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Based on interview and record review, the facility failed to select a mode of transportation capable of providing the treatment required during transfer to another hospital for 1 of 24 sampled patients (Patient 1). Refer to A-2409.

Based on interview and record review, the facility failed to select a mode of transportation capable of providing the treatment required during transfer to another hospital for 1 of 24 sampled patients (Patient 1). The deficient practice resulted in Patient 1's respiratory arrest (stopped breathing) enroute. Patient 1 died after arrival at the receiving hospital.

Findings:

Review of Patient 1's medical record indicated she arrived at the facility's emergency department on 2/24/16 at 4:23 a.m. Review of an "ER [emergency room] SUMMARY" for 2/24/16 indicated the section labeled "DOCTOR NOTES" included an entry at 6:16 a.m. stating "pt [patient] with severe sepsis [infection causing organ damage] vs. [versus] septic shock [severe sepsis plus persistently low blood pressure]. severe leukocytosis [elevated white blood cell count] with blast [immature white blood cell] predominance, concern for acute leukemia." An entry at 7:37 a.m. indicated, "d/w [discussed with] [Provider 2, a hematologist and oncologist]... recommends transfer to [Hospital 1] if pt stable enough for transfer. d/w [Provider 3, a general surgeon] regarding cholecystitis [inflammation of the gallbladder]... not a goo dsurgical [sic] candidate." An entry at 1:26 p.m. indicated, "pt tachypneic [breathing rapidly]... trialing bipap [bilevel positive airway pressure, a form of mechanical ventilation using a mask rather than a tube in the windpipe]..." An entry at 1:55 p.m. indicated, "continues to be tachypneic on bipap but pt does endorse decreased wob [work of breathing] on bipap."

Review of a nursing note dated 2/24/16 at 1:38 p.m. indicated, "pt. tachypneic appear uncomfortable family member at bedside fanning pt... pt. breathing fast using accesory [sic] muscles, RR [respiratory rate]=40 per report pt. condition is getting worse. [Provider 1] made aware Bipap order..." Review of a nursing note dated 2/24/16 at 1:54 p.m. indicated, "Bipap helps breathing better. RR stil [sic] 40's." Review of a nursing note dated 2/24/16 at 3:00 p.m. indicated "Discontinued Bipap as ordered for transfer." A nursing transfer note dated 2/24/16 at 3:01 p.m. indicated, "Transported by urgent ambulance, accompanied by emergency medical services personnel, Paramedic..."

Review of Patient 1's "Patient Referral Form for Transfer" dated 2/24/16 indicated the facility arranged transportation by "ALS AMBULANCE (Advanced Life Support)" at 1:30 p.m. The form indicated Patient 1 was accompanied during transportation by an EMT (emergency medical technician) and a paramedic.

Review of Patient 1's "PATIENT CARE REPORT" from the ambulance company (date of service 2/24/16) indicated, "[Provider 1] STATES THAT THE PATIENT GREW TIRED OF BREATHING ON HER OWN AND WAS ADMINISTERED BIPAP FOR RELIEF... INFORMED [Provider 1], THE ED RT [emergency department respiratory therapist], AND THE SENDING ED RN THAT ALS TRANSPORT DOES NOT CARRY BIPAP MACHINES AND THAT CPAP [continuous positive airway pressure, another form of mechanical ventilation using a mask which provides constant pressure rather than higher pressure during inhalation and lower pressure during exhalation] OR MANUAL BVM [bag valve mask] ARE THE ONLY VENTILATOR THERAPIES AVAILABLE AT THE ALS LEVEL... OFFERED TO CALL FOR CCT [critical care transport] FOR BIPAP CAPABILITY BUT [Provider 1] STATES THAT O [oxygen] BY NRB [non-rebreather mask] OR BVM IS ADEQUATE FOR TRANSPORT AND THAT DELAY OF TRANSPORT IS NOT APPROPRIATE. [Provider 1] STATES THAT TH [sic] PATIENT HAS BEEN STABLE ON BIPAP, THAT HER HYPERVENTILATION IS COMPENSATORY AND EXPECTED TO CONTINUE, AND THAT THE ISSUE IS JUST HER BECOMING TIRED AGAIN... THE PATIENT WAS LIFTED FROM HER BED AT SMC [San Mateo Medical Center] ED TO THE GURNEY FOR TRANSPORT... THE PATIENT REPORTED IMMEDIATE RESPIRATORY FATIGUE WITH THE NRB AND SO RESPIRATIONS WERE TRACKED WITH THE BVM. THE PATIENT VERBALLY REPORTED THAT BVM TRACKING HELPED AND SIGNIFICANTLY IMPROVED COMFORT OVER NRB O2 [oxygen]... APPROXIMATELY 2 MINUTES PRIOR TO ARRIVAL AT [Hospital 1] ED THE PATIENT EXHIBITED A MARKED AND RAPID REDUCTION IN RESPONSIVENESS AND SPONTANEOUS RESPIRATORY EFFORT DROPPED TO NEAR-ZERO... BVM VENTILATION WERE CONTINUED... THE PATIENT BECAME ENTIRELY UNRESPONSIVE AS SHE WAS REMOVED FROM THE AMBULANCE... [sic, document quoted is written in all caps]" The report indicated the ambulance left San Mateo Medical Center at 3:15 p.m. and arrived at Hospital 1 at 3:50 p.m.

Review of Patient 1's "Emergency Department Provider Note" from Hospital 1 dated 2/24/16 indicated "Disposition: Dead After Arrival". An attached timeline indicated Patient 1 arrived 3:53 p.m., suffered a cardiac arrest at 4:39 p.m., and that efforts to resuscitate her were stopped at 5:07 p.m.

Review of the facility's policy "URGENT ED PATIENT INTERFACILITY TRANSPORT" (approved 11/15) indicated, "The transport requires SMMC [San Mateo Medical Center] to provide qualified personnel and transportation equipment, as required, including the use of necessary and medically appropriate life support measures during the transport. San Mateo County 911 Emergency Medical System (EMS) is used for transporting with accompanying paramedics (see Appendix 1...) and nurses from the Emergency Department... The SMMC physician determines method of transport, transport team (ED nurse, paramedic, etc.), and orders to be carried out during transport. Review of the attached, undated "Appendix 1" indicated it listed the capabilities of three types of ambulance: BLS (basic life support), ALS-911 (advanced life support), and CCT (critical care transport). The list indicated "BIPAP assisted ventilation" required CCT. Appendix 1 indicated the response time for ALS was approximately 13 minutes for an unstable patient and approximately 23 minutes for a stable patient. Appendix 1 indicated the response time for CCT was 90 minutes.

In an interview on 3/7/17 at 1:41 p.m., the Relief Charge Nurse stated she was the charge nurse for the ED on 2/24/16 when Patient 1 was there. The Relief Charge Nurse stated she was not involved in arranging the transportation for Patient 1.

In an interview on 3/7/17 at 1:41 p.m., the Clinical Service Manager for the Emergency Department stated CCT would have taken an hour, so Patient was transferred 911. She stated the facility's nurses are trained to go along with an ALS-911 transport in order to create an ad hoc CCT. In an interview on 3/7/17 at 2:10 p.m., the Quality Manager stated an ED nurse was available but the ED physician didn't order an ad hoc CCT.

In an interview on 3/8/17 at 2:00 p.m., ED RN 1 stated was the nurse assigned to Patient 1 starting at 7:00 a.m., on 2/24/16. ED RN 1 stated Patient 1 was transported by ALS and Provider 1 had ordered a high flow mask to be used instead of BiPAP during transportation. ED RN 1 stated Patient 1's BiPAP was removed "not too long, maybe 10 minutes" before the ambulance transportation. ED RN 1 stated the BiPAP was still on when the ambulance arrived and she did not know the reason the BiPAP was removed. ED RN 1 stated she didn't recall whether any additional vital signs were checked after the BiPAP was removed. ED RN 1 stated she did not think the facility checked an ABG (arterial blood gas, a blood test to check the adequacy of a patient's breathing) after Patient 1's BiPAP was removed.

In an interview on 3/8/17 at 2:18 p.m., Provider 1 stated he began caring for Patient 1 at the start of his shift at 6:30 or 7:00 a.m. on 2/24/16. He stated Patient 1 was extremely ill and needed to be transferred as soon as possible. Provider 1 stated Patient 1 was short of breath, so he ordered BiPAP. Provider 1 stated getting a CCT rig would have taken many hours and an ALS rig was available immediately and he thought the fastest mode of transportation would be best. Provider 1 stated he discussed the options for different ambulances with the charge nurse but was not presented the option of sending an ED RN with Patient 1. Provider 1 stated he removed Patient 1's BiPAP before sending her on the ambulance to see if it would be needed during transportation. Provider 1 stated Patient 1 told him she was breathing easier without the BiPAP and her oxygen levels were okay.

In an interview on 3/8/17 at 2:30 p.m., Provider 2 stated the facility did not have the capability of treating acute leukemia.