HospitalInspections.org

Based on document review and staff interview, the acute care hospital's administrative staff failed to ensure the on-call neurosurgeon (Neurosurgeon A) presented to the ED when 3 of 3 patients (Patient #1, #2, and #3) required Neurosurgeon A's specialized abilities, between 6/5/17 and 6/12/17, and Neurosurgeon A's name was listed on the on-call schedule. The hospital's administrative staff identified an average of 83 patients per month transferred by the ED staff to another acute care hospital.

Failure to ensure the on-call neurosurgeon presented to the ED when patients required specialized neurosurgical capabilities resulted in the ED staff transferring 3 patients to a hospital approximately 30 miles away when Neurosurgeon A was listed on the on-call schedule and had surgical privileges to provide the necessary care to the patients.


Findings include:

1. Review of the policy "Emergency Department On-call Coverage," dated 10/20/2015, revealed in part, "The Medical Staff member on-call for the applicable departments and/or sub-groups shall respond ... and come in as necessary to examine, stabilize, treat, and/or admit unassigned patients on an emergency basis."

2. Review of the June 2017 On-Call schedule listed Neurosurgeon A (a surgeon who specialized in surgery of the brain and spine) as available on-call for neurosurgical care "for established patients" each day from 6/5/17 through 6/30/17.

3. Review of Patient #1's medical record revealed Patient #1 presented to the Emergency Department (ED) on 6/5/17 at 12:06 PM. Patient #1 had was not acting correctly after falling. An ED Physician Note, dated 6/5/17 at 12:18 PM, revealed Patient #1 fell on 6/4/17 and later developed a headache and weakness. The radiologist diagnosed Patient #1 with bleeding in his/her brain. ED Physician B directed the hospital staff to transfer Patient #1 to another hospital about 30 miles away since the hospital lacked a neurosurgeon on-call to remove the blood in Patient #1's brain.

4. Review of Patient #2's medical record revealed Patient #2 presented to the ED on 6/6/17 at 3:08 PM with a complaint of lower back pain, hip pain, and new onset confusion. The ED physician performed several tests, including a lumbar puncture (A procedure where the physician inserts a needle into the spinal column to collect spinal fluid for testing. Spinal fluid is normally clear). The lumbar puncture revealed Patient #2 had pus-like material in the spinal fluid. The ED physician transferred Patient #2 to another acute care hospital approximately 30 miles away. The ED physician transferred Patient #2 due to the lack of an on-call neurosurgeon to provide inpatient care for Patient #2 at the hospital.

5. Review of Patient #3's medical record revealed Patient #3 presented to the ED on 6/7/17 at 2:24 PM. Patient #3 had a cut on their head and confusion following a motor vehicular accident (MVA). The hospital staff transferred Patient #3 to another acute care hospital approximately 30 miles away. The ED physician transferred Patient #3 due to the lack of an on-call neurosurgeon to provide care for Patient #3's confusion following the MVA.

6. During an interview on 6/13/17 at 5:33 PM, ED Physician C stated he transferred Patient #3 to another hospital due to the confusion following the MVA. ED Physician C stated Patient #3's condition could change and required a neurosurgeon to monitor Patient #3's condition in case Patient #3 required emergent neurosurgery.

ED Physician C stated the hospital had an on-call neurosurgeon (Neurosurgeon A) at the time of Patient #3 presented to the ED. However, Neurosurgeon A only provided on-call availability to her established patients and did not provide on-call coverage to new patients. Neurosurgeon A's clinic hired a traveling neurosurgeon to provide the hospital with 10 days per month where the hospital would provide emergent neurosurgical care to patients that Neurosurgeon A had not previously seen.

Neurosurgeon A's name appeared on the on-call schedule each day for her established patients only. Neurosurgeon A would go to the ED and evaluate a patient only when an established patient presented to the ED and would not present to the ED if Neurosurgeon A had not previously seen the patient.

7. During an interview on 6/13/17 at 9:55 AM, ED Physician G stated Neurosurgeon A was available and on-call for her established patients. ED Physician G stated Neurosurgeon A hired a contract neurosurgeon to provide care for the hospital's patients who required neurosurgical care on approximately 10 days per month. The contract neurosurgeon accepted all of the patients who presented to the hospital's ED and required neurosurgical care.

8. During an interview on 6/14/17 at 7:03 AM, Neurosurgeon A stated a contracted neurosurgeon provided on-call neurosurgical services for 10 days per month. Neurosurgeon A reviewed the medical records for Patient #1, #2, and #3. Neurosurgeon A acknowledged the governing body of the hospital had granted her privileges to perform the neurosurgical procedures to provide care to Patient #1, #2, and #3.

Neurosurgeon A stated she was only available to provide on-call neurosurgery coverage to her established patients every day. Neurosurgeon A stated if an established patient came to the ED, she would see the patient in the ED and provide care to them. However, if an ED patient was not established in Neurosurgeon A's practice, she would not see the patient. Instead, the ED physician would transfer the patient to another hospital. Neurosurgeon A stated that even if a contracted neurosurgeon was providing on-call coverage at the hospital for her, she would still see her established patients in the ED.

9. During an interview on 6/14/17 at 1:50 PM, the Chief Medical Officer (CMO) stated the ED physicians know if they see Neurosurgeon A's name on the call schedule, Neurosurgeon A is only available to see her established patients in the ED. The ED physician will look at the patient's medical record to see if Neurosurgeon A provided care to the patient in the past or ask the patient directly if they had received care from Neurosurgeon A. If the patient had seen Neurosurgeon A, the ED physician would call Neurosurgeon A. If the patient had not seen Neurosurgeon A, the ED physician would transfer the patient unless the hospital had a contracted neurosurgeon on-call that day.