.1 mg/dL (Hi) (Substance formed from the metabolism of creatine, commonly found in blood, urine, and muscle tissue; indicator of kidney function. Normal levels: 0.6 to 1.2 mg/dL for males, may decrease in elderly patients because of smaller muscle mass, Mosby's Medical Dictionary, 9th edition. © 2009, Elsevier.

PT: 14.8 seconds (Hi) (measures how long it takes blood to clot, www.webmd).

CT Head without contrast:
- No acute intracranial abnormality.
- Continued improvement in size of bilateral high convexity subdural hematomas.
- Large area of encephalomalacia (cerebral softening; a very serious disorder inflicting permanent tissue damage to the brain, www.health-benefits-of.net) in the left frontal lobe and small focus in superior left temporal gyrus (a ridge on the cerebral cortex, wikipedia.org) unchanged.

Final Diagnoses:
- Hyperkalemia (higher than normal potassium level in the blood; critical to function of nerve and muscle cells, including those in the heart, ww.mayoclinic.org/symptoms/hyperkalemia).

- Acute Kidney Injury (abrupt decline in renal function; measured by BUN and Creatinine levels, www.emedicine.medscape.com).

- Encephalopathy (general term that means brain disease, damage, or malfunction; the major symptom is an altered mental state, www.medicinenet.com).

Condition: Stable.

Disposition: Admit Inpatient Unit. .


Nurse Assessment Notes 7/28/16:

7:22 PM: X-ray at bedside.

7:55 PM: Peripheral IV (Intravenous access) placed in right hand. Patient confused at times...

8:52 PM: Asleep; easily arousable. Awaiting disposition.

9:58 PM: BP: 87/48. Albuterol nebulizer treatment started.


Nurse Assessment Notes 7/29/16:

12:25 AM: BP: 85/53. Oxygen 4 Liters per nasal cannula. Systolic blood pressure dropped to 80's then 60's. Medical Doctors at bedside to assess patient. Second IV access obtained. Repeat labs drawn and sent to lab. "Liters 3 and 4 hung" (IV fluid). Hemoccult (test for hidden blood in the stool) done. Foley (urinary catheter) inserted.

1:10 AM:
BP: 122/60. Plasma hung. Packed red blood cells requested.


Nurse Assessment Notes 7/29/16:

1:22 AM: BP: 85/50. Pantapropazole (Protonix) drip hung. (medicine to treat gastroesophageal reflux disease (GERD) and erosive esophagitis,www.rxlist.com).

1:58 AM: BP: 127/66. Octreotide (medication that decreases blood flow to digestive organs,www.medicinenet.com.) started. Awaiting blood.

2:20 AM: Vancomycin ( antibiotic used to treat serious bacterial infections, www.webmd.com) started. Awaiting blood.

3:02 AM: BP: 127/57. Report given to RN at (Hospital off main campus with same provider number as UAB Main Hospital.) Protonix, Octreotide and Vancomycin infusing. Awaiting blood; blood bank contacted again.

3:35 AM: Blood hung as ordered.

4:45 AM: Admitted to ICU at hospital off main campus.

ICU (Intensive Care Unit History and Physical: 7/29/16 at 6:27 AM (after disposition from ED)

Acute Encephalopathy: Likely "mutifactoral" including infectious and metabolic due to uremia (syndrome associated with fluid, electrolyte, and hormone imbalances and metabolic abnormalities, which develop in parallel with deterioration of renal function, emedicine.medscape.com) from Acute Kidney Injury.

Acute Kidney Injury: Current Creatinine level: 2.2 (chemical waste molecule generated from muscle metabolism, www.medicinenet.com).

Hyperkalemia: Potassium 4.5 on admission. Treated with "insulin," Dextrose 50%, Albuterol in ED. Currently 3.6. Monitor.

Normocytic Anemia: "? Due to gastrointestinal bleed versus chronic." Positive hemoccult in ED, but patient on Ferrous Sulfate (iron) so could be false positive. Hold Ferrous Sulfate now. Current Hemoglobin (Hgb): 7.9 (protein molecule in red blood cells that carries oxygen from the lungs to the tissues and returns carbon dioxide from the tissues back to the lungs, www.medicinenet.com). Hgb 10.8 on admission. (Range: 13.8 to 17.2 grams per deciliter).

Scrotal Cellulitis: Treat with Antibiotics: Vancomycin and Zosyn.

Alcoholic Cirrhosis: Concern for bleeding varices (dilated blood vessels in the esophagus or stomach, www.webmd.com).

Seizures: Check EEG (electroencephalogram, test that detects electrical activity in the brain, www.mayoclinic.org).


5). EMTALA Policies and Procedures:

5.A.). Triage of the Emergency Department (ED) Patient
PC.01.02.03

1. Purpose: Provide guidelines for RN's in the UED (University of Alabama at Birmingham Emergency Department) to effectively identify and manage potential life threatening illnesses and injuries and prioritize the order in which emergent, urgent, non-urgent and routine patients will be seen...

3.1.1. Triage Nurse: A RN...who has completed the Emergency Severity Index (ESI) triage program and can demonstrate competency in prioritization of patient care.

3.1.2. Emergency Severity Index (ESI): A tool for use in emergency department triage. The ESI algorithm yields rapid, reproducible, and clinically relevant stratification of patients in five groups, from Level 1 (most urgent) to level 5 (least urgent). The ESI provides a method for categorizing...ED patients by both acuity and resource needs.

3.1.4. Reason for Visit: Refers to the reason as stated by the patient or family member of why they have come to the UED as stated to the Emergency Communication Specialist (ECS).

3.1.5 Emergency Communication Specialist (ECS): ED Staff responsible for receiving, surveying, registering and coordinating placement of patients presenting to the UED, with the Triage RN, and reporting observations to the medical staff...

4.1. Triage Front Desk...

4.2 Triage Ambulance Entrance

4.2.1. Any patient who is reported by prehospital personnel as unstable or emergency shall be directed to an appropriate treatment area for triage stabilization.

4.2.1.1. The patient shall be quick registered and the nursing assessment will be carried out as the patient condition permits.

4.2.1.2. The Emergency Communication Specialist (ECS) shall:

- Enter the patient in the Quick Registration System...
- Ask the patient the reason for the visit, while obtaining pulse oximetry and heart rate, and document results in the computer system.-
- Notify the triage nurse that there is a patient to be triaged at the ambulance entrance...

...4.2.1.3. The Triage Nurse shall notify the Emergency Medical Service (EMS) of the room assignment and direct them to the room.

4.2.1.4. The nurse shall receive report from EMS and sign the patient care report...

4.2.1.5. The primary nurse OR designated nurse shall assume care of the patient...

4.2.1.7. If the patient must remain on the stretcher, the patient shall be directed towards the area of the next coming available bed.

4.2.1.7.1. An available nurse shall complete the nursing assessment...and implement appropriate orders.

4.2.1.8. The triage nurse shall assign the patient to a treatment room as one becomes available.


4.3. Emergency Severity Index (ESI), a five level acuity system:

4.3.1. Level 1: These patients require immediate life saving interventions. Examples: Cardiopulmonary Arrest, Multisystem Trauma.

4.3.2. Level 2: These patients require medical/nursing attention within 30 minutes. Examples: Chest pain, Moderate burns.

4.3.3. Level 3: These patients generally need medical/nursing attention within 60 minutes and two resources. Examples: Minor Motor Vehicle Collision, Non cardiac chest pain.

4.3.4. Level 4: These patients may be seen as space becomes available and require at least one resource. Example: Sore throat, Urinary tract infection

4.3.5. Level 5: These patients may be seen as space becomes available, but do not require any resources. Example: Rash, Medication refill.

4.5.1 Nursing Assessment: The primary RN or designated nurse shall assume care of the patient...

4.5.1. The primary RN shall determine the patient's reassessment needs...in collaboration with the attending physician...

4.6. Triage Examination:

4.6.1. All individuals presenting to the ED shall be triaged by a Registered Nurse.

4.6.1.1. No information related to payor status...or insurance information will be obtained prior to triage.

4.6.2.. Triage categories utilized in the ED for priority rating shall be
- Emergent
- Urgent
- Non-urgent

4.1.3. Triage shall consist of:

4.1.3.1. Primary Assessment as soon as possible after arrival.

4.1.3.1.1. Determine the chief complaint (subjective data) from patient, family/significant other, and/or EMS personnel.

...4.1.3.1.2. A rapid physical examination (objective data) of ABCDs:
Airway
Breathing
Circulation
Disability.

4.1.3.1.3. Continuation of the assessment is carried out by the primary nurse in the treatment area.

4.1.3.2. Secondary Assessment

4.1.3.2.1. Collect subjective data...History of Present Illness, Past Medical History, current medications, allergies, tetanus status...

4.1.3.2.1.2. Collect objective data: a brief targeted physical examination to include, but is not limited to respiratory, cardiovascular, neurological, musculoskeletal status and mentation. Includes a complete set of vital signs.

...4.1.3.2.3. The secondary assessment may be stopped at any point if the objective and subjective date indicate high acuity.

4.1.3.2.4. The primary MD (Medical Doctor)/RN shall complete the assessment of the Emergent and Urgent patients in the treatment area with ongoing reassessment.

4.1.3.2.5. Reassessment, including vital signs of those Non-Urgent patients awaiting treatment area assignment shall occur every 60 minutes and PRN (as needed).

4.1.3.3. The results of the assessment shall be recorded on the triage portion of the ED patient record...

4.2. Triage Categories (Treatment):...

4.2.1.1. Emergent Patients are immediately transported to the treatment area by ED staff and/or EMS personnel...

4.2.1.2. Urgent patients are transported to the appropriate treatment area by ED staff and/or EMS personnel as soon as possible...

4.2.1.3. Non - urgent patients are directed to the ED waiting area after registration....and will be escorted to an appropriate treatment area by ED staff and/or EMS personnel. (According to the ED Manager, these three levels are used to prioritize room assignments and do not correspond with the Emergency Severity Index).

4.2.1.4. Patient conditions or situations that require special consideration in which deviation from the routine/triage process include:

4.2.1.4.1. Ambulance Patients: Any patient reported by pre-hospital personnel as unstable/emergent shall be directed to an
appropriate treatment area for triage stabilization. The secondary assessment shall be carried out as the patient condition permits...


5. B.). EMTALA Policy ( Reference Number not documented): Issued 8/26/15

1. Hospital Campus means: the Hospital's Main Campus and UAB Highlands Campus...

2. The hospital is committed to screening and stabilizing all individuals who request medical treatment...

3.1.1. Hospital Campus means:
- the Hospital's (UAB) Main Campus and UAB Highlands...

3.1.2. Medical Screening Examination: that medical evaluation required to reach with reasonable clinical confidence, the point at which it can be determined whether an individual has an emergency medical condition...

3.1.3. Emergency Medical Condition means:

3.1.3.1. A medical condition manifesting itself by acute symptoms of sufficient severity, psychiatric disturbances, and/or other symptoms of substance abuse,
such that the absence of immediate medical attenuation could reasonably be expected to result in:
- Placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy.
- Serious impairment to bodily functions; or
- Serious dysfunction of any bodily organ or part...

3.1.4. Stabilize means to provide such medical treatment of the emergency medical condition necessary to assure, within reasonable medical probability, that no material deterioration of the condition is likely to result from or occur during transfer...

6). UAB ED Census Report:
7/28/16:
Number of Beds: 46
Census: 238
ICU Admissions: 10
Arrival of patient via ambulance: 55
Boarding Patients (patients waiting in the ED greater than 4 hours for an inpatient bed ): 18
Boarding Hours: 41
Acuity Level 11 Patients: 150
Acuity Level 111 Patients: 98

7). Summary of Interviews:

Interview with Employee Identifier (EI) # 1, RN (Registered Nurse), UAB ED Manager, on 9/21/16 at 9:39 AM and 9:45 AM:

According to the Manager, the primary role of the POD 1 RN (POD 1,
a term for the triage RN (stationed in the back of the ED near the ambulance bay) is the assessment of the patient arriving via ambulance and assignment of an Emergency Service Index level to the patient. The Manager said Emergency Severity Index (ESI) is an assignment of patient acuity and an estimation of resources the patient will require.

According to the Manager, the Emergency Communication Specialist (ECS), who sits at the ambulance bay/entrance to the ED, greets the patient and EMS staff and notifies the POD I RN of the patient's arrival via ambulance. All ECS staff are Paramedics or Emergency Medical Technicians. Ambulance staff give a brief report to the ECS on arrival to the ED.

(According to EMTALA Policy # PC.01.02.03, the ECS is responsible for asking the patient the reason for the visit, while obtaining pulse oximetry and heart rate, and documenting the results in the computer system.)

The ECS staff notifies the triage nurse that there is a patient to be triaged at the ambulance entrance...The information documentation by the ECS about the condition of an ambulance patient on arrival is automatically replaced when the charge nurse or RN enters the patient's chief complaint in the computer system. According to the Manager, the documentation by the ECS personnel cannot be reproduced.

The Manager verified the first documentation in Patient Identifier # 1 (PI # 1's ) medical record by ED staff was the arrival time at 2:03 PM on 7/28/16. There is no documentation in PI # 1's ED medical record by the POD 1 RN about the patient's ESI and/or triage level at the time of arrival. The Manager verified the next documentation was the triage time and nursing assessment at 5:50 PM, three hours and 57 minutes after PI # 1 arrived in the ED. The Medical Screening Examination was not provided for PI # 1 until 6:52 PM (almost six hours after PI # 1's arrival).

The Manager reviewed the ED schedule for 7/28/16 and said the RN responsible for the triage of PI # 1 is out of the country. The Shift Lead is the RN assigned to manage the overall flow of the Emergency Department. According to the Manager, no physician orders were written (documented in computer system) until sometime after 6:30 PM on 7/28/16. PI # 1 was discharged to UAB Highlands ICU (Intensive Care Unit) at 4:09 AM on 7/29/16. Ten patients were admitted from the ED to inpatient status on 7/28/16.

The period of time a patient arrives in the ED via EMS on a stretcher until they are moved to an ED bed, report is received from EMS personnel and care is assumed by ED staff from EMS personnel is defined as "wall time." According to EI # 1, all ambulance patients who remain on an EMS stretcher waiting for an ED bed are placed in line of sight of ED staff at POD 4 (close proximity to the ambulance entrance) until an ED bed is available.

According to the Manager, seven ambulance patients arrived one hour before and one hour after PI # 1 arrived at 2:03 on 7/28/16. A summary of the ED Performance Report containing Emergency Severity Index (ESI) information dated 7/28/16 (same day PI # 1 presented to the ED) was provided by the Manager included:
- ESI Level 1: 7 patients
- ESI Level 2: 150 patients
- ESI Level 3: 98 patients
- ESI Level 4: 31 patients
- ESI Level 5: 8 patients.

The Manager stated EMS (Emergency Medical Services) is responsible for care of the patient until ED staff is able to receive report from EMS staff. EMS patients on stretchers are placed in line of sight of ED staff at all times until a room is available. All EMS/ambulance patients are assessed on arrival by RN, but the assessment is not always documented. The ED went on diversion approximately one hour after PI # 1 arrived on 7/28/16. ED Diversion began on 7/28/16 at 3:01 PM and ended on 7/29/16 at 5:43 AM for a total of 14.7 hours.

Interview with ED RN Shift Lead 7:00 AM- 7:00 PM, EI # 2, on 9/15/16 at 10:10 AM:

The ED RN confirmed she functioned as the Shift Lead on 7/28/16 when PI # 1 arrived in the ED. According to the RN Lead the POD 1 RN, "Lays eyes on the patient because EMS is with the patient until room placement." The Emergency Communication Specialist and the RN receive a brief report from the ambulance staff when the patient arrives in the ED. The RN anticipates the patient's arrival based on the report called in by ambulance/EMS personnel. On arrival, the RN assesses the patient to determine if the EMS report matches the visual assessment by the RN and/or notes any changes in the patient's condition. "Every ambulance patient is visualized by an Emergency Communication Specialist and a RN (Registered Nurse) on arrival. " Although the POD I RN usually documents the triage of EMS patients, any RN can assess and document as needed based on activity in the ED. The POD 1 RN may be pulled to work in trauma and acts as secondary triage for the patients who enter the ED from the front.

According to the Shift Lead RN, if there are multiple patient arrivals via EMS, some RN's document on paper and later document in the electronic system. The surveyor asked the RN to define "time done" as documented in the electronic medical record. The RN stated "time done" indicates the time an action was performed in reference to patient care/status.

The RN was asked how ED staff determined PI # 1 could wait for over three hours based on an arrival time of 2:03 PM, but no triage documentation until 5:50 PM. At 5:50 PM, PI # 1 was assessed as a Level 111 based on the Emergency Services Index. According to the RN, although it was not documented in PI # 1's medical record, she "assumes" PI # 1 was visualized by an RN on arrival based on the normal process of placement of ambulance patients near POD 4 (nursing station close to ambulance bay/entrance). There is no physical structure to block visualization of patients by staff at POD 4.

The ECS, POD 1 RN and the Triage RN (located at the front desk) communicate via phone regarding all patient arrivals, acuity and bed availability. The RN verified the triage time for PI # 1 was documented at 5:50 PM.

According to the Shift Lead RN, when the ED is busy with multiple emergencies (including multiple patient arrivals via ambulance) that ambulance patients are "parked"on EMS stretchers until staff can safely move from the most acute patient to the less acute patient. ED staff is dependent on EMS personnel to notify staff of any change in the patient's condition. According to the Shift Lead RN, staffing looked "good" on 7/28/16.


Interview with EI # 3, ED RN, on 9/21/16 at 10:37 AM:

The RN confirmed (using a copy of PI # 1's medical record provided by the hospital) she was responsible for the triage assessment and assignment of the ESI Level III to PI # 1 on 7/28/16 at 5:50 PM, but did not recall the patient. She stated as the POD 1 RN on 7/28/16, she was responsible for the triage of patients arriving via EMS to the ED. However, the POD I RN may be pulled by the RN Shift Lead if assistance is needed for a trauma patient and /or the RN may be assigned to more acute patients. When pulled to fulfill another priority, the RN no longer functions as the POD 1 RN. According to the RN, this occurs on a frequent basis due to the number and acuity of the patients who present to the ED.

Interview with EI # 1, ED Manager, on 9/21/16 at 3:30:

EI # 1 acknowledged the extended "wall"/wait time for PI # 1 from arrival to time of Triage and arrival to time of Medical Screening Examination on 7/28/16. According to the Manager, staff recognizes the impact on patients transported to the ED via ambulance and the extended "wall"/wait time for EMS personnel.

In response to the hospital's identification of these concerns, an "Ambulance Triage Project" was initiated in Match 2016. The goals were to reduce ambulance wait times and provide optimal patient care. During the project patients arriving via ambulance were sent directly to a designated ambulance triage area where they were received by ED staff. As a result, the return of EMS crews to their communities was improved. The trial also resulted in a reduction of ambulance wait times by almost 50%. Seventy-four patients were seen in the ambulance triage area and were provided with 153 hours of patient care during the trial. The trial was deemed effective, but it has not been implemented because staff has to be hired. The plan is to create a designated ambulance triage area and staff the area with paramedics and emergency medical technicians.

Interview with EI # 4, Assistant ED Clinical Manager, on 9/21/16 at 11: 40 AM:

EI # 4 stated the Pod 1 RN is responsible for assessing EMS patients on arrival to the ED and assigning ESI levels. Many times there are multiple emergencies, but the sickest patient takes priority. The Emergency Communication Specialists (ECS), positioned at the ambulance bay, are "good" about communicating differences in the patient based on report and patient status on arrival. The hospital is a Level 1 Trauma Center and a Stroke Center.

Telephone Interview with EI # 5, Paramedic with Ambulance Service, on 9/21/16 at 11: 40 AM:

The paramedic confirmed he transported PI # 1 to UAB ED on 7/28/16. He stated a report was called by EMS to UAB's ED via radio prior to arrival (see Communication Control Log). The paramedic was asked to define "RN check in" as documented in the EMS report narrative. According to the paramedic, "RN check in" means the RN confirms the patient's name on arrival and assigns the patient to a room or the wall. When the paramedic arrived with PI # 1, the patient was assigned to "the wall." According to the paramedic's report, vital signs were taken by ED staff four hours after arrival of PI # 1. Otherwise, no treatment was given to PI # 1 while the patient waited on the stretcher. Based on documentation in the EMS report, the paramedic gave report at the bedside to the MD/RN at 6:38 PM.

The paramedic acknowledged the ED was busy and three to four ambulances were present when he arrived wi