HospitalInspections.org

Based on reviews of clinical records, review of hospital policies and procedures, and staff interviews, it was determined the hospital failed to enforce policies and procedures that comply with the requirements of 42CFR 489.20 and 42 CFR 489.24, responsibilities of Medicare participating hospitals in emergency cases as evidenced by:

Tag A-2411 Recipient Hospital Responsibilities.

Valleywise Health Medical Center (Hospital #1) failed to accept patients from outside facilities who required the specialized services of an Ear/Nose/Throat (ENT) physician even when they had ENT services on-call. An Emergency Department physician from another hospital called the Valleywise call center requesting transfer of a patient (Patient #1) who required ENT. The ED physician was told Valleywise had ENT on-call coverage but only for patients within their system. The other hospital had to locate another acute care hospital with ENT on-call coverage who accepted the patient in transfer. This deficient practice poses the risk of a delay in treatment and potential harm to the patients requiring specialized services.

Based on review of clinical records, policies and procedures, hospital documents, and staff interviews, it was determined Valleywise Health Medical Center (Hospital #1) failed to accept patients from outside facilities who required the specialized services of an Ear/Nose/Throat (ENT) physician even when they had ENT services on-call. An Emergency Department physician from another hospital called the Valleywise call center requesting transfer of a patient (Patient #1) who required ENT. The ED physician was told Valleywise had ENT on-call coverage but only for patients within their system. The other hospital had to locate another acute care hospital with ENT on-call coverage who accepted the patient in transfer. This deficient practice poses the risk of a delay in treatment and potential harm to the patients requiring specialized services.

Findings include:

The hospital's policy and procedure titled, "Compliance/EMTALA: Registration, Triage, and Medical Screening Exam," included: "Definitions...On-Call List refers to the list that the hospital is required to maintain that defines those physicians who are on the hospital's medical staff or who have privileges at the hospital, or who are on staff...and are available to provide treatment necessary after the initial examination to stabilize individuals with EMCs (Emergency Medical Conditions). The list should be maintained in accordance with the resources available to the hospital...The purpose of the on-call list is to ensure that the DED (Dedicated Emergency Department) is prospectively aware of which physicians, including specialist and subspecialists, are available to provide treatment necessary to stabilize individuals with EMCs. The services included in the on-call list will be determined by the hospital administration and physicians in accordance with the resources available to the hospital...9. Administrative Requirements...d. Duty to Accept Transfers. Valleywise Health will accept transfers of persons with [unstabilized] emergency medical conditions from other hospitals when Valleywise Health has the specialized capabilities and capacity to treat the person's medical condition.

The hospital's policy titled, "Compliance/EMTALA: On-Call Physician Responsibility," included: "Policy...A list of on-call physicians will be maintained by Valleywise Health and the on-call physician will respond appropriately, when requested to provided emergency services...Procedure: 1. On-Call List...a. Per the Valleywise Health Medical Staff Rules and Regulations, each clinical department must have an Attending Physician on call that is available to provide emergency consultation services...b. The chair of each clinical department will furnish the emergency department with rosters of on-call physicians for every month...2. On-Call Physician Responsibilities...In emergency situations, the consulting service is responsible to respond to the initial call within 30 minutes of the consultation request...."

Article 2 of the Medical Staff Bylaws included responsibilities for Active Staff and included: "Active Staff members must assume all the responsibilities of membership on the Active Staff, including...(b) providing call coverage per the appropriate department call schedule...."

The Valleywise Health Protocol titled "Medical Staff: Facilitation of the Co-management of Transferred Patients" included: "Responsibilities/roles: Patient Logistic Center (PLC) - Admission Transfer Center (ATC) - Is the centralized location for receiving calls for all incoming patients except for Burn, NICU, and L&D Programs. The PLC can provide the following: information regarding census and open bed status...information on staffing resources...information on services open to receive transfers." The protocol did not include how incoming calls for transfers and admissions were recorded, documented, and monitored. The Patient Flow Administrator job description included: "...Typically, decisions made in this position could positively or negatively affect the entire hospital. Work is subject to strategic guidance and evaluation from senior management."

Patient #1 presented to Hospital #2 on 09/06/2020 for a chief complaint of "dental pain." The patient reported having a left upper molar extracted about six days prior and developed immediate swelling after the procedure. The patient's temperature was 99.9 F and 100.8 F while in the ED with a reported pain level of "10" on a pain scale of 1 to 10. The patient received a medical screening examination (MSE) by the ED physician on duty at the time of presentation (Physician #1). Physician #1 ordered a maxillofacial CT scan which revealed the following: "There is a large multilocular in capsulated fluid collection in the soft tissues of the left malar eminence/abscess which measures 4 cm by 2.8 x 3.5 cm with surrounding induration/panniculitis. Additionally, there is a subperiosteal abscess of 1.7 by 0.9 by 1.7 cm, adjacent to the extracted left superior 1st molar tooth. Labwork performed revealed a high white blood cell (WBC) count of 15.3 (reference range 4.8 to 10.8). Physician #1 documented at 11:17 a.m. that there was no "ENT/OMF" (Ear/Nose/Throat / Oromaxillofacial) specialist on call for consultation at their hospital. The physician documented: "Called Valleywise - who refused to even discuss patient due to 'our CMO (Chief Medical Officer" has instructed us that our ENT group will not care for any patients outside the system' I asked (name) how that works with EMTALA - she repeated that issue." Another acute care hospital (Hospital #3) was contacted who accepted Patient #1 in transfer.

Documentation in the clinical record from Hospital #3 revealed an incision and drainage of the abscesses was performed at the bedside with "20 ml purulence in facial spaces removed." A drain was placed, and the patient was admitted for observation. The drain was removed several hours later, and the patient was discharged.

An interview was conducted with Staff #1 on 10/19/2020. Staff #1 reported a call was received from another acute care hospital reporting a concern that they requested to transfer a patient to them for ENT services and that they (Valleywise) refused to accept the patient even though they had ENT coverage. She stated there are two ENT providers on-staff and that they are only on-call for inpatients. Staff #1 was asked if the ENT providers take call from their dedicated emergency departments (DED), and she responded, no. She added that even though Valleywise Health Medical Center is a Trauma Center, they are not required to have coverage by all specialities. She stated an investigation was completed and they did not feel there was any violation or need for any changes in their policies and/or training.

Staff #1 was asked about their system to manage outside calls coming in requesting transfer to Valleywise. She responded that all incoming calls requesting transfers in are answered by a Patient Flow Administrator (PFA) and are recorded and logged.

There were two recorded calls from Hospital #2 regarding Patient #1 on 09/06/2020. The first call (time unknown) included the following:

-Hospital #2: "I have a patient we want to transfer over for ENT."

-Valleywise (Staff #6): "Our ENT service is (sic) currently has enough demand from our current facilities and we can't accept any outside ENT patients."

-Hospital #2: "You're not accepting any outside? Okay."

-Valleywise (Staff #6): Nope. Thank you."

The second call was from Physician #1 at Hospital #2 and included the following:

-Physician #1: "Hey, this is Dr. (name) calling from (name of Hospital #2)."

-Staff #6: "Hi."

-Physician #1: "We're trying to transfer a patient to you but we were told that you're not accepting outside patients for ENT consult? I'm not really sure what an on-call physician is and kind of feels very EMTALA-ish to me so I figured I'd call and try and get to the bottom of that."

-Staff #6: "So our ENT service currently has enough demand from our current facilities. We are not able to accommodate any additional patients at this time."

-Physician #1: "So you don't have ENT on-call then for your system?"

-Staff #6: "We have ENT on-call for our system but they are not able to accommodate anybody from the outside facilities because of the demand we have from our current facilities."

-Physician #1: "I don't understand how that works from a medical-legal EMTALA thing. Because usually, right?, higher level of care, right? So all of us little hospitals with no one and places that have specialists on-call technically take call for outside facilities that need higher level of care."

-Staff #6: "Sure. And where are you located?"

-Physician #1: I'm at (name of Hospital #2)

-Staff #6: "In Laveen and so I know that there are facilities with closer,uh, that are closer to you that have ENT on call so the same would apply to them"

-Physician #1: "Right, but I called you guys which is why I'm asking."

-Staff #6: "...this is per our CMO (Chief Medical Officer)...our current ENT service has enough demand from our current facilities that we cannot accommodate any outside transfers.:

-Physician #1: "Does that go for other specialities as well?"

-Staff #6: "That currently applies to ENT."

-Physician #1: Just ENT alone?"

-Staff #6: "Uh-huh."

There was no External Admission Record (the written log) completed for the above two calls by Staff #5.

Valleywise Health Medical Center's September 2020 on-call schedule for Surgery contained documentation that there was no "ENT Attending" on-call on 09/06/2020, however, there was "ENT Surgery" coverage by Physician #3 on that date.

Thirty-seven ED records from the two main dedicated emergency departments (not including the Burn Unit ED and the OB ED) were randomly selected for review. Five of those ED records contained documentation that ENT was consulted while the patients were in the ED.

-Patient #30 presented to the main hospital's ED on 07/05/2020 with a chief complaint of sore throat and worsening difficulty swallowing. A CT scan revealed the patient had a peritonsillar abscess. The ED physician's documentation included: "I consulted ENT and spoke to resident on-call who recommended admission for IV antibiotics and steroids, as well as airway management."

-Patient #34 presented to the main hospital's ED on 09/09/2020. The ED physician's documentation included: "...presents with right-sided jaw swelling and respiratory difficulty. CT obtained demonstrated large right submandubular mass with moderate airway compromise, ENT consulted for assessment."

-Patient #43 presented to the main hospital's ED on 07/27/2020 with swelling of the right side of her face. A CT revealed: "...6.5 cm heterogeneous fluid collection within the soft tissues adjacent to the right mandibular ramus. May represent an abscess/pyomyositis of the right masseter muscle possibly of odontogenic origin arising from the dental disease in the right mandibular molars...ENT was consulted for management, who evaluated the patient...."

-Patient #44 presented to the main hospital's ED on 08/17/2020 with right sided facial pain and swelling. The patient was found to have an intraoral abscess and the ED physician documented an ENT consult was obtained.

-Patient #45 presented to the hospital's main ED on 09/07/2020 and was found to have a "right-sided submandibular abscess." The ED physician documented: ENT consulted for assessment."

An interview was conducted with the CMO (Physician #2) on 10/27/2020. Physician #2 was asked to clarify the on-call status for their two credentialed ENT providers. Physician #2 stated the two ENT physicians only take call for in-patients. Physician #2 acknowledged the ENT physicians were on the "hospital-wide" call schedule, and there was not a separate on-call schedule for in-patients. Physician #2 was asked if they took call for patients presenting to their DED's and he responded no, and repeated that they only take call for inpatients. Physician #2 was advised that five ED clinical records had been reviewed that contained documentation of ENT consults obtained in the ED, and he responded that they would consult after the patients were admitted. Physician #2 was advised that the consults were obtained prior to the patients' admission or transfer. Physician #2 was asked if the Medical Staff Bylaws and Rules and Regulations addressed exceptions to the on-call requirements for Active Staff, and he responded that he did not know.

Documentation in the credential files for Physicians #3 and #4 revealed they were Active Staff. There was no documentation in those files that exempted them from providing on-call coverage.

An External Admission Record dated 07/09/2020 revealed the PLC received a call from another acute care hospital requesting transfer of a patient with cardiac arrest and rule out COVID (Patient #49). There was no documentation on the record of whether or not the patient was accepted for transfer.

An External Admission Record dated 09/12/2020 revealed the PLC received a call from a rural hospital requesting transfer of a critical care patient (Patient #51). The transfer was not accepted, however, there was no reason documented.

An interview was conducted with Staff #1, #2, #3, #4, and #5 on 10/27/2020. Staff #1 again reported the ENT physicians only provided on-call coverage for inpatients. They were advised that ED records were reviewed during the investigation that contained documentation of ENT consults obtained for patients presenting to the ED prior to the patients being admitted, discharged, or transferred. This was confirmed by Staff #2. Staff #2 was told there was no External Admission Record located in the September 2020 logs for the two calls on 09/06/2020 for Patient #1, and she responded that it was the expectation that every call be logged. The External Admission Records for Patients #49 and #51 documented above were reviewed during the interview, and they acknowledged the documentation was incomplete. They were asked if the External Admission Records were reviewed to ensure compliance with regulatory requirements and the response was no.

Staff #6 was not available for interview during the complaint investigation.

In summary, Valleywise Health and Medical Center received two calls from Hospital #2 requesting to transfer Patient #1 to them for ENT specialized services. Hospital #2 was told by Staff #6 at Valleywise during both calls that they had ENT coverage available but only to the patients within their "system" and not to outside patients. Physician #1 at Hospital #2 reminded Staff #6 of their obligations under EMTALA, however, Staff #6 persisted in refusing to accept the patient even though they had ENT on-call coverage. Staff #6 did not attempt to obtain any information on Patient #1, and there was no log completed of the two calls. Patient #1 was sent to another acute care hospital where she required surgical intervention and admission for observation. Interviews conducted revealed Valleywise had two ENT physicians credentialed as Active Staff and subject to on-call responsibilities as documented in the Medical Staff Bylaws / Rules and Regulations. There was no documentation provided that clarified how and why those physicians were exempt from on-call coverage. However, there were five ED records in the total sample that contained documentation of ENT consults obtained of patients presenting to the ED and prior to admission, discharge, or transfer. Although the hospital was notified of a concern of a possible EMTALA violation prior to this investigation, they determined there were no opportunities for improvement.