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Based on findings from document review and interviews, hospital emergency department (ED) staff did not ensure that a patient's emergency medical condition was stabilized, within capabilities, prior to the patient's transfer to a higher level of care at another hospital.
Findings include: -- Review of Patient A's medical record reveals the following information: This 46 year old patient presented to the Emergency Department (ED) on 01/08/13 at 01:00 pm via ambulance due to shortness of breath (SOB). She was immediately evaluated by ED Registered Physician Assistant (RPA) #1. The patient stated she was receiving chemotherapy for metastatic ovarian cancer. She was status post hysterectomy and eight days prior a Port-A-Cath had been placed. Vital signs at triage were: temperature (T) - 97.2, pulse (P) - 139, respirations (R) - 28, blood pressure (BP) - 114/74, and oxygen saturation (O2 sat) - 100% on O2 at 5 liters (L) via non-rebreather (NRB) mask. She was placed on cardiac and oxygen saturation monitoring upon arrival; blood work, urinalysis, chest x-ray, and CT scanning for pulmonary embolism study were performed. Patient also received a nebulizer treatment. The CT scan revealed moderate to large size pulmonary emboli in the lungs, bilaterally. D-Dimer was 13.55 (normal 0.19-0.50), arterial blood gas (ABG) testing results included PCO2 (partial pressure of carbon dioxide in arterial blood) 46.0 (normal 35-45) and PO2 (partial pressure of oxygen) 191 (normal 95-100). RPA #1 contacted the patient's oncologist to discuss her condition; he/she recommended the patient receive 140 units of Lovenox. Due to inability to establish peripheral intravenous (IV) access, the patient's right chest Port-A-Cath was utilized for IV fluids; 800 cc of normal saline was infused. The patient received Ativan at 03:13 pm, and 04:58 pm, and Lovenox at 03:25 pm.

RPA #1 contacted the on call supervising ED physician (Physician #1) who agreed with transfer to a higher level of care. RPA #1 contacted a physician at another hospital who agreed to accept the patient. The patient was transferred out at 05:30 pm via ambulance with a paramedic in attendance; she was on O2 at 5 L via NRB mask. Vital signs obtained by Registered Nurse (RN) #1 at 05:30 pm just prior to transfer were T-96, P-140, R-40, BP-88/50, and O2 sat 93%. Later, RPA #1 received a call that while in transit to the other hospital, the patient developed cardiac arrest and was being diverted to a closer hospital. The RPA received no further updates regarding the condition of the patient.
This patient's emergency medical condition was not stabilized prior to transfer. The deteriorating vital signs (which included increasing respirations, decreasing BP, and oxygen saturation of 93% while on 5 L of oxygen via NRB mask), as well as the arterial blood gas test results, together demonstrated Patient A was going into respiratory failure. Stabilizing treatment for the impending respiratory failure was not provided prior to transfer. -- These findings were acknowledged during interview on 02/ 21/13 at 01:30 pm of the hospital ED Medical Director who reviewed the case 3 days after the transfer, and during interview on 02/22/13 at 08:30 am of RPA #1.-- During interview of RN #1 at 10:30 am on 02/22/12, he/she could not confirm believing the patient's condition was stable at the time of transfer.

Based on findings from document review and interviews, hospital ED staff did not ensure that the transfer of a patient to another medical facility was appropriate.
Findings include: -- Review of Patient A's medical record reveals the patient's emergency medical condition was not stable at the time the patient was transferred to another hospital. See the findings in Tag C2407.