HospitalInspections.org

Based on policy review, document review, medical record review and interview, it was determined the hospital failed to ensure the Emergency Department (ED) accepted transfer of a patient requiring specialized services available through physician On-Call scheduling for 1 of 8 (Patient #28) sampled patients reviewed for appropriate transfer.

Refer to findings in deficiency A 2411.

Intakes: TN 00030328

Based on document review, medical record review, and interviews, the hospital failed to accept the transfer of a patient who required specialized services for 1 of 8 (Patient #28) sampled patients reviewed for appropriate transfer.

The findings included:

1. Review of the EMERGENCY MEDICAL TREATMENT AND PATIENT TRANSFER policy with revision date March 2002 for Hospital B revealed, " The treatment and transfer of an individual shall not be predicated upon arbitrary, capricious, or discrimination based upon race, religion, national origin, age ... "

Review of the EMTALA - Provision for On-call Coverage policy with effective date 2003 for Hospital B revealed, " If a Hospital offers a service to the public, the service should be available through on-call coverage of the Dedicated Emergency Department and should be reflected on the On-Call List ... Each Hospital must establish a process for identifying those physicians ' on-call ' for a given specialty ... "

Review of the EMTALA - Emergency Transfers policy with revision date April 2004 for Hospital B revealed, " Receiving or Recipient Hospital Responsibilities ... A Hospital that has specialized capabilities or facilities ...may not refuse to accept from a referring Hospital an appropriate Transfer of an individual requiring such specialized capabilities or facilities, if the receiving or recipient Hospital has the capacity to treat the individual. "

2. Review of the August 2012 On-Call schedule for Hospital B revealed Physician #2 was the urologist on call for 8/18/12.

3. Review of the Urology Clinical Privileges for Physician #2 revealed, " Urology core privileges ... Admit, evaluate, diagnose, treat (medically or surgically) and provide consultation to patients of all ages ... The core privileges in this specialty include the procedures on the attached list ... "
Review of the attached list referred to in this document revealed, " Surgery of the testicle, scrotum, epididymis, and vas deferens, including biopsy, excision and reduction of testicular torsion ... "


4. Review of the medical record from Hospital A revealed Patient #28 arrived in the Emergency Department (ED) at Hospital A on 8/18/12 at 10:43 with complaints of abdominal pain. The patient was a 13 year old male weighing 120 pounds and was 5 feet 10 inches tall. The patient ' s pain was rated 8 on a scale to 10. A medical Screening Examination (MSE) was performed at 10:45 with the testicular pain identified as the chief complaint. The EMERGENCY PHYSICIAN RECORD documented on the second page on the right side of the page, " Urologist at [Hospital B] refused call 11:01 message to send to [Hospital D] would not talk to me relayed message he was not peds [pediatric] urologist. " The clinical impression was documented as, " Testicular Torsion. " An ultrasound of the scrotum was ordered at 10:50 and a preliminary report given at approximately 11:00 stating, " IMPRESSION: No evidence of flow within the right testicle. Torsion and infarction would be the primary concerns. There is a large amount of surrounding fluid. " ED COURSE notes documented: " 11:09 Contacted [name of Emergency Medical Service] for transportation to [Hospital B] ... 11:12 Called [Hospital B] transfer coordinator for transfer-urologist will call [Physician #1] back ... 11:21 [name] house supervisor at [Hospital B] called and said the patient ' needed to go to [Hospital D] per [Physician #2] ... 11:22 Called [name], house supervisor at [Hospital B], to inquire as to why [Physician #2] declined to see patient. [name of house supervisor for Hospital B] informed this nurse that she would talk to [Physician #2] directly and either [Physician #2] would call to speak with [Physician #1] or she would call and tell [Physician #1] to call [Physician #2] directly to talk about this patient ... 11:37 [name] house supervisor at [Hospital B] called and said that [Physician #2] said, ' I am not a pediatric urologist, the patient will not be coming to this facility, and I will not talk to anyone on the phone about it because I am too damn busy. ' " The patient left the ED for transfer to Hospital C by Emergency Medical Service on 8/18/12 at 11:44.

Review of the medical record from Hospital C revealed Patient #28 arrived on 8/18/12 at 12:42 and triaged at 12:44. Anesthesia visited the patient at 12:46, the surgeon visited at 12:54 and patient #28 was transferred to surgery at 13:06. The operative report documented the patient did have a right testicular torsion that was de-torsed during the surgical procedure and it was felt the testicle was then viable.

Review of the only document present at Hospital B for Patient #28 revealed a Patient Transfer Request Form had been initiated on 8/18/12 which documented the transfer type as ED, the referring provider as Physician #1 and the accepting provider as Physician #2. Handwritten under Transportation Method was, " 11:14 NO ' This patient needs to [Hospital D] He needs a pediatric urologist & I ' m getting ready to go into surgery anyway and am too busy. " Handwritten in the lower portion of the page without identification of the author or the source was a note that documented, " I don ' t know what's wrong but our doctor said he needs to get there now. "

5. Review of the 8/17/12 surgery schedule for Hospital B revealed Patient #26 was scheduled for ureteroscopy with laser at 12:45 for Physician #2. Patient #26 was admitted on 8/17/12 at 19:30.
Review of the Actual Procedure By Physician document revealed the procedure was not performed until 13:32 which was 2 hours and 20 minutes after Hospital A contacted Hospital B asking to transfer Patient #28.

6. During an interview in the Quality conference room on 9/4/12 at 8:30 AM, the ED Director for Hospital B stated when the facility gets calls from other ED ' s it is doctor to doctor. There is no log of a call if patient doesn't come to Hospital B.

During an interview in the Quality conference room on 9/4/12 at 10:30 AM, the Medical Staff Coordinator for Hospital B stated that at Hospital B it was up to physician desecration which patients they see. If a physician is on call and doesn't accept pediatric patients it's his perogative to refuse. The Urologist would be responsible to talk to the physician trying to transfer patient if that was the specialty needed. She stated the doctors especially want pediatric patients to go to the children's hospital. When the Medical Staff Coordinator was asked about ED call for unassigned patients she stated, to her knowledge they (on-call physicians) should see pediatric patients. When asked if Physician #2 treats pediatric patients, the Medical Staff Coordinator verified he did see pediatric patients in his office and had seen patients as young as 3 - 6 months old.

During an interview in the Quality conference room on 9/5/12 at 7:35 AM, the House Supervisor for Hospital B was asked if she remembered a call from the ED of Hospital A asking to transfer a 13 year old with a possible testicular torsion? The House Supervisor stated she got a call from Hospital A that there was a patient in ED that needed to come to Hospital B. The nurse said the patient had "abdominal pain" and that an ultrasound had been done but the nurse did not know the results. The House Supervisor stated she told the nurse she needed more information and the nurse stated, "the doctor said he needs to come now!" The House Supervisor stated she told the nurse she would contact the doctor and call her back. The House Supervisor sated she called the urologist who was on call (Physician #2) and he said he was going into surgery. She told him what the nurse at Hospital A had said and that, " I suspected testicular torsion. " The urologist (Physician #2) stated, "Sounds like he needs to go to [Hospital D], I'm going to surgery now."
When asked the procedure related to unaccepted transfers, the House Supervisor stated, "The doctor usually takes the doctor's name and number and calls the doctor to determine if he will accept the transfer."

During an interview in the Quality conference room on 9/5/12 at 10:15 AM with Physician #2, the urologist on-call for Hospital B on 8/18/12, the physician was asked if he recalled the House Supervisor calling him on 8/18/12 regarding a referral from Hospital A of a 13 year old with possible testicular torsion. Physician #2 stated, "I was on call when the House Supervisor called and said that [Hospital B] has a patient with a surgery condition needed to go to OR [operating room] immediately. I was consulting on a pregnant patient who possibly had an obstruction, flank pain and possible infected kidney who might need a stent ... also already had a patient going to surgery that was a transfer from Hospital A the night before with possible obstructive stones. I thought in the best interest of the patient I would not take the patient I was not sure how long my surgery would take or what I would run into that could extend it. With testicular torsion you only have a short window to address it or they could lose the testicle. That's why I said he needed to go to [Hospital D] for immediate treatment." During this interview, Physician #2 stated he did not speak with anyone at Hospital A.

During a telephone interview on 9/6/12 at 10:15 AM, the ED Director for Hospital A stated, I feel this stems from a patient transfer by force to that hospital because the day before this patient we tried to send another urology patient. The same urologist was on-call. I don ' t know why he
didn ' t want to accept that patient either ... The hospital higher ups got involved and demanded that he take the patient. I know if you offer the service then you must provide it. I don ' t know if he does pediatrics or not, doesn't matter, if the service is offered you must provide ..."

During a telephone interview on 9/6/12 at 11:08 AM, the Unit Secretary for Hospital A stated, " I called [Hospital B] first and asked if they had a urologist on-call ... told them something going on with testicle. I was trying to get someone to talk with the doctor ... they said they had urology on [call] that day. "

During a telephone interview on 9/6/12 at 10:42 AM, the Registered Nurse (RN) on duty at Hospital A on 8/18/12 stated that she had taken the return call from the House Supervisor for Hospital B who stated the urologist (Physician #2) would not take the patient for a transfer. The RN stated she thanked the House Supervisor hung up. The RN stated, " I told our doctor and he said ' you call them back and ask why. ' " She stated she called and spoke with [Hospital B ' s House Supervisor] who said when they first got the call they didn't know anything about the patient. The RN stated she told the House Supervisor it was a possible testicular torsion and needed a urologist. The House Supervisor said she would tell the doctor and have him call back to Hospital A. The RN told her that would be great and told Physician #1. The RN stated, the House Supervisor [for Hospital B] called back said the doctor was not a pediatric urologist, would not accept the patient or talk to the Hospital A doctor, he was " too damn busy."