HospitalInspections.org

Based on policy review, medical record review, Patient Logistic's Center data review, census review, on-call schedule review, and staff and physician interviews, the hospital failed to accept a request for transfer of a patient with an Emergency Medical Condition (EMC) from a referring Dedicated Emergency Department (DED) for specialized inpatient care when the receiving/recipient hospital had capacity and capability to provide care for one (1) of 4 sampled requests for transfer from other emergency departments, (Patient #26).

Findings included:

Refer to 489.24(f), Recipient Hospital Responsibilities - A2411 for findings.

Based on policy review, Patient Logistic's Center (PLC) data review, medical record review, census review, on-call schedule review, and staff and physician interviews, the hospital failed to accept a request of a patient with an emergency medical condition (EMC) from a referring Dedicated Emergency Department (DED) for specialized inpatient care when the receiving/ recipient hospital had capacity and capability to provide care for one (1) of 4 patients reviewed (Patient #26) with requests for transfer from other emergency departments.

The findings included:

Review of the policy titled "Treatment of Patients with Emergency Medical Conditions" revealed the most recent policy revision was dated 04/2019 but the revision in effect at the time of the requested transfer was effective 09/2013. Review of the 09/2013 revision revealed "...III. Definitions .... The term 'capability' means having qualified personnel and facilities available at the hospital to provide a medical screening exam and treatment as required to stabilize the individual's medical condition. The term 'capacity' means the ability of the hospital to accommodate the individual requesting examination or treatment, and encompasses such things as numbers and availability of qualified staff, beds, and equipment, as well as the hospital's past practices of accommodating additional patients in excess of its occupancy limits.... IV. Policy. A. Procedure....4. Accepting Transfers and Reporting Improper Patient Transfers. A. [ Hospital A] must accept the requested transfer of a patient who is in an emergency medical condition when [Hospital A] has the capacity and specialized capabilities that are not available at the requesting hospital. [Hospital A] is obligated to accept a transfer if the requesting hospital has no beds, is overcrowded, or does not have the specialized capability of [Hospital A]. ..."

Review of the PLC (Patient Logistic Center- Call Center for incoming transfers to Hospital A) Physician Service Lines Backup List Pathway revealed " ...1. Contact Primary Physician Wait 15 Minutes Contact again Wait 15 minutes ...2. Contact Secondary Physician (if non listed above, skip this step and contact Tertiary Physician listed) Wait 15 Minutes Contact again Wait 15 Minutes ..."

1. Review on 10/02/2019 of Patient #26's (57-year-old female) incoming transfer documentation revealed Hospital B's ED (Emergency Department) MD (Medical Doctor) requested to transfer Patient #26 to Hospital A for " ...New onset hepatic encephalopathy. Tachy 110-115 ..." on 02/07/2019 at 1605. Review revealed Patient #26's insurance was Medicare. At 1611 MD #13 (the on-call hepatologist at Hospital A) was paged by the PLC. At 1623 MD #13 was conferenced with Hospital B's ED MD. Review of the PLC (Patient Logistic's Center ) notes of the call revealed "Pt (patient) came in from MD office. Pt has been followed by ENT (Ear, Nose, Throat), ID (Infectious Disease) Pt has had Epstein Barr. Was scheduled to have CT (Computed Tomography) of sinuses and chest today. Was confused late last night per the family. New onset hepatic encephalopathy. Labs from the Jan 23 office visit given as a baseline. 7.9 Hgb (hemoglobin) Guaiac negative per digital rectal exam 32,000 WBC (White Blood Cells) 9.1 bilirubin (bili) 251 ALF (acute liver failure) 182 Ammonia 37.2 PT Mild cholecystitis Not a known cirrhotic patient. Per husband, the pt is not a drinker. (MD #13) has concern for acute liver injury, may be drug induced. Pt has been on many antibiotics. Pt is in liver failure. (MD #13) thinks the pt does need to come to a liver center/(Hospital A). Pt has seen ENT here per (MD #13) who is reviewing the record. (Hospital B's MD) read off labs from September 10, 2018. (MD #13) reports pt needs to come here to the ED if they are accepting patients. Pt is jaundiced. 3.76 INR (International Normalized Ratio) Lactulose given per (Hospital B's MD). Pt has been pan cultured. Zosyn given. (MD #13) reports the pt will need ICU (Intensive Care Unit) level of care ALF per (MD #13). PLC will try to reach out to MDI (Medical Intensivist) for acceptance first since they discussed ICU level of care for the pt. Albumin 3.5 Creat 2.3 No reports of pt taking Tylenol. No ABG (Arterial Blood Gas) drawn. Bicarb 10 ...Pt is renal failure (sic) Unknown ALF cause. Give NAC (N-acetylcysteine) per (MD #13), pt meets the criteria for NAC. (MD #13) reports that if we don't have available ICU beds the pt may need to go to another facility. Call ended @ 1637." Review of MD #13's Progress note revealed "Spoke to ER physician at (Hospital B) regarding 57 yo female who presented with confusion. She has a h/o DM, HTN (history/of Diabetes, Hypertension), elevated lipids, chronic sinusitis with multiple recent antibiotics. No prior h/o any liver issue with labs 9/10/18 ALT 25 AST 27 AP 83 TB 0.7. Today she is jaundiced with asterixis. Labs revealed AST 738 ALT 251 INR 3.76 TBili 7.1 WBC 32,000 Cr 2.3, Bicarb 10, ammonia 160. CT scan did not show cirrhosis per report. Patient was cultured and given IV antibiotics (Zosyn). Marked acidosis. She was given a dose of Lactulose also. Recommended starting NAC as meets ALF criteria. Unclear if this is infection with decompensation of undiagnosed chronic liver disease (Possible NAFLD-Non-alcoholic fatty liver disease) or acute liver failure perhaps from recent antibiotic. Patient should come to a liver center and will need ICU level care. Please notify hepatology on call if patient comes to (Hospital A)."

Review revealed the Medical Intensivist (MD #14) was paged by the PLC at 1642. Review revealed no response and MD #14 was paged again at 1656 (14 minutes later). Review revealed no response from MD #14 and at 1717 a PLC note that stated "Attempted to conference (Hospital B's MD) from (Hospital B) with (MD #15-ED attending) ...Initial pt information given, (MD #15) declined to accept the pt due to the capacity in the ED. (Hospital B's MD) notified of this. PLC will reach out the the (sic) MDI physician ..." At 1725 a third page was sent to MD #14 (29 minutes after the second page). Review revealed MD #14 called back at 1750 (1 hour and 8 minutes after the first page) " ...Called back to conference with (Hospital B's MD) Patient accepted by: (MD #14) Service: MDI Level of Care: ICU Pt is located in ED ...OSH/(Hospital A' Transport Team) will provide transportation No hx of alcoholism/ drug abuse. Over the last 2 years pt has been on a number of abx chasing an unknown infection. AST 730, ALT 251, Alk/ Phos 548 Na (Sodium) 138, k (Potassium) 4.7, CO2 10, BUN (Blood Urea Nitrogen) 21, cr 2.3, Hgb 7.9 CT fluid surrounding gallbladder. BP (blood pressure) 127/79, HR (heart rate) 115, RR (respiratory rate) 24, 92-94% on 2LNC (liters nasal canula)..." At 1807 PLC notes revealed "Advised Flow CN (charge nurse-bed coordinator) of pt acceptance." At 1904 PLC notes revealed "(MD #14) reports he would like to take this pt into the first open bed. He is going to talk to (MD #17-Oncoming MDI) about this. Connected for MD conference with: (MD #14 and Hospital B's MD) Connected @ (at) 1906 (MD #14) endorses that they will bring pt over. It may be a little time to get the room cleaned. He reports she will be the first pt they will bring over. PIV's (peripheral intravenous line) in place. (MD #14) asks if OSH could place a central line. (Hospital B's MD) reports he had called numerous hospitals for transfer. (Vital signs) 105 (heart rate) 122/62 (blood pressure) 24 (respiratory rate) 97% on 2L nc Worsening metabolic acidosis. Pt will need frequent gases. Serial VBG's will be needed. If intubated pt will need rates of 30's minute ventilation in the teens, TV 500. (Hospital B's MD) reports that the pt is stable for transport. (MD #14) would like flight for the pt. PLC to send a request to (Flight Transport). OSH to give bicarb, get an additional gas (MD #14) asks for encounter notes and images to be sent. Weight 65 kg (MD #17) agreed to bring this pt over now. Call ended @ 1915." Review revealed at 1920 " ...Flow charge, notified that (MD #14) would like to bring in pt to their open bed." At 1924 (Flight Transport) was notified of Patient #26's transfer information " ...Physicians requesting flight for (Patient #26). Will notify you guys when pt has a bed assignment ..." Review of MD #14's Progress note at 1953 revealed " ...Transfer Center Request Note ...57-year-old with DM, HTN, HL, smoking, COPD (Chronic Obstructive Pulmonary Disease), psych history. Recently getting work up for recurrent sinus and other infections with multiple antibiotic courses. Was in ok health until this morning when more confused leading to ED presentation. Initially answering appropriately, now waxing and waning. Icteric sclerae and non-tender belly. CXR (chest x-ray) negative small cholecystitis with fluid around it on CT scan; liver looks ok Salicylate and Tylenol level-neg, getting NAC per discussion with MD #13 Got lactulose Most Recent Vitals: BP 127/79, P115, 2L, Pertinent Labs: Significant lab abnormalities: -T bili 9.1 -AST 730, ALT 251, Alk 548, --normal in September -INR 3.8 -Ammonia 182 -BMP 138/4.7/99/10/21/2.3 -AG 20 -Lactic acidosis 15.3-20.4 but with very dark (chocolate?) blood so lab unsure if this real -Hgb 7.9, Hct 22.3, WBC 32.7 (58% poly, 7% bands, 30 lymphs) - CBC normal Jan 13 IV Access: PIV x 3 Airway/Vent: On 2L Infusions: Recommended starting bicarb infusion Plan Upon Arrival: -Call liver team -upload OSH imaging -CVC -assess if protecting airway and tiring out from respiratory compensation for metabolic acidosis -continue NAC -repeat lactic acidosis, coags Bed Type: ICU Accepting Service: MDI ..." At 2012 (4 hours and 7 minutes after the initial transfer request) PLC notes revealed " ...Bed assignment given to (Hospital B's Nurse) Pt assigned to bed 4313 in MICU ...RN Handoff Nurse report with (Hospital B's RN, Hospital A's RN, and Flight Transport Paramedic) All parties connected @ 2016 Pt. jaundiced. 3.5 L nc in place. Pt is not intubated. Husband at bedside. Pt does not follow commands. 116 HR Pt will not keep on pulse ox 137/70 BP 24-25 RR 98.7 temp Patient has 2 #20 gauge PIV's Foley in place. Husband's contact number given. No known source of liver failure. Per (Flight Transport Paramedic), there is no ETA at this time. (Flight Transport) to do a weather check and get back with nurses about transportation Call ended @ 2026." At 2029 PLC notes revealed "Spoke with (Flight Transport). PLC to cancel bed assignment for pt for now. Bed is needed for a patient in house." At 2040 PLC notes revealed "PLC called to notify OSH that we are canceling bed assignment for pt for now. Spoke with (Hospital B's RN), primary RN. (Hospital B's RN) to let the provider know about canceled bed." At 2247 PLC notes revealed "(MD #17) called and asked for the following: Please call (Hospital B) and let them know that it does not look like we will be able to facilitate a bed tonight. Ask them to do ABG and have provider call the PLC once the ABG is done to discuss." At 2248 PLC notes revealed "Spoke to (Hospital B's MD). Pt Was pronounced approx. 2 min prior to calling." At 2255 PLC notes revealed "Called (MD #17) and informed that the patient is deceased." Review revealed at 2256 the request was canceled due to "Patient expired."

Review of the on-call physician list for the Medical ICU on 02/07/2019 revealed MD #14 was on call for incoming transfers to the MICU.

Review of the incoming admissions and outgoing discharges from the MICU on 02/07/2019 revealed the patient in bed 4313 was transferred out of the MICU on 02/07/2019 at 1557 (greater than 4 hours before Patient #26 was assigned bed 4313 at 2012). Review revealed bed 4313 was empty until Patient #41 was transferred into it at 2056 on 02/07/2019.

Review of Hospital A's inpatient census for 02/07/2019 revealed no ICU beds except for one open bed in the Surgical ICU and no step-down beds open.

Review of the ED Hourly Census with the ED Director on 10/04/2019 at 0955 revealed 87 to 98 patients in the ED on 02/07/2019 between 1500 and 0000. Review revealed there were between 19 to 27 patients being boarded (waiting for inpatient beds) between 1500 to 0000 on 02/07/2019. Review revealed there were between 5 to 18 patients waiting in the lobby between 1500 and 0000 on 02/07/2019. Interview revealed the ED was over bed capacity but was not on diversion on 02/07/2019 between 1500 and 0000.

Interview with the PLC Manager #20 on 10/04/2019 at 1500 revealed Hospital A was not closed to outside transfers on 02/07/2019. Interview revealed Hospital A could be open to outside transfers but not be able to accept transfers of certain patients based on bed capacity.

Interview on 10/02/2019 at 0930 with MD #13 revealed she specialized in Transplant Hepatology. Interview revealed when the PLC received a call from an outside hospital to transfer a patient to Hospital A, for acute liver failure or acute on chronic liver failure the on-call liver attending was the first physician to be called, to determine if a patient was in acute liver failure. Interview revealed MD #13 was on-call 02/07/2019. Interview revealed MD #13 would decide if the incoming patient would be appropriate for transplant and would need to come to Hospital A. Interview revealed when MD #13 got the call about Patient #26 she looked in the medical record system to see if Patient #26 had been to Hospital A before. Interview revealed Patient #26 had been followed previously by ENT and ID. Interview revealed Hospital B's MD described Patient #26 as a patient who had normal liver function and now had coagulopathy, jaundice and encephalopathy. Interview revealed Patient #26 met criteria for acute liver failure and potentially needed a liver transplant. Interview revealed in conversation with Hospital B's MD, MD #13 "realized the patient was in a lot of trouble." Interview revealed Patient #26 was acidotic, "clearly needed ICU level care," and usually acute liver failure patients go to the MICU. Interview revealed MD #13 could not accept patients because Hepatology was a consulting service. Interview revealed the MICU intensivist would have to accept the patient. Interview revealed patients would normally go to the ER unless they needed ICU level of care. Interview revealed the PLC would coordinate with the on-call MICU intensivist about accepting the patient. Interview revealed MD #13 wrote a note about Patient #26 and put to notify hepatology when the patient arrived to (Hospital A).

Interview on 10/02/2019 at 1015 with Patient Access Coordinator (PAC) #21 revealed she worked in the PLC. Interview revealed PAC #21 took most of the calls for Patient #26's transfer from Hospital B. Interview revealed PAC #21 paged the on-call hepatologist when Hospital B first requested Patient #26 to be transferred because the patient had new onset hepatic encephalopathy. Interview revealed after the call was completed and MD #13 recommended ICU level care, PAC #21 paged the on-call medical intensivist, MD #14. Interview revealed if physicians did not call back after 15 minutes they were paged again. Interview revealed PAC #21 paged MD #14 again because he did not call back. Interview revealed if the physicians did not call back 15 minutes after the second page, PAC #21 could escalate the call to the secondary physician. Interview revealed PAC #21 did not escalate the call because sometimes the on-call medical intensivist was busy and could not be reached. Interview revealed PAC #21 then called MD #15, the ED physician to see if Patient #26 could be accepted to the ED. Interview revealed MD #15 declined Patient #26 due to capacity in the ED. Interview revealed PAC #21 paged MD #14 a third time and was able to connect MD #14 to Hospital B's MD at 1750. Interview revealed MD #14 accepted Patient #26. Interview revealed Patient #26 was then placed on a waiting list for the MICU. Interview revealed PAC #21 also notified the flow nurse who was the bed coordinator that Patient #26 was accepted for transfer. Interview revealed once an MICU bed was available the intensivist decides which patient from the accepted MICU waiting list comes first. Interview revealed MD #14 wanted Patient #26 to come over first when a bed was open. Interview revealed at 2039 the bed was canceled because a patient in house needed the MICU bed. PAC #21 stated Hospital B was notified that the bed was canceled. Interview revealed when a bed was canceled a patient would remain on the wait list. Interview revealed the PLC would not immediately look for other open ICU beds or ED beds unless the physician requested that. Interview revealed it was physician driven.

Interview on 10/03/2019 at 1130 with Flight Paramedic #24 revealed a weather check could take between 30 seconds to 15 minutes. Interview revealed the Flight Transport were notified of changes in transport by the PLC.

Interview on 10/02/2019 at 1125 with MD #15 revealed she was one of the ED physicians on 02/07/2019. Interview revealed she did not recall Patient #26 and Patient #26 was not accepted in the ED due to capacity. Interview revealed MD #15 decided about the ED's capacity based on if there were greater than 25 people in the waiting room, if beds were full in the ED and if there were admitted patients being held due to limited beds in Hospital A. Interview revealed there had been times when the ED would accept an incoming ICU transfer if an ICU bed would be available soon. Interview revealed MD #15 did not accept patients if there were no place for them to go. Interview revealed accepting an ICU level patient in the ED could take up multiple resources if the ED was already at capacity and the facility "can't accept everyone." Interview revealed it "takes a lot to turn a patient away."

Interview on 10/02/2019 at 1330 with MD #14 revealed he was the on-call MICU physician on 02/07/2019 for incoming transfers. Interview revealed when responding to pages from the PLC MD #14 responds "as timely as possible." Interview revealed regarding Patient #26, MD #14 was told she had been seen at Hospital A previously but not for anything complex. MD #14 was conferenced with the Hospital B's MD and told what had been going on clinically with Patient #26. Interview revealed MD #14 was the accepting physician for Patient #26. MD #14 would help with the management of Patient #26 while she was at the outside hospital and getting her to Hospital A. Interview revealed MD #14 also asked for imaging and notes to be sent to Hospital A. Interview revealed after accepting Patient #26 he told the MICU team and on-coming physician (MD #17) about Patient #26 and that he wanted her to come to the first open MICU bed. Interview revealed MD #14 thought Patient #26 was "extremely ill." Interview revealed MD #14 changed shifts at 1900 and MD #17 took over in the MICU. When asked if Patient #26 could go to a different ICU or the ED after the MICU bed was taken by an in-patient, MD #14 explained that it would be hard for Patient #26 to be in the ED because she was so sick and would take up so many resources, it would also be hard for Patient #26 to be boarded in a different ICU because of the distance from the MICU team and the comfort level of the nursing staff who were boarding the patient.

Interview on 10/03/2019 at 0930 with MD #17 revealed she was the 7pm-7am physician in the MICU on 02/07/2019. Interview revealed she was told about Patient #26 by MD #14. Interview revealed MD #17 canceled Patient #26's bed because it was needed for an inpatient in respiratory failure (Patient #41). Interview revealed MD #17 called the MICU charge nurse to notify her the bed was going to be used for an inpatient and the charge nurse would communicate that to the PLC. Interview revealed Patient #26 could possibly have gone to a different ICU but generally that did not happen because of the capacity of the provider team. Interview revealed MD #17 did not know the bed availability of the other ICUs at the time. Interview revealed Patient #26 could potentially have gone to the ED. Interview revealed if the transport for Patient #26 had been at Hospital B and picked up Patient #26, MD #17 explained they "would have figured something else out." Interview revealed since transport was not set up and had not picked up Patient #26 the bed was canceled. Interview revealed MD #17 requested the PLC to notify the outside hospital about the bed and to get an ABG on Patient #26 to help with the management of the patient.

In summary, a request was made by Hospital B to transfer Patient #26 to Hospital A on 02/07/2019 at 1605 and the on-call hepatologist (MD #13) was conferenced with Hospital B's MD at 1623. MD #13 recommended transfer and the intensivist was paged for transfer at 1642. MD #14 was paged two more times before returning the page at 1750 (1 hour and 8 minutes after the first page). MD #14 accepted Patient #26 to the MICU at 1807 and to take Patient #26 into the first available bed. Patient #26 was assigned a bed at 2012 and the previous patient who was in the bed Patient #26 was assigned had been transferred out of the MICU at 1557 (greater than 4 hours before Patient #26's bed assignment). At 2029 Patient #26's bed was canceled for an in-house patient. Hospital B was notified the bed assignment had been canceled at 2040 and at 2248 Hospital A was notified Patient #26 had expired.