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Based on medical record review, policy review, and staff interview, the hospital failed to follow the policies and procedures to ensure stabilizing treatment occurred within the hospital's capability for 1 of 30 sampled patient (Patient #11). The hospital had an average of 4,579 patients presenting to the emergency department (ED) requesting care monthly.

Failure to provide appropriate stabilizing treatment resulted in the patient's transfer to a hospital 130 miles away by ambulance and delayed the initial debridement of a patient's hand injury with fractures and an open wound contaminated with grass and gravel debris by several hours.

Finding include:

1. A review of Patient #11's medical record revealed the 10 year old patient arrived in the ED by private vehicle accompanied by his family on 8/16/13 at 8:32 PM. At that time, the initial triage nursing assessment by RN C revealed the patient presented to the ED for evaluation of a left hand injury. The patient sustained the injury when he rolled the go-cart he was riding about one hour earlier. The patient had a laceration and a crush injury of the left hand resulting from the accident. The patient reported the injury was painful but there was no radiation of pain. Patient #11 reported pain in the wrist, but denied pain in elbow or shoulder. The triage assessment revealed the patient did not hit his head during the go-cart accident and denied chest, abdominal, back and other extremity pain. The patient had no difficulty with vision or speech, no neck pain, and denied any numbness or tingling.

a. The ED Physician A documented the patient's Chief Complaint was the hand injury and that all systems reviewed were negative. The patient was alert. The physical exam of the left hand revealed decreased range of motion, tenderness, bony tenderness, deformity, laceration and swelling. The patient exhibited normal two-point discrimination and normal capillary refill with normal sensation and strength. The physician's documentation included further observations regarding slight angulation ulnarly (away from the thumb) of the left index finger and noted normal flexion and extension (movement) of all digits. The patient responded to light touch and had capillary refill of less than 2 second (normal) . The patient's radial and ulnar (at the wrist) pulses were intact. Bone was palpable within the wound, but that it was unclear whether there was communication with the bone. ED Physician A documented suspecting it was not. The laceration was examined with significant foreign debris present, extensive edema and soft tissue swelling with serosanguineous (thin yellow) drainage present.

b. The results of x-rays of Patient #11's left hand revealed fractures in the second and third metacarpal, extensive soft tissue air in the hand and over the wrist from soft tissue laceration/injury, and distal forearm lacerations. There was a distal ulnar greenstick fracture (near the wrist).
c. On 8/16/13 at 9:41 PM, ED Physician A documented the following in Patient #11's medical record. He still has movement of the fingers but is painful. Capillary refill is appropriate. He has good radial and ulnar pulses. He has a lot of air and probable hematoma (blood clot) based on the looks of the x-ray with just a small amount of debris in the wound. We discussed the case with the on-call Orthopedist Physician D and he is uncomfortable managing this because he is not a hand specialist. Requested that he evaluate the patient prior to transfer and he stated that he is unable to manage this wound and feels his evaluation is not warranted. ED Physician A documented I don't believe that he needs hand surgery emergently necessarily but he does need the wound washed out and the on-call orthopedic physician was uncomfortable doing that.

On 8/16/13 at 11:18 PM, the ED physician assistant PA-C B documented the following Assessment and Plan for Patient #11 in the medical record: Ulnar fracture, multiple fractures of metacarpal bones and hand laceration with contamination. Patient requires irrigation of the wound likely under general anesthesia. Fractures will be managed as well. We unfortunately do not have hand surgical coverage here in Cedar Rapids today. Spoke with the general orthopedist who felt this was outside of his scope of practice. I did have some concern about an EMTALA violation. The (on-call Orthopedist D) felt he did not need to evaluate the patient in the Emergency Department to come to the determination that this was outside his scope of practice. Attempted to find coverage for the patient in Iowa City. They have general orthopedics as well and also had no hand covered. We were ultimately able to get a (hand surgeon) in Des Moines at (Hospital B) who is happy to oblige us and the patient and manage the injuries. IV lock is established the patient kept n.p.o (nothing to eat or drink), given fentanyl (pain medication) for analgesic and Ancef (to prevent infection) started. Wound was dressed with a wet to dry bulky dressing and patient transferred by ambulance to Des Moines. Spoke with the higher ups in medical staff/hospital services as well about the case to ensure compliance was proper. Disposition: Transfer to Another Facility.


d. On 8/17/13 at 12:18 AM, the hospital transferred Patient #11 by ambulance to Hospital B in Des Moines according to the patient's medical record.

e. The funding source for Patient #11's care was listed as Medipass (a type of Medicaid insurance) according to the patient's medical record.


2. The hospital's policy titled Emergency Examination and Transfer Policy - EMTALA, effective 7/12 included the following relevant guidance for staff.

* On-Call Physician Responsibilities. The on-call physician must come to the SLH (St. Luke's Hospital) when requested by the ED physician, registered nurse, or any hospital staff making the request on behalf of a physician or registered nurse. (The words "must come" appeared in bold print on the policy.)

* The on-call physician must be physically present in the Emergency Department within a reasonable time of being requested.

* If requested, the on-call physician shall be physically present in the Emergency Department to assist in providing an appropriated medical screening examination, as well as in assisting in the ongoing stabilization and treatment of the individual prior to transfer or treatment. The on-call physician shall remain to assist in stabilization and treatment of the individual until released by the ED physician, another physician, or nurse practitioner.

* If the on-call physician disagrees about the need to come to the emergency Department, the on-call physician must come to the hospital and render care irrespective of the disagreement. The on-call physician may address the disagreement with his/her Chair/Director at a later time. (The words "must come" appeared in bold print on the policy.)

* The on-call physician shall not consider the patient's financial circumstances or the patient's insurance or means of payment in the decision to respond to, treat, or transfer the patient.

3. The following interviews were conducted during the investigation of this complaint.

a. During an interview on 8/21/13 at 3:30 PM, ED Physician A, stated PA-C B saw the patient first and ordered x-rays and antibiotics. The x-rays showed fractures and laceration. We could not clean out the laceration here due to the patient having open fractures and the potential for large amount of contamination in the wound and infection. The patient was a child and there was potential for extension of the open wound to the fractured bones. The patient had a lot of swelling. The child had underlying fractures, needed some debridement and had a large wound. It is was not included in the delineation of privileges (for On-Call Orthopedist D). It is a level of comfort to provide correct care by the physician. We consulted On-Call Orthopedist D but he is not a hand surgeon. We debated calling him. On-Call Orthopedist D was not comfortable handling this case. He said he was not comfortable handling this case but he reviewed the x-rays on computer (remotely). On-Call Orthopedist D said he was not comfortable with this injury and that we should send the patient somewhere else for care by a physician that is comfortable with this injury. The scope of privileges of a physician is determined by our credentials committee. We called Hospital C the ER staff reported this was a lateral transfer (same capability for providing care) and they did not have a hand surgeon on-call. The ED staff at Hospital C reported they did not know why On-Call Orthopedist D was not able to care for this patient. We decided to find a hand surgeon qualified for this case. We called Hospital B where Hand Surgeon E accepted the transfer. We transferred the patient to Hospital B by ambulance.

b. During an interview on 8/21/13 at 4:00 PM, PA-C B, reported the following. The patient came in with his hand wrapped up and was in a lot of pain. He had a lot of soft tissue swelling, an open wound with foreign material in the wound - between the thumb and finger. The x-rays showed he also had several fractures - second metatarsal, distal ulnar, PIP index finger disruption. The patient needed to have the wound evaluated and irrigated as it was contaminated. The patient had an open wound with underlying fractures and the only way to know for sure what was going on was to take the patient to surgery to clean and evaluate the wound to determine the extent of the injury. PA-C B reported ED Physician A evaluated the injury and agreed that the patient needed a transfer to a hospital with a higher level of care since On-Call Orthopedist D was not comfortable treating Patient #11.
PA-C reported calling On-Call Orthopedist D prior to completion of Patient #11's x-rays and the orthopedist stated he did not feel he could handle the patient's injuries but agreed to look at the x-rays. After reviewing Patient #11's x-rays electronically from a remote location and the orthopedist repeated he was not comfortable with treating the patient as it was beyond his scope of practice. ED staff decided to call other hospitals to locate a hand surgeon and subsequently transferred the patient to Hospital B where Hand Surgeon E was willing to accept the patient. PA-C B reported the patient was stable for the transfer by ambulance as the wound was wrapped, antibiotics and pain medications were given and the IV was in place. This was an emergent transfer due to the hand injury - fractures, increased potential for infection. The ED staff wanted the child to have the best chance to maintain the function of his hand after the injury and time was in the essence for transfer.

c. During an interview on 8/21/13 at 4:45 PM, On-Call Orthopedist D, Orthopedic Surgeon, reported the following information. PA-C B called him about the case so he did look at the x-rays. On-Call Orthopedist stated he was not a hand surgeon and did not do any hand surgeries. Although he had not examined the patient, he stated patient had several fractures - shattered bones and had open wound with gravel in it. PA-C B had explained how extensive the injuries were and treating these injuries was not in his scope of practice. On-Call Orthopedist D reported his training covered hand surgeries but it was not within the scope of his practice. He is a fellowship trained knee and shoulder surgeon. He stated: In reality they should not have called me, this is not within the scope of my practice. I evaluated the x-rays remotely on the computer but I don't have privileges for this type of injury.

The On-Call Orthopedist stated my obligation for orthopedic surgery on-call is that if I am called from ER, I discuss the case with the physician and then decide whether I need to come in and evaluate the patient or not. If the patient is not emergent, then I can see the patient in my office. If emergent, then I would come and see the patient if immediate intervention was required. I came in for another case on 8/16/13 and provided treatment for the other patient. Our group has 3 hand surgeons and 9 other orthopedic surgeons but no hand surgeon was on-call for the ED on 8/16/13.

d. During a second interview on 8/22/13 at 8:35 AM, ED Physician A who is also the ED Medical Director, stated the following when asked what is the difference between an orthopedic surgeon and a hand surgeon. A hand surgeon is a plastic surgeon or orthopedic surgeon with extra training and board certification to provide hand surgery care. Also orthopedic surgeon has training in residency but not the continuing education/training/certification for hands. This goes back to the level of comfort for the orthopedic surgeon and also for specific hand surgery procedures. On-Call Orthopedist D was contacted as a general consult for Patient #11. We did not know if this case required a higher level of care - it was not a formal consult for him to come in, just to see if he could manage this case. I have no idea if On-Call Orthopedist D is privileged for hand surgery. We did not have a hand surgeon on call that day, 8/16/13. If he would have come in and washed it out, he would not have been providing hand surgery. He was not comfortable to manage the wound care because if a complication arose, he could not manage it.

e. During a telephone interview on 8/21/13 at 8:29 AM, Hand Surgeon E, the accepting physician for Patient #11 at Hospital B reported the following information. He spoke with PA-C B on Friday, 8/16/13 at 10:30 PM, and PAC-C B described the injuries of Patient #11 and provided other information related to the care of the patient. The patient wrecked on a go cart going at a speed about 5 miles per hour. The injuries were isolated to the left hand and forearm but there was a contaminated wound with extensive laceration to the palm of the hand. The patient had intact circulation to all digits. The ED staff at Hospital A had contacted the on-call orthopedist and asked him to come in and wash and evaluate the wound but the on-call Orthopedist refused to come in and examine the patient.

Hand Surgeon E reported that the injuries of Patient #11 did not require a hand surgeon. They did not need a hand surgeon, they needed a qualified person to care for this hand injury. The treatment for this patient was to wash out the wound and close the skin laceration and splint the the fractures. There was no vascular involvement and [the fractures] did not need immediate attention. Patient #11 was taken to surgery and we washed out the wound, closed the laceration, and placed a splint on the hand and arm.

Based on medical record review, policy review, peer review and staff interview, the hospital failed to provide stabilizing treatment within the hospital's capability for 1 of 30 sampled patient (Patient #11). The hospital had an average of 4,579 patients presenting to the emergency department (ED) requesting care monthly.

Failure to provide appropriate stabilizing treatment resulted in the patient's transfer to a hospital 130 miles away by ambulance and delayed the initial debridement of a patient's hand injury with fractures and an open wound contaminated with grass and gravel debris by several hours.

Finding include:

1. A review of Patient #11's medical record revealed the 10 year old patient arrived in the ED by private vehicle accompanied by his family on 8/16/13 at 8:32 PM. At that time, the initial triage nursing assessment by RN C revealed the patient presented to the ED for evaluation of a left hand injury. The patient sustained the injury when he rolled the go-cart he was riding about one hour earlier. The patient had a laceration and a crush injury of the left hand resulting from the accident. The patient reported the injury was painful but there was no radiation of pain. Patient #11 reported pain in the wrist, but denied pain in elbow or shoulder. The triage assessment revealed the patient did not hit his head during the go-cart accident and denied chest, abdominal, back and other extremity pain. The patient had no difficulty with vision or speech, no neck pain, and denied any numbness or tingling.

a. The ED Physician A documented the patient's Chief Complaint was the hand injury and that all systems reviewed were negative. The patient was alert. The physical exam of the left hand revealed decreased range of motion, tenderness, bony tenderness, deformity, laceration and swelling. The patient exhibited normal two-point discrimination and normal capillary refill with normal sensation and strength. The physician's documentation included further observations regarding slight angulation ulnarly (away from the thumb) of the left index finger and noted normal flexion and extension (movement) of all digits. The patient responded to light touch and had capillary refill of less than 2 second (normal) . The patient's radial and ulnar (at the wrist) pulses were intact. Bone was palpable within the wound, but that it was unclear whether there was communication with the bone. ED Physician A documented suspecting it was not. The laceration was examined with significant foreign debris present, extensive edema and soft tissue swelling with serosanguineous (thin yellow) drainage present.

b. The results of x-rays of Patient #11's left hand revealed fractures in the second and third metacarpal, extensive soft tissue air in the hand and over the wrist from soft tissue laceration/injury, and distal forearm lacerations. There was a distal ulnar greenstick fracture (near the wrist). c. On 8/16/13 at 9:41 PM, ED Physician A documented the following in Patient #11's medical record. He still has movement of the fingers but is painful. Capillary refill is appropriate. He has good radial and ulnar pulses. He has a lot of air and probable hematoma (blood clot) based on the looks of the x-ray with just a small amount of debris in the wound. We discussed the case with the on-call Orthopedist Physician D and he is uncomfortable managing this because he is not a hand specialist. Requested that he evaluate the patient prior to transfer and he stated that he is unable to manage this wound and feels his evaluation is not warranted. ED Physician A documented I don't believe that he needs hand surgery emergently necessarily but he does need the wound washed out and the on-call orthopedic physician was uncomfortable doing that.

On 8/16/13 at 11:18 PM, the ED physician assistant PA-C B documented the following Assessment and Plan for Patient #11 in the medical record: Ulnar fracture, multiple fractures of metacarpal bones, and hand laceration with contamination. Patient requires irrigation of the wound likely under general anesthesia. Fractures will be managed as well. We unfortunately do not have hand surgical coverage here in Cedar Rapids today. Spoke with the general orthopedist who felt this was outside of his scope of practice. I did have some concern about an EMTALA violation. The (on-call Orthopedist D) felt he did not need to evaluate the patient in the Emergency Department to come to the determination that this was outside his scope of practice. Attempted to find coverage for the patient in Iowa City. They have general orthopedics as well and also had no hand covered. We were ultimately able to get a (hand surgeon) in Des Moines at (Hospital B) who is happy to oblige us and the patient and manage the injuries. IV lock is established the patient kept n.p.o (nothing to eat or drink), given fentanyl (pain medication) for analgesic and Ancef (to prevent infection) started. Wound was dressed with a wet to dry bulky dressing and patient transferred by ambulance to Des Moines. Spoke with the higher ups in medical staff/hospital services as well about the case to ensure compliance was proper. Disposition: Transfer to Another Facility.


d. On 8/17/13 at 12:18 AM, the hospital transferred Patient #11 by ambulance to Hospital B in Des Moines according to the patient's medical record.

e. The funding source for Patient #11's care was listed as Medipass (a type of Medicaid insurance) according to the patient's medical record.


2. The hospital's policy titled Emergency Examination and Transfer Policy - EMTALA, effective 7/12 included the following relevant guidance for staff.

* On-Call Physician Responsibilities. The on-call physician must come to the SLH (St. Luke's Hospital) when requested by the ED physician, registered nurse, or any hospital staff making the request on behalf of a physician or registered nurse. (The words "must come" appeared in bold print on the policy.)

* The on-call physician must be physically present in the Emergency Department within a reasonable time of being requested.

* If requested, the on-call physician shall be physically present in the Emergency Department to assist in providing an appropriated medical screening examination, as well as in assisting in the ongoing stabilization and treatment of the individual prior to transfer or treatment. The on-call physician shall remain to assist in stabilization and treatment of the individual until released by the ED physician, another physician, or nurse practitioner.

* If the on-call physician disagrees about the need to come to the emergency Department, the on-call physician must come to the hospital and render care irrespective of the disagreement. The on-call physician may address the disagreement with his/her Chair/Director at a later time. (The words "must come" appeared in bold print on the policy.)

* The on-call physician shall not consider the patient's financial circumstances or the patient's insurance or means of payment in the decision to respond to, treat, or transfer the patient.

3. The following interviews were conducted during the investigation of this complaint.

a. During an interview on 8/21/13 at 3:30 PM, ED Physician A, stated PA-C B saw the patient first and ordered x-rays and antibiotics. The x-rays showed fractures and laceration. We could not clean out the laceration here due to the patient having open fractures and the potential for large amount of contamination in the wound and infection. The patient was a child and there was potential for extension of the open wound to the fractured bones. The patient had a lot of swelling. The child had underlying fractures, needed some debridement and had a large wound. It is was not included in the delineation of privileges (for On-Call Orthopedist D). It is a level of comfort to provide correct care by the physician. We consulted On-Call Orthopedist D but he is not a hand surgeon. We debated calling him. On-Call Orthopedist D was not comfortable handling this case. He said he was not comfortable handling this case but he reviewed the x-rays on computer (remotely). On-Call Orthopedist D said he was not comfortable with this injury and that we should send the patient somewhere else for care by a physician that is comfortable with this injury. The scope of privileges of a physician is determined by our credentials committee. We called Hospital C the ER staff reported this was a lateral transfer (same capability for care) and they did not have a hand surgeon on-call. The ED staff at Hospital C reported they did not know why On-Call Orthopedist D was not able to care for this patient. We decided to find a hand surgeon qualified for this case. We called Hospital B where Hand Surgeon E accepted the transfer. We transferred the patient to Hospital B by ambulance.

b. During an interview on 8/21/13 at 4:00 PM, PA-C B, reported the following. The patient came in with his hand wrapped up and was in a lot of pain. He had a lot of soft tissue swelling, an open wound with foreign material in the wound - between the thumb and finger. The x-rays showed he also had several fractures - second metatarsal, distal ulnar, PIP index finger disruption. The patient needed to have the wound evaluated and irrigated as it was contaminated. The patient had an open wound with underlying fractures and the only way to know for sure what was going on was to take the patient to surgery to clean and evaluate the wound to determine the extent of the injury. PA-C B reported ED Physician A evaluated the injury and agreed that the patient needed a transfer to a hospital with a higher level of care since On-Call Orthopedist D was not comfortable treating Patient #11.
PA-C reported calling On-Call Orthopedist D prior to completion of Patient #11's x-rays and the orthopedist stated he did not feel he could handle the patient's injuries but agreed to look at the x-rays. After reviewing Patient #11's x-rays electronically from a remote location and the orthopedist repeated he was not comfortable with treating the patient as it was beyond his scope of practice. ED staff decided to call other hospitals to locate a hand surgeon and subsequently transferred the patient to Hospital B where Hand Surgeon E was willing to accept the patient. PA-C B reported the patient was stable for the transfer by ambulance as the wound was wrapped, antibiotics and pain medications were given and the IV was in place. This was an emergent transfer due to the hand injury - fractures, increased potential for infection. The ED staff wanted the child to have the best chance to maintain the function of his hand after the injury and time was in the essence for transfer.

c. During an interview on 8/21/13 at 4:45 PM, On-Call Orthopedist D, Orthopedic Surgeon, reported the following information. PA-C B called him about the case so he did look at the x-rays. On-Call Orthopedist stated he was not a hand surgeon and did not do any hand surgeries. Although he had not examined the patient, he stated patient had several fractures - shattered bones and had open wound with gravel in it. PA-C B had explained how extensive the injuries were and treating these injuries was not in his scope of practice. On-Call Orthopedist D reported his training covered hand surgeries but it was not within the scope of his practice. He is a fellowship trained knee and shoulder surgeon. He stated: In reality they should not have called me, this is not within the scope of my practice. I evaluated the x-rays remotely on the computer but I don't have privileges for this type of injury.

The On-Call Orthopedist stated my obligation for orthopedic surgery on-call is that if I am called from ER, I discuss the case with the physician and then decide whether I need to come in and evaluate the patient or not. If the patient is not emergent, then I can see the patient in my office. If emergent, then I would come and see the patient if immediate intervention was required. I came in for another case on 8/16/13 and provided treatment for the other patient. Our group has 3 hand surgeons and 9 other orthopedic surgeons but no hand surgeon was on-call for the ED on 8/16/13.

Review of Orthopedist D's Delineation of Hospital Privileges, dated 9/7/12, revealed his privileges included closed and open fracture reduction, upper extremity casting, strapping and splinting, incision and drainage of bone, tendon, muscle and joints ant tissue repair of tendon, muscle, skin and vascular (blood vessels). The privileges did not include hand surgery.

d. During a second interview on 8/22/13 at 8:35 AM, ED Physician A who is also the ED Medical Director, stated the following when asked what is the difference between an orthopedic surgeon and a hand surgeon. A hand surgeon is a plastic surgeon or orthopedic surgeon with extra training and board certification to provide hand surgery care. Also orthopedic surgeon has training in residency but not the continuing education/training/certification for hands. This goes back to the level of comfort for the orthopedic surgeon and also for specific hand surgery procedures. On-Call Orthopedist D was contacted as a general consult for Patient #11. We did not know if this case required a higher level of care - it was not a formal consult for him to come in, just to see if he could manage this case. I have no idea if On-Call Orthopedist D is privileged for hand surgery. We did not have a hand surgeon on call that day, 8/16/13. If he would have come in and washed it out, he would not have been providing hand surgery. He was not comfortable to manage the wound care because if a complication arose, he could not manage it.

e. During a telephone interview on 8/21/13 at 8:29 AM, Hand Surgeon E, the accepting physician for Patient #11 at Hospital B reported the following information. He spoke with PA-C B on Friday, 8/16/13 at 10:30 PM, and PAC-C B described the injuries of Patient #11 and provided other information related to the care of the patient. The patient wrecked on a go cart going at a speed about 5 miles per hour. The injuries were isolated to the left hand and forearm but there was a contaminated wound with extensive laceration to the palm of the hand. The patient had intact circulation to all digits. The ED staff at Hospital A had contacted the on-call orthopedist and asked him to come in and wash and evaluate the wound but the on-call Orthopedist refused to come in and examine the patient.

Hand Surgeon E reported that the injuries of Patient #11 did not require a hand surgeon. They did not need a hand surgeon, they asked needed a qualified person to care for this hand injury. The treatment for this patient was to wash out the wound and close the skin laceration and splint the the fractures. There was no vascular involvement and [the fractures] did not need immediate attention. Patient #11 was taken to surgery and we washed out the wound, closed the laceration, and placed a splint on the hand and arm.

4. Review of the State Quality Improvement Organization peer review, dated 9/2/2013, revealed the hospital provided the individual a medical screening examination and determined an emergency medical condition. The peer review identified the emergency medical condition as a laceration of the left hand with contamination and hand and wrist fractures. Further, the hospital was capable of providing orthopedic care to debride the wound and treat the fractures. The hospital had the specialized facilities and staff this patient needed but the on-call orthopedist declined to come to the hospital to evaluate and debride the wounds and splint the fractures. This refusal resulted in the hospital transferring the patient 130 miles for care.