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Based document review and staff interviews, the acute care administrative staff failed to ensure medical staff followed the hospital's policies when 1 of 1 on call Interventional Cardiologist scheduled for 7/30/2019 (Interventional Cardiologist A) failed to respond to the ED when paged for a STEMI Alert (a call made to staff, which requires a rapid response, a patient is experiencing a specific type of heart attack, identified on an EKG,.and for which a cardiac catheterization, done as quickly as possible, can restore blood flow through the blocked blood vessel in the heart and reduce heart damage and death) Failure of on call Interventional Cardiologist A to respond to a STEMI Alert resulted in both a delay in treatment of Patient #7's heart attack and required transfer to another outside hospital, 5 miles away, to obtain a cardiac catheterization. The hospital's administrative staff identified an average of 1727 patients per month who presented to the ED for an emergency medical condition.


Findings include:

1. Review of the hospital policy, "EMTALA; ON CALL PHYSICIANS," dated 8/2016, revealed in part, "Hospital will maintain a list of physicians who are on-call for duty ...to provide treatment necessary to stabilize and individual with an emergency medical condition. ...If requested by the emergency physician the on-call physician shall respond in a timely manner. Practitioners designated as on-call...should be available by phone..within a reasonable period of time. ... on-call roster ...utilized to ensure..physicians available to provide...stabilizing treatment to patients...who are believed to have emergency medical conditions."

2. Review of the hospital document, "MercyOne Waterloo Medical Center Medical Staff Rules and Regulations," dated April 5, 2018, revealed in part, "When on the Emergency Department on-call schedule, the only acceptable reasons for failure to respond to a request for consultation by the Emergency Department is sudden illness, unavoidable detainment such as attending to another emergency, or ... event that physically prohibits the on-call physician from appearing in the hospital.... Failure to respond to a request ... when on the Emergency Department on-call schedule, may constitute a violation of the EMTALA guidelines."

3. Review of the hospital policy, "STEMI ALERT" (ST Elevation MI) dated 06/18, included in part, ..."A STEMI (ST segment elevation myocardial infarction) is characterized by ST-segment elevation (refers to a finding on an electrocardiogram wherein the trace in the ST segment is abnormally high above the baseline and may or may not be indicative of a heart attack), ... recognition and treatment of a STEMI is an emergent process. Patients with a STEMI usually have complete occlusion of an .. .coronary artery. Direct catheter-based reperfusion reduces mortality and saves the heart muscle; the shorter the time to reperfusion, the greater the benefit.... policy provides guidelines to ensure timely and effective treatment for patients of [MercyOne Waterloo] exhibiting signs and symptoms of ST elevation MI (STEMI).... If a STEMI is confirmed by the ED physician, the ED physician/staff initiates STEMI ALERT...The call will go out ... the group page goes to the "on call" Interventional Cardiologist, house supervisor, and STEMI team.... if no return from the on-Call Interventional Cardiologist within 5 minutes, call his/her cell phone directly.... Goal for patient time in ED prior to transfer (to cath lab) is less than 45 minutes ... Total door to balloon time (the reperfusion of the artery) goal to be achieved is < 90 minutes.

4. Review of hospital document, "MercyOne WATERLOO DAILY PHYSICIAN CALL SCHEDULE'' dated 7/30/2019 revealed in part, "HEART CARE: [Interventional Cardiologist A's name]" 7 AM 7/30/19 to 7 AM 7/31/19.

5. Review of document "Delineation of Privileges" revealed in part, "Provider Name: [Interventional Cardiologist A] - Active, Appointment: 07/31/2018 - 07/31/2020, ... INTERVENTIONAL CARDIOLOGY GENERAL PRIVILEGES, ... Cardiac Catheterization General Privileges to include .... technical procedures and medications to treat abnormalities that impair the functions of the heart...coronary stents..." approved by the Chair, Board of Directors 06/07/2018.

6. Review of Patient # 7's medical record revealed:

a. On 7/31/2019 at 01:42 AM, Patient #7 presented to the ED by ambulance with a complaint of chest pain, a severe substernal crushing discomfort that radiated to the jaw and left arm, along with some diaphoresis (sweating) and nausea. Chest pain was a 5 out of 10 (pain scale). Ambulance staff had administered 2 sublingual (under the tongue) nitroglycerin tablets prior to arrival.

b. At 01:44 AM, an electrocardiogram (EKG), read by the ED Physician C, revealed sinus tachycardia with a rate of 124 beats per minute and there was ST segment elevation consistent with a lateral wall infarct. Acute STEMI (an emergency that needs immediate attention).

c. At 01:47 AM, the ED staff called a STEMI ALERT.

d. At 01:50 AM, RN E documented Patient #7;s vital signs are BP 172/97, heart rate 120, respiratory rate 20.

e. At 02:10 AM, ED Dr C documented "updated from the nursing supervisor that [Interventional Cardiologist A's name] has not called back and multiple attempts to contact him by phone have been unsuccessful. Cath lab team is here. We attempted to contact [Interventional Cardiologist B] who is not on call and he did not answer his phone. Given the emergency of this patient's condition and need for emergent timely [cardiac catheterization] intervention I was advised to transfer to [Hospital A's name] by nursing supervisor."

f. At 02:11 AM, ED Physician C documented "spoke [ER Physician D] from [Hospital A] ER and explained the situation to him and he accepted the transfer and requested that the patient receive a heparin bolus, [heparin] drip (medication that prevents blood from clotting) and Plavix 600 mg [by mouth]."

g. At 02:17 AM, ED RN E documented they received a call that Patient #7 had a critical lab test result of Troponin T at 0.043 ng/mL (normal range <= 0.010 ng/mL, which indicated Patient #7 had injured heart muscle).

h. At 02:19 AM, ED Physician C documented "Patient loaded up on EMS gurney for emergent transfer and Plavix and heparin bolus have been given but not the drip as pharmacy could not get this ready in a timely manner and I did not want to delay the transport of this patient.... I did update [Hospital A's ER Physician D] that the drip was not started but everything else was completed. Patient stated ... was very nervous prior to transfer to [Hospital A] and wanted valium (a medication to reduce anxiety). ... Administration was notified of the current situation regarding inability to contact [Interventional Cardiologist A's name] who is on call."

i. Review of the "Patient Transfer Form," dated and signed by ER Physician C on 7/31/10 at 02:10 AM, revealed "REASON FOR TRANSFER: On-call MD [Interventional Cardiologist A's name] refused or failed to respond within a reasonable period of time. .. Diagnosis: Acute STEMI... Medical Benefits: Service not available at this facility. ... Service Cardiology... Receiving Facility [Hospital A ER] Receiving MD [ER Physician D's name]." Verbal consent for transfer to Hospital A obtained from patient and documented at 02:18 AM by RN E.


7. Please refer to A-2404 for additional information.

Based on review of hospital documents, medical records, and staff interviews, the acute care hospital failed to ensure 1 of 42 patients (Patient # 7) received all care needed and services available at the hospital when the interventional cardiologist on call failed to respond to the hospital when a STEMI Alert was called. Failure to respond to a STEMI Alert (a call made to all staff, which requires a rapid response, that a patient is experiencing a specific type of heart attack, identified on an EKG, and for which a cardiac catheterization done as quickly as possible can restore blood flow through the blocked blood vessel in the heart and reduce heart damage and death) resulted in both a delay in treatment of Patient #7's heart attack and required transfer to another outside hospital, 5 miles away, to obtain a cardiac catheterization. The hospital's administrative staff identified an average of 1727 patients a month who presented to the ED for an emergency medical condition.



Findings include:

1. Review of the hospital policy, "STEMI ALERT" (ST Elevation MI) dated 06/2018, included in part, ..."A STEMI (ST segment elevation myocardial infarction) is characterized by ST-segment elevation (refers to a finding on an electrocardiogram wherein the trace in the ST segment is abnormally high above the baseline and may or may not be indicative of a heart attack), ...recognition and treatment of a STEMI is an emergent process. Patients with a STEMI usually have complete occlusion of an...coronary artery. Direct catheter-based reperfusion reduces mortality and saves the heart muscle; the shorter the time to reperfusion, the greater the benefit. ...policy provides guidelines to ensure timely and effective treatment for patients of [MercyOne Waterloo] exhibiting signs and symptoms of ST elevation MI (STEMI). ...If a STEMI is confirmed by the ED physician, the ED physician/staff initiates STEMI ALERT...The call will go out...the group page goes to the "on call" Interventional Cardiologist, house supervisor, and STEMI team.... if no return from the on-Call Interventional Cardiologist within 5 minutes, call his/her cell phone directly. ...Goal for patient time in ED prior to transfer (to cath lab) is less than 45 minutes...Total door to balloon time (the reperfusion of the artery) goal to be achieved is < 90 minutes.

2. Review of the hospital document, "MercyOne Waterloo Medical Center Medical Staff Rules and Regulations" dated April 5, 2018 revealed in part, "When on the Emergency Department on-call schedule, the only acceptable reasons for failure to respond to a request for consultation by the Emergency Department is sudden illness, unavoidable detainment such as attending to another emergency, or ...event that physically prohibits the on-call physician from appearing in the hospital. ...Failure to respond to a request...when on the Emergency Department on-call schedule, may constitute a violation of the EMTALA guidelines

3. Review of Patient # 7's medical record revealed:

a. On 7/31/2019 at 01:42 AM, Patient #7 presented to the ED by ambulance with a complaint of chest pain, a severe substernal crushing discomfort that radiated to the jaw and left arm, along with some diaphoresis (sweating) and nausea. Chest pain was a 5 out of 10 (pain scale). Ambulance staff had administered 2 sublingual (under the tongue) nitroglycerin tablets prior to arrival.

b. At 01:44 AM, an electrocardiogram (EKG), read by the ED Physician C, revealed sinus tachycardia with a rate of 124 beats per minute and there was ST segment elevation consistent with a lateral wall infarct. Acute STEMI (an emergency that needs immediate attention).

c. At 01:47 AM, the ED staff called a STEMI ALERT.

d. At 01:50 AM, RN E documented Patient #7's vital signs were BP 172/97, heart rate 120, respiratory rate 20.

e. At 02:10 AM, ED Physician C documented "updated from the nursing supervisor that [Interventional Cardiologist A's name] has not called back and multiple attempts to contact him by phone have been unsuccessful. Cath lab team is here. We attempted to contact [Interventional Cardiologist B] who is not on call and he did not answer his phone. Given the emergency of this patient's condition and need for emergent timely cath intervention I was advised to transfer to [Hospital A's name] by nursing supervisor."

f. At 02:11 AM, ED Physician C documented "spoke [to ER Physician D's name] from [Hospital A's name] ER and explained the situation to him and he accepted the transfer and requested that the patient receive a heparin bolus, [a heparin] drip (medication that prevents blood from clotting), and Plavix 600 mg [by mouth]."

g. At 02:17 AM, ED RN E documented receiving a call that Patient #7 had a critical lab test result of Troponin T at 0.043 ng/mL (normal range <= 0.010 ng/mL, which indicated Patient #7 had injured heart muscle).

h. At 02:19 AM, ED Physician C documented "Patient loaded up on EMS gurney for emergent transfer and Plavix and heparin bolus have been given but not the drip as pharmacy could not get this ready in a timely manner and I did not want to delay the transport of this patient.... I did update [Hospital A ER Physician D's name] that the drip was not started but everything else was completed. Patient stated ... was very nervous prior to transfer to [Hospital A's name] and wanted valium (a medication to reduce anxiety).... Administration was notified of the current situation regarding inability to contact [Interventional Cardiologist A] who is on call."

i. Review of the "Patient Transfer Form," dated and signed by ER Physician C on 7/31/10 at 02:10 AM, revealed in part, "REASON FOR TRANSFER: On-call MD [Interventional Cardiologist A's name] refused or failed to respond within a reasonable period of time. .. Diagnosis: Acute STEMI... Medical Benefits: Service not available at this facility. ... Service Cardiology... Receiving Facility: [Hospital A ER] Receiving MD: [ER Physician D's name]." Verbal consent for transfer to Hospital A obtained from patient and documented at 02:18 AM by RN E.

j. Review of the ambulance transfer record "Prehospital Care Report," dated 7/31/2019, revealed in part, "Interfacility Transfer...Destination [Hospital A's name] ... Unit dispatched: 7/31/2019 02:24:00 ... At scene: 7/31/19 02:25:00 ... Departed: 7/31/2019 02:25:00 ... Arrived at Dest.: 7/31/2019 02:37:00 ... In service 02:47:00. Vitals ... 02:27:34 BP 161/104, Pulse 94, Resp 14 , Pain 3 ... 02:33:14 BP 168/96, Pulse 87, Resp 14, Pain 3."

5. Review of the hospital document "MercyOne WATERLOO DAILY PHYSICIAN CALL SCHEDULE'' dated 7/30/2019 revealed in part, "HEART CARE: [Interventional Cardiologist A's name]" 7 AM 7/30 to 7 AM 7/31.

6. Review of the document "Delineation of Privileges," revealed in part, "Provider Name: [Interventional Cardiologist A's name] - Active, Appointment: 07/31/2018 - 07/31/2020, ... INTERVENTIONAL CARDIOLOGY GENERAL PRIVILEGES, ... Cardiac Catheterization General Privileges to include ... technical procedures and medications to treat abnormalities that impair the functions of the heart ... coronary stents ..." and approved by the Chair of the Medical staff and Board of Directors on 06/07/18.

7. Review of the hospital document "Archived Message, STEMI ALERT [MercyOne Waterloo]" revealed in part, "STEMI TEAM RESPOND, CALLED [INTERVENTIONAL CARDIOLOGIST A's name] CELL/NO ANSWER, CALLED WIFE CELL/NO ANSWER, CALLED DAUGHTER WENT TO VOICEMAIL, PAGED DR TO CALL A.S. ... 7/31/2019 02:28 A [House Supervisor J's name] SENT THE POLICE TO [INTERVENTIONAL CARDIOLOGIST A's] HOME." Dial out history contained 32 separate entries of calls and pages, each dated, timed and included number called. First call made 7/31/2019 @ 2:02:00, last call 7/31/2019 at 2:28:00 AM. Each call identified the callers initials, Communications Attendant H and Communications Attendant I.

8. During an interview on 8/12/2019 at 2:00 PM, ED Physician C revealed that Patient #7 presented to MercyOne ED with chest pain, a STEMI, and required an emergent procedure to open a blood vessel in Patient #7's heart (cardiac catherization). A STEMI Alert was called. Within 10 minutes the cath lab team had arrived and were ready. The cath lab team was waiting for the cardiologist, who had not returned the call. At least 6-8 phone calls and pages went out, but all were unsuccessful in reaching him. After 20 to 25 minutes, the hospital staff tried to reach Interventional Cardiologist B, who was not on call and did not answer the phone. At the 30-35 minute mark, the decision was made to transfer the patient to Hospital A. ER Physician C explained to the Patient #7 and his family that they couldn't get a hold of Interventional Cardiologist A and needed to transfer Patient #7 to Hospital A for the cardiac procedure Patient #7 required. ER Physician C explained any further delay in having the procedure performed might result in serious consequences, potentially leading to permanent heart damage and death. ER Physician C then called Hospital A's Transfer Center and was put on the phone with Hospital A's ER Physician D. ER Physician C explained MercyOne had Patient #7 in the ER with a STEMI, they had called a STEMI Alert and the cath lab team was present, but they were unable to reach on call Interventional Cardiologist A. Hospital A's ER Physician D accepted Patient #7. Patient #7 was stabilized as much as possible at MercyOne Waterloo and was transferred by ambulance to Hospital A, where Patient # 7 went promptly to the cath lab. ER Physician C reported hospital staff contacted the Cedar Falls Police Department to do a welfare check on Interventional Cardiologist A. Interventional Cardiologist A called the ER and told the staff that his phone was on vibrate, he had forgotten to turn the volume up before went to bed, and never heard the phone go off.

9. During an interview on 8/7/2019 at 9:30 AM, House Supervisor J revealed House Supervisor J was already in the ER when the STEMI Alert was called. House Supervisor J reported they heard back form all 4 of the cath lab team members, but Interventional Cardiologist A had not responded. House Supervisor J asked ER Physician C if he had talked with Interventional Cardiologist A, and was told he had not. House Supervisor J then talked to the communications office that placed the STEMI calls. They had 2 other contact numbers, 3 numbers in all for Interventional Cardiologist A, were trying all three numbers, and still hadn't made contact. House Supervisor J asked the communications staff to try Interventional Cardiologist B, who was not on call. Interventional Cardiologist B did not answer. House Supervisor J stated she then called the on-call administrator, Administrator O, to inform him of the inability to contact on call Interventional Cardiologist A, the ED had a patient with a STEMI, a STEMI Alert had been called, the cath lab team was present but no Interventional Cardiologist. House Supervisor J explained time was critical and they needed to transfer Patient #7 to Hospital A for cardiac catheterization. Administrator O agreed and House Supervisor J informed ER Physician C to begin the transfer process. House Supervisor J reported that a nurse and ER Physician C explained to Patient #7 why transfer was needed, Patient #7 agreed, and the transfer was arranged. House Supervisor J contacted Administrator O, discussed the next steps, and decided to have the Cedar Falls Police Department do a welfare check on Interventional Cardiologist A. House Supervisor J reported Interventional Cardiologist A contacted the ED around 2:40 AM following being awakened by the police. House Supervisor J revealed Interventional Cardiologist A explained his phone had inadvertently been left on silent.

10. During an interview on 8/7/2019 at 4:05 PM, Communications Attendant H revealed she and Communications Attendant I attempted unsuccessfully to call Interventional Cardiologist A for at least 10 minutes and used Interventional Cardiologist A's pager, personal cell phone number, and the back up cell phone numbers of spouse and daughter. Communications Attendant H reported House Supervisor J asked her call Interventional Cardiologist B, and that call also went unanswered.

11. During an interview on 8/7/2019 at 1:49 PM, Communications Attendant I revealed a STEMI Alert had been paged and they have 5 minutes to get everybody called. Communications Attendant I reported she and Communications Attendant H called and paged back to back for almost an hour in attempt to reach Interventional Cardiologist A utilizing a pager, cell phone number, spouse's cell phone number, and daughter's cell phone number, all without success. Communications Attendant I reported they stopped attempts to reach Interventional Cardiologist A when House Supervisor J said she would call the police.

12. During an interview on 8/7/2019 at 11:14 AM, Interventional Cardiologist A confirmed Interventional Cardiologist A was on call 7/30/2019 and did not respond when MercyOne ED called a STEMI Alert. Interventional Cardiologist A reported his pager and phone did not go off, the page also comes through his cell phone. Intevetenional Cardiologist A verified the back up numbers provided are those of his wife and daughter, both were out of town on 7/30/19. Interventional Cardiologist A verified the hospital staff did the right thing and transferred Patient #7 to Hospital A. Interventional Cardiologist A disclosed when a patient has a STEMI, we have up to 90 minutes to salvage cardiac heart muscle, longer than that and there is higher mortality for the patient and a higher risk of permanent damage to the heart.

13. During an interview on 8/8/2019 at 9:45 AM, Administrator O revealed he had received a phone call shortly after 2:00 AM on 7/31/2019 from House Supervisor J and was told they had called a STEMI Alert for a patient in the ED. On call Interventional Cardiologist A could not be reached. Administrator O reported House Supervisor J had provided a thorough assessment, explained the immediate need for transfer of the patient to Hospital A for an emergent cardiac procedure, and Administrator O agreed with the plan. Administrator O revealed he had a total of 3 phone calls from House Supervisor J over about a 45 minute period, the second call concluded with the decision to have police do a welfare check, and final call when contact with Interventional Cardiologist A had been established.

14. During an Interview on 8/8/19 at 9:15 AM, the Chief Nursing Office confirmed she had 3 phone calls and an email upon arriving to work early in the morning on 7/31/2019, that the ER staff had tried multiple times to contact on call Interventional Cardiologist A for a STEMI patient, and were unable to reach him. This resulted in Patient #7 being transferred to Hospital A for a procedure that the staff had the capability of performing at MercyOne and resulted in a delay of treatment for Patient #7. The CNO verified the police performed a welfare check on Interventional Cardiologist A, and Interventional Cardiologist A then contacted the ED.

15. Review of Patient #7's medical record from Hospital A revealed:

a. the document "Transfer Acceptance/Direct Admission" form, dated 7/31/2019, signed at 2:08 AM by Hospital A's ED Physician D, revealed in part, "Origin of Transfer: MercyOne, ... Clinical Situation: STEMI, [aspirin given 3 sub-lingual nitroglycerin given], Heparin, Cath Lab Team there but cannot get a hold of cardiologist." Transfer accepted.

b. Patient #7 arrived at Hospital A's ED by ambulance at 2:38 AM on 7/31/2019. ED Physician D, Interventional Cardiologist G were at bedside on Patient #7's arrival. An EKG performed at 2:40 AM confirmed a STEMI. A Troponin I (test that may indicate injured heart muscle) at 2:45 AM was 0.99 ng/mL (normal range 0.00-0.04 ng/mL). Patient #7 was taken to the Cath Lab for a cardiac catheterization (procedure to open a blocked vessel) at 2:48:47 AM.

c. Review of the document "Cardiac Procedure Log" dated 7/31/2019, revealed in part, "2:50 AM Patient to room, ... 2:56: Patient ready, ... 3:02 Case started, ... 3:13 Balloon Inflation, .... 3:36 AM Procedure ended, ...3:45 AM To ICU."

d. A post procedure note by Interventional Cardiologist G noted a successful angioplasty (procedure to open narrow or blocked blood vessel that supply the heart) and stenting of proximal intermedius artery was performed using drug eluting stent (a tubular support placed into a narrowed artery that slowly releases a drug to prevent it from reblocking).

e. Patient #7 was discharged to home from Hospital A on 8/1/2019 at 12:30 AM, in good condition.


16. During an interview on 8/14/2019 at 7:00 AM, ER Physician D revealed he received a call in the early morning hours of 7/31/19 from ER Physician C at MercyOne asking to transfer a STEMI patient (Patient #7) as the patient needed to get to a cath lab as soon as possible. ER Physician D stated he asked ER Physician C if MercyOne had the capability to do that procedure there. ER Physician C responded yes they do, the cath lab team was at MercyOne but they had been unable to contact Interventional Cardiologist A, and time had become critical. ER Physician D agreed to accept the transfer of Patient #7 and paged a STEMI Alert. Interventional Cardiologist G presented to the ER immediately and was present when Patient #7 arrived by ambulance from MercyOne. Patient #7 was taken straight to the cath lab for cardiac catheterization.

17. An interview on 8/8/2019 at 1:05 PM with Interventional Cardiologist G revealed he received a page at approximately 2:13 AM, responded, and was put on the phone with ER Physician D. ER Physician D informed him that a patient with a STEMI (Patient #7) was being transferred from MercyOne. The cath lab team was present at MercyOne, but MercyOne had been unable to reach the on call Interventional Cardiologist. Interventional Cardiologist G stated he had been present when the Patient #7 arrived and they had taken Patient #7 straight to the cath lab, placed a stent, and fixed the blockage. Interventional Cardiologist G reported Patient #7 experienced approximately an hour delay in receiving the cardiac catheterization due to the inability to reach the on call Interventional Cardiologist at MercyOne which resulted in the need for transfer of Patient #7 to Hospital A. Interventional Cardiologist G revealed a delay in could potentially result in damage to the heart.

Based on document review and staff interview, the Acute Care Hospital's administrative staff failed to ensure the hospital staff did not delay providing stabilizing treatment within the hospital's capability for 1 of 42 selected emergency department (ED) patient who required emergency care (Patient #7) and presented to the hospital between 2/1/19 and 7/31/19. Failure to provide all available stabilizing treatment, including cardiac catheterization (a procedure used to diagnose and treat certain heart conditions), resulted in the hospital transferring Patient #7 to another outside hospital, 5 miles away, to obtain a cardiac catheterization procedure. The delay in stabilizing treatment could potentially result in Patient #7 sustaining greater damage to the heart muscle and potentially dying. The hospital's administrative staff identified an average of 1727 patients per month who presented to the hospital and requested emergency medical care.

Findings include:

1. Review of the hospital policy, "STEMI ALERT" (ST Elevation MI) dated 06/18, included in part, ..."A STEMI (ST segment elevation myocardial infarction) is characterized by ST-segment elevation (refers to a finding on an electrocardiogram wherein the trace in the ST segment is abnormally high above the baseline and may or may not be indicative of a heart attack), ...recognition and treatment of a STEMI is an emergent process. Patients with a STEMI usually have complete occlusion of an...coronary artery. Direct catheter-based reperfusion reduces mortality and saves the heart muscle; the shorter the time to reperfusion, the greater the benefit. ...policy provides guidelines to ensure timely and effective treatment for patients of [MercyOne Waterloo] exhibiting signs and symptoms of ST elevation MI (STEMI). ...If a STEMI is confirmed by the ED physician, the ED physician/staff initiates STEMI ALERT...The call will go out...the group page goes to the "on call" Interventional Cardiologist, house supervisor, and STEMI team.... if no return from the on-Call Interventional Cardiologist within 5 minutes, call his/her cell phone directly. ...Goal for patient time in ED prior to transfer (to cath lab) is less than 45 minutes...Total door to balloon time (the reperfusion of the artery) goal to be achieved is < 90 minutes.

2. Review of Patient # 7's medical record revealed:

a. On 7/31/2019 at 01:42 AM, Patient #7 presented to the ED by ambulance with a complaint of chest pain, a severe substernal crushing discomfort that radiated to the jaw and left arm, along with some diaphoresis (sweating) and nausea. Chest pain was a 5 out of 10 (pain scale). Ambulance staff had administered 2 sublingual (under the tongue) nitroglycerin tablets prior to arrival.

b. At 01:44 AM, an electrocardiogram (EKG), read by the ED Physician C, revealed sinus tachycardia with a rate of 124 beats per minute and there was ST segment elevation consistent with a lateral wall infarct. Acute STEMI (an emergency that needs immediate attention).

c. At 01:47 AM, the ED staff called a STEMI ALERT.

d. At 01:50 AM, RN E documented Patient #7's vital signs were BP 172/97, heart rate 120, respiratory rate 20.

e. At 02:10 AM, ED Physician C documented "updated from the nursing supervisor that [Interventional Cardiologist A's name] has not called back and multiple attempts to contact him by phone have been unsuccessful. Cath lab team is here. We attempted to contact [Interventional Cardiologist B] who is not on call and he did not answer his phone. Given the emergency of this patient's condition and need for emergent timely cath intervention I was advised to transfer to [Hospital A's name] by nursing supervisor."

f. At 02:11 AM, ED Physician C documented "spoke [to ER Physician D's name] from [Hospital A's name] ER and explained the situation to him and he accepted the transfer and requested that the patient receive a heparin bolus, [a heparin] drip (medication that prevents blood from clotting), and Plavix 600 mg [by mouth]."

g. At 02:17 AM, ED RN E documented receiving a call that Patient #7 had a critical lab test result of Troponin T at 0.043 ng/mL (normal range <= 0.010 ng/mL, which indicated Patient #7 had injured heart muscle).

h. At 02:19 AM, ED Physician C documented "Patient loaded up on EMS gurney for emergent transfer and Plavix and heparin bolus have been given but not the drip as pharmacy could not get this ready in a timely manner and I did not want to delay the transport of this patient.... I did update [Hospital A ER Physician D's name] that the drip was not started but everything else was completed. Patient stated ... was very nervous prior to transfer to [Hospital A's name] and wanted valium (a medication to reduce anxiety).... Administration was notified of the current situation regarding inability to contact [Interventional Cardiologist A] who is on call."

i. Review of the "Patient Transfer Form," dated and signed by ER Physician C on 7/31/10 at 02:10 AM, revealed in part, "REASON FOR TRANSFER: On-call MD [Interventional Cardiologist A's name] refused or failed to respond within a reasonable period of time. .. Diagnosis: Acute STEMI... Medical Benefits: Service not available at this facility. ... Service Cardiology... Receiving Facility: [Hospital A ER] Receiving MD: [ER Physician D's name]." Verbal consent for transfer to Hospital A obtained from patient and documented at 02:18 AM by RN E.

j. Review of the ambulance transfer record "Prehospital Care Report," dated 7/31/2019, revealed in part, "Interfacility Transfer...Destination [Hospital A's name] ... Unit dispatched: 7/31/2019 02:24:00 ... At scene: 7/31/19 02:25:00 ... Departed: 7/31/2019 02:25:00 ... Arrived at Dest.: 7/31/2019 02:37:00 ... In service 02:47:00. Vitals ... 02:27:34 BP 161/104, Pulse 94, Resp 14 , Pain 3 ... 02:33:14 BP 168/96, Pulse 87, Resp 14, Pain 3."


3. During an interview on 8/12/2019 at 2:00 PM, ED Physician C revealed that Patient #7 presented to MercyOne ED with chest pain, a STEMI, and required an emergent procedure to open a blood vessel in Patient #7's heart (cardiac catherization). A STEMI Alert was called. Within 10 minutes the cath lab team had arrived and were ready. The cath lab team was waiting for the cardiologist, who had not returned the call. At least 6-8 phone calls and pages went out, but all were unsuccessful in reaching him. After 20 to 25 minutes, the hospital staff tried to reach Interventional Cardiologist B, who was not on call and did not answer the phone. At the 30-35 minute mark, the decision was made to transfer the patient to Hospital A. ER Physician C explained to the Patient #7 and his family that they couldn't get a hold of Interventional Cardiologist A and needed to transfer Patient #7 to Hospital A for the cardiac procedure Patient #7 required. ER Physician C explained any further delay in having the procedure performed might result in serious consequences, potentially leading to permanent heart damage and death. ER Physician C then called Hospital A's Transfer Center and was put on the phone with Hospital A's ER Physician D. ER Physician C explained MercyOne had Patient #7 in the ER with a STEMI, they had called a STEMI Alert and the cath lab team was present, but they were unable to reach on call Interventional Cardiologist A. Hospital A's ER Physician D accepted Patient #7. Patient #7 was stabilized as much as possible at MercyONE Waterloo and was transferred by ambulance to Hospital A, where Patient # 7 went promptly to the cath lab. ER Physician C reported hospital staff contacted the Cedar Falls Police Department to do a welfare check on Interventional Cardiologist A. Interventional Cardiologist A called the ER and told the staff that his phone was on vibrate, he had forgotten to turn the volume up before went to bed, and never heard the phone go off.

4. During an interview on 8/7/2019 at 9:30 AM, House Supervisor J revealed House Supervisor J was already in the ER when the STEMI Alert was called. House Supervisor J reported they heard back form all 4 of the cath lab team members, but Interventional Cardiologist A had not responded. House Supervisor J asked ER Physician C if he had talked with Interventional Cardiologist A, and was told he had not. House Supervisor J asked the communications staff to try Interventional Cardiologist B, who was not on call. Interventional Cardiologist B did not answer. House Supervisor J stated she then called the on-call administrator, Administrator O, to inform him of the inability to contact on call Interventional Cardiologist A, the ED had a patient with a STEMI, a STEMI Alert had been called, the cath lab team was present but no Interventional Cardiologist. House Supervisor J explained time was critical and they needed to transfer Patient #7 to Hospital A for cardiac catheterization. Administrator O agreed and House Supervisor J informed ER Physician C to begin the transfer process.

5. During an interview on 8/7/2019 at 11:14 AM, Interventional Cardiologist A confirmed Interventional Cardiologist A was on call 7/30/2019 and did not respond when MercyOne ED called a STEMI Alert. Interventional Cardiologist A verified the hospital staff did the right thing and transferred Patient #7 to Hospital A. Interventional Cardiologist A disclosed when a patient has a STEMI, we have up to 90 minutes to salvage cardiac heart muscle, longer than that and there is higher mortality for the patient and a higher risk of permanent damage to the heart.


6. Review of Patient #7's medical record from Hospital A revealed:

a. the document "Transfer Acceptance/Direct Admission" form, dated 7/31/2019, signed at 2:08 AM by Hospital A's ED Physician D, revealed in part, "Origin of Transfer: MercyOne, ... Clinical Situation: STEMI, [aspirin given 3 sub-lingual nitroglycerin given], Heparin, Cath Lab Team there but cannot get a hold of cardiologist." Transfer accepted.

b. Patient #7 arrived at Hospital A's ED by ambulance at 2:38 AM on 7/31/2019. ED Physician D, Interventional Cardiologist G were at bedside on Patient #7's arrival. An EKG performed at 2:40 AM confirmed a STEMI. A Troponin I (test that may indicate injured heart muscle) at 2:45 AM was 0.99 ng/mL (normal range 0.00-0.04 ng/mL). Patient #7 was taken to the Cath Lab for a cardiac catheterization (procedure to open a blocked vessel) at 2:48:47 AM.

c. Review of the document "Cardiac Procedure Log" dated 7/31/2019, revealed in part, "2:50 AM Patient to room, ... 2:56: Patient ready, ... 3:02 Case started, ... 3:13 Balloon Inflation, .... 3:36 AM Procedure ended, ...3:45 AM To ICU."

d. A post procedure note by Interventional Cardiologist G noted a successful angioplasty (procedure to open narrow or blocked blood vessel that supply the heart) and stenting of proximal intermedius artery was performed using drug eluting stent (a tubular support placed into a narrowed artery that slowly releases a drug to prevent it from reblocking).

e. Patient #7 was discharged to home from Hospital A on 8/1/2019 at 12:30 AM, in good condition.

7. During an interview on 8/14/2019 at 7:00 AM, ER Physician D revealed he received a call in the early morning hours of 7/31/19 from ER Physician C at MercyOne asking to transfer a STEMI patient (Patient #7) as the patient needed to get to a cath lab as soon as possible. ER Physician D stated he asked ER Physician C if MercyOne had the capability to do that procedure there. ER Physician C responded yes they do, the cath lab team was at MercyOne but they had been unable to contact Interventional Cardiologist A, and time had become critical. ER Physician D agreed to accept the transfer of Patient #7 and paged a STEMI Alert. Interventional Cardiologist G presented to the ER immediately and was present when Patient #7 arrived by ambulance from MercyOne. Patient #7 was taken straight to the cath lab for cardiac catheterization.