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Based on medical record reviews, review of facility policies and interviews for one of two patients (Patient #1) who had a cardiac arrest in the OR (operating room), the facility failed to ensure staff utilized the overhead peri-operative paging system during an emergency in accordance with facility policy and/or that infection control practices were followed in accordance with facility policy/standard of practice.

The findings include:

a. Patient #1 was admitted to the hospital on 12/30/18 with a diagnoses of thyrotoxicosis with a goiter and thyroid storm. P#1 had a history of Graves disease. P #1 was assessed as an ASA (American Society of Anesthesiologists) surgical risk "4" (patients with severe systemic disease) and underwent an uncomplicated thyroidectomy under general anesthesia on 1/9/19 by MD #1. Review of the immediate operative report dated 1/9/19 identified a 10cc (cubic centimeters) (minimal) blood loss during the operative procedure. Review of the anesthesia record dated 1/9/19 indicated that P #1 was easily intubated for the procedure and was extubated by CRNA #2 (certified registered nurse anesthetist) uneventfully at 5:39 PM while deeply sedated and breathed spontaneously post extubation. P #1's BP (blood pressure) was 100/50 at the time of extubation. P #1's BP began to slowly increase following extubation (despite the administration of Dilaudid at 5:44PM and at 5:48PM with the BP noted to be 170/80 at 5:48PM. The anesthesia record at 5:49 PM indicated that P #1 was short of breath, nodded yes when asked if he/she was having difficulty breathing, was assessed as having wheezes (by CRNA #1) and 3 puffs of Albuterol (bronchodilator) was administered into P #1's mask without relief. Review of CRNA #2's documentation at 5:51 PM identified that P #1's breathing progressed to slight stridor, was provided breathing support via mask, slight neck swelling was observed and both MD #1 and Anesthesiologist #2 were called to the operating room via phone (not via overhead page). Review of Anesthesiologist #2's note dated 1/9/19 indicated the he/she was called to the operating room at 5:52 PM (4 minutes after breathing difficulty began), and P #1 was stridorous, had swollen oral tissue and, with the use of a glidescope (for visualization) Anesthesiologist #2 had difficulty intubating with an ETT (endotracheal tube). Further review of the Anesthesiologist's #2's note identified that during intubation, P #1's arterial line went flat, P #1 became pulseless and CPR (cardio-pulmonary resuscitation) was initiated at 5:48pm.

Review of the operative report dated 1/9/19 by MD #1 (surgeon) noted that the surgical resident called him back to the operating room (OR) and that he was unaware a code had been called in the OR. Room.

Review of the discharge summary dated 1/19/19 identified that after several minutes during CPR, another assessment was conducted to look at the ETT noted that it was not in the trachea, the outcome was a severe anoxic brain injury and P#1 subsequently expired on 1/19/19.

Interviews with RN #1 (Charge) and RN #2 (Circulator) on 1/25/19 at 10:37 AM and 12:02 PM respectively indicated that the cardiac code was not paged on the overhead system. Interview with RN #1 on 1/25/19 at 10:37 AM noted that he/she called the PACU (post anesthesia care unit) via phone and asked for assistance because P #1 was "coding".

Interview with the Regional Director of Perioperative Services on 1/25/19 at 10:37 AM identified that the "TOA" (overhead perioperative paging system) was the process for requesting immediate assistance on the OR. The facility policy for medical response in the perioperative setting directed to use TOA and announce "Medical Response, Cardiac" and your location.

Subsequent to the event, the facility provided immediate re-education to perioperative staff regarding the use of the TOA system.


b. A tour of the perioperative area was conducted on 2/6/19 at 8:38 AM. Observations on 2/6/19 of the main OR at 9:02 AM of the cystoscopy room and of OR #2 at 9:04 AM identified a build-up of dust on the horizontal surfaces of electronic monitor screens. Observations on 2/6/19 of the ASU (Ambulatory Surgical Unit) at 9:29 AM noted a build-up of dust on the horizontal surfaces of monitors located in OR's #3, #4 and #5.

Interview with the Supervisor of Perioperative Services on 2/6/19 at 9:02 AM indicated that monitor screens should be cleaned as part of room cleaning.

The facility policy for surgical areas cleaning identified that daily terminal cleaning included to damp wipe and disinfect all horizontal and vertical surfaces.

c. A tour of the perioperative area was conducted on 2/6/19 at 8:38 AM. Observations on 2/6/19 in the ASU at 9:41 AM identified the CRNA (certified registered nurse anesthetist) in OR #3 drawing up medications from three medication vials into three separate syringes. The observation further noted that the CRNA would pop off the top to each vial and immediately access each vial without the benefit of first sanitizing the septum of the vial with an alcohol wipe. Interview with Anesthesiologist #2 on 2/6/19 at 9:43 AM indicated that anesthesia staff know that the vial septum should be wiped off with an alcohol wipe prior to access.

The facility anesthesia policy for medication management directed to clean the top of the vial with alcohol before drawing medication into the sterile syringe.

Based on medical record reviews, review of facility documentation, review of facility policies and interviews for one of ten patients who had cardiac resuscitation with intubation (Patient #1), the facility failed to ensure that staff utilized the overhead peri-operative paging system during an emergency in accordance with facility policy and/or that lung sounds and/or ETT (endotracheal tube) placement were accurately assessed and/or that extubation protocols were followed per facility policy.

The CoP for Anesthesia Services has not been met.
Refer to A951, A1002

Based on medical record reviews, review of facility policies, review of facility documentation and interviews for one of seven patients reviewed for anesthesia services during a cardiac arrest (Patient #1), the facility failed to ensure that extubation protocols were followed and/or that lung sounds and/or ETT (endotracheal tube) placement were accurately assessed and/or that facility policy for medical response during the cardiac code was followed.

The finding includes:

Patient #1 was admitted to the hospital on 12/30/18 with diagnoses of thyrotoxicosis with goiter and thyroid storm. P#1 had a history of Graves Disease. P #1 was assessed as an ASA surgical risk "4" (patients with severe systemic disease) and underwent an uncomplicated thyroidectomy under general anesthesia.on 1/9/19 by MD #1. Review of the immediate operative report dated 1/9/19 identified a 10cc (minimal) blood loss during the operative procedure.
Review of the anesthesia record dated 1/9/19 indicated that P #1 was easily intubated for the procedure, was extubated by CRNA #2 (certified registered nurse anesthetist) uneventfully at 5:39 PM while deeply sedated and breathed spontaneously post extubation in the absense of the anesthesiologist. P #1's BP (blood pressure) was 100/50 (low range) at the time of extubation. P #1's BP began to slowly increase following extubation (despite the administration of Dilaudid at 5:44PM and at 5:48PM) with the BP noted to be 170/80 at 5:48PM.

Review of the anesthesia record authored by CRNA #2 at 5:49 PM noted that P #1 was short of breath, nodded yes when asked if he/she was having difficulty breathing, was assessed as having wheezes (by CRNA #1) and 3 puffs of Albuterol (bronchodilator) was administered into P #1's mask without relief. Review of CRNA #2's documentation at 5:51 PM identified that P #1's breathing progressed to slight stridor, was provided breathing support via mask, slight neck swelling was observed and both MD #1 and Anesthesiologist #2 were called to the room via phone (not via overhead page).

Review of Anesthesiologist #2's note dated 1/9/19 indicated the he/she was called to the room at 5:52 PM (4 minutes after breathing difficulty began), arrived immediately, P #1 was stridorous, had swollen oral tissue and with the use of a glidescope (for visualization) the patient was difficult to intubate with an ETT (endotracheal tube). Further review of Anesthesiologist's #2's note identified that during intubation, P #1's arterial line went flat, P #1 became pulseless and CPR (cardio- pulmonary resuscitation) was initiated at 5:48 PM.

Although Anesthesiologist #2 documented that the ETT placement was verified by an anesthesiology team member (CRNA #1), P #1's CO2 (carbon dioxide) level was 49 at 5:20PM then dropped to 6 at 5:35PM and 3 at 5:45pm (normal CO2 levels are 35-45), the pulse oximeter kept falling off P #1's finger (therefore unable to adequately monitor oxygen level in the blood/respiratory resuscitation effectiveness) and Anesthesiologist #1 taped the ETT to P#1 to free her hands. Review of the documentation by Anesthesiologist #2 identified that she palpated P #1's stomach herself, noted that it felt firm (air entering stomach instead of lungs), removed the ETT and with the glidescope reinserted the ETT (at 6:05 PM). Further review identified that within 7 minutes into the code, P #1 had immediate ROSC (return of spontaneous circulation).

Review of the discharge summary dated 1/19/19 identified that after several minutes during CPR, another assessment was conducted at the ETT which indicated that it was not in the trachea. Further review identified that the outcome was severe anoxic brain injury and P#1 subsequently expired on 1/19/19.

Interview with the Senior VP of Clinical Services for the facility (contracted anesthesia group) on 1/25/19 at 11:00 AM identified that the elevated BP caused increased venous congestion which lead to bleeding. Further interview identified that per protocol, Anesthesiologist #2 should have been in the room at the time P #1 was extubated as P #1 had a "high risk" airway. In addition, the Senior VP further identified that there was a delay in calling Anesthesiologist #2 to the room and CRNA #2 was responsible to ensure that this was done.

Interview with Anesthesiologist #2 on 1/29/19 at 8:35 AM indicated that he/she told the CRNA that P #1 was probably stridorous from the beginning and was inaccurately assessed. Anesthesiologist #2 noted that CRNA #1 confirmed ETT placement after P #1 was intubated.

Interview with CRNA #1 on 1/29/19 at 10:05 AM identified that he/she informed Anesthesiologist #2 that he/she heard something but, that it sounded distant (questionable ETT placement). CRNA #1 further indicated that he/she had directed RN #2 to get the "code cart" when P #1 became pulseless.

Interview with Anesthesiologist #1 on 1/29/19 at 10:05 AM identified that in terms of the code, there was a failure to delegate and during the code, someone had to identify themselves as the leader. Further interview identified that Anesthesiologist #1 noted that end title CO2 was the gold standard for determining proper ETT placement.

Interview with Anesthesiologist #5 on 2/6/19 at 1:10 PM indicated factors including effective manual ventilation, symmetrical chest rise and an end-tidal CO2 waveform on the gas analyzer would indicate if the airway was placed correctly.

Interview with MD #2 on 2/5/19 at 2:24 PM identified that, upon review, P #1's airway (ETT) was never in place until it was readjusted because after readjustment, P #1 had immediate ROSC (return of spontaneous circulation).

Review of facility policy for medical response in the perioperative setting identified that the anesthesiologist is the physician in charge of the "Medical Response, Cardiac or Respiratory". The amended anesthesia agreement dated 8/1/13 identified that the anesthesia group will be responsible for the supervision of the post anesthesia care of the patient.

Subsequent to the event, all anterior neck surgeries were suspended prior to an internal review. Post review, the facility revised their perioperative Medical Response policy approved on 1/16/19 to include the use of the hospital- wide paging system and code team response followed by staff education. In addition, Anesthesia Staff will be required to complete an advanced airway refresher course.