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Based on interviews, record review, and review of audio recordings, the facility (Hospital 1) failed to follow its policy for accepting transfers for patients experiencing emergency medical conditions when Physician D did not accept a patient presented for transfer, Patient 100, who required the specialty and intensive care that Hospital 1 had the capacity to provide. This failure resulted in an undue delay in treatment for Patient 100, who was experiencing a hemorrhagic stroke (also called intracerebral hemorrhage, happens when a blood vessel breaks and bleeds into the brain, brain cells begin to die within minutes) at a small, rural hospital, Hospital 2. Hospital 1 had a Level II trauma designation status, had available ICU beds, and had an on-call neurosurgeon who was capable of performing the potentially needed neurosurgery. Patient 100 ultimately was flown to a hospital approximately 204 miles away, approximately 53 miles farther than Hospital 1, in order to access the higher level of care he required.

Findings:

On 4/16/21, the Department received a complaint that indicated Patient 100 was seen in the emergency department (ED) at Hospital 2 with an intracerebral bleed on 4/13/21. The ED physician sought to transfer Patient 100 to Hospital 3, but because there was no neurologist, the neurosurgeon refused to accept the patient for transfer. The ED physician then sought to have Patient 100 admitted to Hospital 1. The complaint indicated, "Upon hearing that the neurosurgeon at [Hospital 3] refused to accept the patient because there was no neurologist there, the neurosurgeon at [Hospital 1] refused to accept the patient as well, contending that the [Hospital 3] neurosurgeon was not justified in refusing the transfer."

During an interview on 7/15/21 at 2:45 p.m., Physician H stated he had worked at Hospital 2 for 40 years and they transfer patients (out) on every shift. Physician H stated that on 4/13/21 he had a very difficult time finding a transfer for Patient 100. He stated Hospital 3 had neurosurgery, but no neurology. He stated it ended up being hours and hours before Patient 100 got to neurosurgery capabilities. Physician H stated he was concerned about the hours it took and stated Patient 100 needed a craniotomy. The CT (computed tomography, a scan that shows detailed images of internal organs) scan showed a significant midline shift (the brain was pushed to one side) and a significant bleed, significant intracranial pressure (high pressure inside the skull). Physician H stated patients tend to have a terrible outcome anyway with that significant of a bleed. Physician H stated he spoke to the neurosurgeon at Hospital 1 and they said Hospital 3 had a neurosurgeon and they were closer, so they (the neurosurgeon at Hospital 1) refused the patient (indicating Patient 100 should go to Hospital 3). Physician H stated Hospital 3 was one hour away by ambulance and Patient 100 was declining quickly. He stated that after that many hours (trying to find an accepting hospital and travel time), his survival rate was almost zero. Physician H stated, "It was a catastrophic event."

Review of medical records for Patient 100 (from Hospital 2) indicated Patient 100 was seen in the ED on 4/13/21 by Physician H after being found unresponsive by his wife. A CT scan of the head, performed at Hospital 2 on 4/13/21 at 6:53 p.m., showed a left frontoparietal (in the area of the front and middle lobes of the brain) intra-axial (in the brain itself) hemorrhage measuring 8 cm (centimeters) x 5.3 cm x 6.2 cm and a midline shift rightward measuring 7 millimeters. Patient 100's blood pressure was 207/120 at 6:55 p.m.. After Patient 100 was placed on a ventilator (a machine that moves air in and out of the lungs) at 7:38 p.m., his blood pressure came down to 156/98. Patient 100 was given intravenous mannitol (medication to keep the pressure down in his head). Patient 100 left Hospital 2 by ambulance at "about 1 a.m." to be transported to a fixed-wing aircraft that would transport him to the receiving hospital, Hospital 4.

Review of the audio recordings of the calls made to and from the Transfer Center (TC) on 4/13/21 revealed:

At 7:11 p.m.:

TC Dispatcher: Transfer Center. This is [TC Dispatcher].
Physician H: Yeah, hi. [Physician H] in the ER in [town named]. Um, I've got a patient with a large, um, hemorrhagic stroke I'm calling about transferring to [Hospital 3] for neurosurgery.
TC Dispatcher: Ok, give me one second. And what ED room is the patient in?
Physician H: Uh, one. . .
TC Dispatcher: And [Physician H]?
Physician H: Yes.
TC Dispatcher: Are you wanting to run this as a trauma?
Physician H: Uh, no, um, hemorrhagic stroke, uh, so it would be neurosurgery.
TC Dispatcher: Ok, give me one second. . . .

At 7:48 p.m.:

TC Dispatcher: . . . Hi, it's [TC Dispatcher] calling from the Transfer Center.
Physician H: Yes? Uh, huh.
TC Dispatcher: Hey, yeah, I was calling back on patient [Patient 100]. I just wanted to let you know we spoke with neurosurgery at [Hospital 3], um, and they said it would be best if they, if we try to take the patient somewhere like [Hospital 1] since they do not have neurology on and most hemorrhagic strokes are non-surgical. Um, so I just wanted to confirm with you it would be ok for us to try . . . [Hospital 1].
Physician H: Well, I've, I've just intubated him so he doesn't have a real good chance of, of making it that far.
TC Dispatcher: Mmm hmm. . . .
Physician H: . . . Ok, let's let's try [Hospital 1], because [Hospital 3] is not accepting them.
TC Dispatcher: Ok, I'll try [Hospital 1].
Physician H: Thank you.
TC Dispatcher: Ok.

At 8:14 p.m.:

Physician H: . . . Yeah, hi. [Physician H] here.
TC Dispatcher: Hey, it's [TC Dispatcher] calling from . . . Transfer Center. I'm wondering if I can get you connected with neurosurgery regarding patient [Patient 100]?
Physician H: Uh, yes, [Patient 100].
TC Dispatcher: Give me one second, ok?
Physician H: (on hold for two minutes)
TC Dispatcher: Hi, [Physician H]?
Physician H: Yes.
TC Dispatcher: So sorry about that hold. Um, so, [Physician D], uh, neurosurgery at [Hospital 1], um, uh, basically says that [Hospital 3] should have been able to handle this patient
Physician H: He said what now?
TC Dispatcher: He says that [Hospital 3] should be able to handle your patient, that they don't need
Physician H: They, they refused, they refused to take him because they don't have a neurologist
TC Dispatcher: Yes, I know, so I told him that, and he says that neurology's not needed, um
Physician H: Well, I can't force [Hospital 3] to do this
TC Dispatcher: Yes. I know. So doctor
Physician H: I can't force them to take him
TC Dispatcher: I know, . . . so I'm going to follow up with, um, [Hospital 3]'s neurosurgeon. Let me see if I can get a hold of them again, um, and see just what they say at that point.
Physician H: Ok, ok, and then call me back?
TC Dispatcher: Yeah. . . .

At 8:16 p.m. (while Physician H was on hold):

Physician D: Hello?
TC Dispatcher: Hi, it's [TC Dispatcher] calling from the Transfer Center?
Physician D: Ok.
TC Dispatcher: Hi, I'm calling in regards of a patient currently over at [Hospital 2] in the Emergency Room. It's a 74 year old female with a hemorrhagic stroke that they're looking to send
Physician D: Where, where is the patient?
TC Dispatcher: Um, at [Hospital 2].
Physician D: Where is that?
TC Dispatcher: It's in [town named].
Physician D: [town named]?
TC Dispatcher: Yeah.
Physician D: Ok, and they can't go to [Hospital 3] where they have three neurosurgeons?
TC Dispatcher: Uh, so [Hospital 3] suggested the patient go to go to [Hospital 1] just 'cause they don't have neurology as a back up. Um, [Hospital 3]
Physician D: You don't need neurology for a hemorrhagic stroke. This is getting to be ridiculous, ok? Blood in the head is taken care of by the neurosurgeon. It's not shunted to [Hospital 1] because we have neurology. Ok? Neurologists don't manage hemorrhagic strokes. So, you can tell the neurosurgeons that we're tired of getting inappropriate transfers that they can take care of and they can manage a hemorrhagic stroke.
TC Dispatcher: Ok, I will relay that message.
Physician D: Great.
TC Dispatcher: Thanks.

At 8:52 p.m.:

Physician C (administrator on duty for Hospital 1): Hi, this is [Physician C].
TC Dispatcher: Hi, it's [TC Dispatcher] calling from the Transfer Center.
Physician C: (inaudible)
TC Dispatcher: Hi, I just wanted to, um, advise you of a physician decline, um, for neurosurgery, uh, [Physician D]. It was a patient from [Hospital 2] they were trying to present with a hemorrhagic stroke.
Physician C: Mmm hmm.
TC Dispatcher: Um, I had a, I told him we had tried [Hospital 3], and [Hospital 3] neurosurgery wants the patient to go to [Hospital 1]where they had neurology as back up. Uh, so we presented to [Hospital 1], she gave me the go ahead and [Physician D] said that, uh, [Hospital 3] should be able to handle the patient. . . .
Physician C: Thank you for having me be aware. Where is the patient at?
TC Dispatcher: The patient's over at [Hospital 2] in [town named].
Physician C: Ok, ok. Are you re-presenting that patient back up to [Hospital 3]?
TC Dispatcher: Uh, yeah, so I called back to neurosurgery up in [Hospital 3], um, and kind of was like what do I do now? Like, we need to get this patient somewhere. . . .
Physician C: . . . Ok, um, I will reach out to [Hospital 3 CMO], . . . and try to see if we can come to some sort of solution. . . .


At 9:06 p.m.:

TC Dispatcher: . . . Hey, just wanted to give you an update on patient [Patient 100]
Physician H: Yes.
TC Dispatcher: Uh, so, uh, I have it, uh, I've escalated to our AOD (administrator on duty) about this transfer to [Hospital 3] and to [Hospital 1], um, but I just wanted to let you know 'cause we're kind of like at a standstill right now, so I don't know if you have it open with any other facilities?
Physician H: No, we don't . . . . [Hospital 3] or [Hospital 1], neither one are taking him?
TC Dispatcher: Correct. At this point, no. I do have it, uh, I have escalated it, but I just don't want you guys to just be waiting and waiting. You know what I mean?
Physician H: Yeah, yeah. Ok, I'll work on what I can. Ok.
TC Dispatcher: Ok, and I'll give you a call back if I hear anything. . . .

At 9:08 p.m.:

TC Dispatcher: . . . Hi, thanks for holding. This is [TC Dispatcher].
Hospital 3 CMO: Hey [TC Dispatcher], . . . I'm the CMO up in [Hospital 3]. I was checking on a, a, uh, hemorrhagic stroke that's coming from [hospital named] trying to go to [Hospital 3]?
TC Dispatcher: Yeah. . . . So I actually just spoke to [Physician H] at [Hospital 2] and asked if he had the case open with any other facilities, and he said no, that they don't have it open with anybody else, you know, that they were just waiting on us, uh, and the patient is now intubated.
Hospital 3 CMO: Yeah, I don't have a bed. I just talked to the house [supervisor], and so I don't have an ICU bed, but let me, um, check on that and check with [Hospital 3 neurosurgeon named] and I'll call you back.
TC Dispatcher: Ok, thank you so much. . . .

At 10:39 p.m. (2 hours and 23 minutes after Transfer Center presented Patient 100 to Hospital 1 for transfer):

Staff: [Hospital 2] ER, this is [staff named].
TC Dispatcher: Hi [staff named], it's [TC Dispatcher] calling from the . . . Transfer Center?
Staff: Hi there.
TC Dispatcher: Hi, I just want to follow up on patient [Patient 100]. Just wanted to see if you guys had any luck getting placement for the patient?
Staff: Yes we did.
TC Dispatcher: Ok, um, is he going to the tertiary?
Staff: Uh, he's going to [Hospital 4] ICU.
TC Dispatcher: Awesome. Ok, thank you so much.
Staff: Thank you. . . .

During an interview on 7/15/21 at 9:35 a.m., Physician C stated transfer requests that are declined are reviewed weekly for how they related to capacity, physician skills or abilities, and services. Physician C reviewed the CAD (computer assisted dispatch), dated 4/13/21, a document which contained notes taken by the Transfer Center dispatcher of the calls and texts that were made while attempting to transfer Patient 100 to Hospital 1 and Hospital 3. Physician C stated the notes did not include a doctor-to-doctor conversation between the sending physician at Hospital 2 (Physician H) and the neurosurgeon at Hospital 1. Physician C stated he called the chief medical officer (CMO) at Hospital 3 (on the night of 4/13/21) and said, "What can we do to find this patient a bed?" Physician C confirmed he was the administrator on duty (AOD) that day, 4/13/21. As AOD, he took calls from the Transfer Center for all physician declines (of transfers), which he got in real time.

During an interview on 7/15/21 at 10:23 a.m., Lead Nurse J stated he had worked in the emergency department at Hospital 1 for 30 years. Lead Nurse J stated 90% of fresh transfers came through the emergency department. When queried about the transfer process, he stated the sending hospital would call the Transfer Center, then the [sending] physician there would talk to the [specialist] here and the sending physician would ask if they can take the patient. The Transfer Center would be there on the call. Lead Nurse J stated, "It is not common practice for the [doctors] to talk outside the Transfer Center. Not standard practice, you go through the Transfer Center."

During an interview on 7/19/21 at 11:05 a.m., when queried about the transfer process, Director F stated, "We have a Transfer Center. The sending [hospital] contacts the Transfer Center. The Transfer Center contacts the nursing supervisor (at the receiving hospital), finds out 'do we have a bed?' . . . If bed available, next the doctors talk. The Transfer Center contacts the receiving doctor and lets them know there's a transfer request. . . . If the doctor accepts the patient, the next step is deciding how and when they get here."

During an interview on 7/19/21 at 2:30 p.m., when queried about the transfer process, Physician K stated the sending physician would call the Transfer Center and tell them they have this need. They would find out if a bed was available. Physician K confirmed Hospital 1 did have the capability to manage hypertensive bleeds, but not aneurysmal bleeds. Two conversations would then happen. The first was between the sending physician and the neurosurgeon. The second was between the sending physician and the attending, almost always an intensive care physician. A specialist could decline a patient with only the Transfer Center's information, for example the Transfer Center tells the specialist and presents a patient with an aneurysmal stroke. If the Transfer Center does not specify what type of hemorrhage, then the neurosurgeon would proceed with the doctor-to-doctor conversation.

During a record review and concurrent interview on 7/19/21 at 3:15 p.m., Director E reviewed the CAD from 4/13/21 and confirmed Patient 100 was presented to Hospital 3 (for transfer) first. Director E further reviewed the CAD and confirmed the documented attempt to connect Physician H to Physician D (the neurosurgeon at Hospital 1) implied the attempt failed. Director E stated the 8:26 p.m. call was the dispatcher placing a call to Physician H, then placing Physician H on hold to get Physician D on the line with him. The dispatcher came back on the line to tell Physician H that Physician D was not accepting the patient. Director E stated they (the physicians) did not get to talk to each other.

During a record review and concurrent interview on 7/20/21 at 9:33 a.m., Director G stated according to the CAD dated 4/13/21, Hospital 1 did have bed availability at the time Patient 100 was declined transfer. Director G stated the escalation process the dispatchers follow after a physician had declined a patient transfer was for the dispatcher to notify the AOD in order for the AOD to determine if it was appropriate, and to see if the AOD could help facilitate the transfer for the patient. When queried if the Transfer Center received a call back from Physician C after he was notified Physician D declined transfer for Patient 100, Director G stated the Transfer Center did not get a call back from Physician C.

During an interview on 7/20/21 at 2:05 p.m., Physician D stated he had been a neurosurgeon at Hospital 1 since 2014. He took six surgical cases per week, 25% of which were cranial. When queried about the transfer process, he stated the Transfer Center would call him on his cell phone, then put him in contact with the sending physician, he reviewed imaging (such as CT scans) if possible, then if accepting the patient, he would inform the Transfer Center he was accepting the patient. When asked how much information the Transfer Center provided about a patient they were presenting, Physician D stated there was not much the Transfer Center can say, he needed to talk to a physician (to get the information).

During the same interview on 7/20/21 at 2:05 p.m., when asked about the case involving Patient 100, Physician D stated he reached out to Physician C (not Physician H, the transferring physician). He wanted to make sure there wasn't a bed closer to home (Hospital 2). He stated he did not decline the patient, he just wanted to investigate further. He stated he asked Physician C what the situation was, and if he recalls, there was no ICU bed (intensive care unit). Later when he wanted to go to bed, he stated he called the Transfer Center to see if Patient 100 was coming, and they said he was not coming. The audio recording of the Transfer Center's call to Physician D on 4/13/21 was played, and Physician D confirmed the voice on the recording was him. He stated that to transfer Patient 100 to Hospital 1 for neurology (versus neurosurgery) was not an appropriate transfer. Informed Physician D of the size of Patient 100's hemorrhage, and he stated it sounded like he potentially needed surgery. He stated Patient 100 "should not be traveling five hours to [location of Hospital 1], he should go 10 minutes down the road to [location of Hospital 3]."

During an interview on 7/20/21 at 2:33 p.m., Physician C stated that on 4/13/21 he received a call from the Transfer Center, and then called the CMO of Hospital 3 to ask if there was any opportunity for Patient 100 to transfer to them, to accept the patient. Physician C stated he called the CMO of Hospital 3 one time, and did not hear back. Physician C stated that he conveyed to the dispatcher that he was going to see what he could do, which he felt left the door open, it was not a true decline. When asked if he called the Transfer Center to let them know that Hospital 1 was still an option, Physician C stated he did not. After the Transfer Center informed him Patient 100 had been declined transfer, Physician C then spoke with Physician D about his perspective, to get his take on it. Physician C stated Physician D felt Hospital 3 had the capability. When asked if he told Physician D that the Transfer Center dispatcher had informed him that Patient 100 had been declined, Physician C stated he did not. When asked if Physician D should have talked to Physician H, Physician C stated generally the doctors should talk. He did not know why they didn't. Physician C confirmed that Physician D could not determine if Patient 100 was an appropriate transfer without the doctor-to-doctor conversation.

During a record review and concurrent interview on 7/21/21 at 11:32 a.m., an email written by Director E to Director A, dated 7/21/21, regarding the declined transfer of Patient 100, indicated, "In reviewing our follow-up tracker, we did review this case on 4/21 with the group. The only follow-up from the review was for me to determine why the case was not represented (a process/practice where the Transfer Center requests a patient transfer to a higher level of care to a facility that has already declined the patient) to [Hospital 1] after [Hospital 3] declined for no ICU beds. After confirming with [Director G], the transfer was not represented because it was lost to competitor ([Hospital 4] accepted the transfer). This follow-up item was closed." When queried about when Transfer Center dispatchers were expected to re-present a patient, Director E stated a patient will be re-presented to a hospital that had declined the patient if a patient's condition was deteriorating or the sending hospital requested to re-present. Director E stated the CAD had no indication there had been a worsening of Patient 100's condition (after Physician D declined his transfer request) or that the sending physician, Physician H, requested to have Patient 100 re-presented, so the Transfer Center dispatcher would not have been expected to re-present the patient.

During an interview on 7/21/21 at 2:20 p.m., in response to a request for the Transfer Center's procedure for re-presenting a patient and handling of declines for patient transfer, Director A and Specialist B stated the Transfer Center had no written procedure for re-presenting a patient for transfer, and no written procedure for decline of a patient transfer, other than in the "Trauma" section of their written work flow.

Review of facility policy "Screening, Stabilizing and Transfer of Individuals with Emergency Medical Conditions (EMTALA - CA), B1-38," last revised 4/2013, indicated, "To the extent that the Hospital has specialized capabilities or facilities, including, but not limited to burn unit, a shock-trauma unit, or a neonatal intensive care unit, that are not available at a United States facility that has asked the Hospital to accept the transfer of a [sic] individual needing those capabilities or facilities, the Hospital shall accept Appropriate Transfers of such individuals if the Hospital has the Capacity to treat the individual."