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Based on record review and staff interview, one of one applicable Patient's (#1) was not provided with the opportunity for prompt intubation and airway support management while in the Intensive Care Unit (ICU). Instead, the ICU staff called the operating room for Anesthesiologist #1 who was not immediately available.

The findings are as follow:

Patient #1, a young adult, was evaluated in the Emergency Department (ED) for shortness of breath.

Review of the ED Record dated 01/31/11 at 10:30 AM indicated ED Attending Physician #1 documented Patient #1 had been briefly hospitalized the previous year of asthma at another facility. Patient #1 was awake on arrival, anxious and unable to speak secondary to respiratory distress. ED Attending Physician #1 indicated Patient #1 was unable to provide a medical history secondary to respiratory difficulty. Patient #1 had decreased breath sounds at both bases and was positive for wheezing both anterior and posterior on inspiration and expiration. ED Attending Physician #1 indicated symptoms had occurred within hours and were severe Patient #1's vital signs were recorded as a temperature of 98 degrees Fahrenheit, blood pressure 170/94, heart rate 162 to 177 beats per minute, respirations 35 breaths per minute with an oxygen saturation level of 85%. Patient #1's initial arterial blood gases (ABG's) were recorded as a pH of 7.36, a low PO2 76, and PCO2 40.

ED Attending Physician #1 was interviewed in person on 02/09/11 at 1:40 PM. ED Attending Physician #1 said Patient #1 was very ill and required whatever we needed to do to improve Patient #1's breathing. Pulmonologist/Hospitalist #1 was consulted and evaluated Patient #1 while Patient #1 was in the ED. ED Attending Physician #1 said Patient #1 did not have an impressive infiltrate. ED Attending Physician #1 said Patient #1 was administered continuous nebulizers (DuoNeb and Albuterol) via a facial mask, intravenous steroids (SoluMedrol), Magnesium and antibiotics Rocephin and Azithromax). Patient #1 was not able to tolerate continuous positive pressure airway pressure (CPAP)as a respiratory treatment. ED Attending Physician #1 said Patient #1 improved at the time of transfer into ICU.

Review of the Respiratory Care Treatment Flow Sheets between 10:35 AM and 11:25 AM while Patient #1 was in the ED indicated Patient #1's vital signs both before and after nebulizer treatment were recorded as a heart rate of 160 to 179 beats per minute, with a pulse oxymetry of 93% to 94%. Respiratory Therapist #1 indicated Patient #1's lung sounds were tight. Between 11:10 AM to 11:25 AM, Respiratory Therapist #1 indicated Patient #1 improved following the nebulizer treatments.However, Patient #1's respiratory rate increased to 42 to 44 breaths per minute. There was no further documentation by Respiratory Therapist #1 after 11:25 AM.

Respiratory Therapist #1 was interviewed in person on 02/10/11. Respiratory Therapist #1 said Patient #1 had shortness of breath, a rapid heart rate and lung sounds were very wheezy. Respiratory Therapist #1 said Respiratory Therapist #2 assumed the care of Patient #1.

Continued review of the ED record dated 01/31/11 at 12 PM indicated Patient #1' temperature was 102.4 degrees Fahrenheit, blood pressure 128/59, heart rate 172 beats per minute and respirations 38 breaths per minute. Patient #1 remained on 55% Vente Mask at 6 liters per minute with an oxygen saturation level of 91%.

Review of Patient #1's ABG's taken at 1:15 PM in the ED by Respiratory Therapist #2 recorded the results as a low pH of 7.24, low P02 of 77, elevated PC02 53 (from 40 done at 10:35 AM) and oxygen saturation level of 92% on 55% Vente mask and 6 liters of oxygen by nasal cannula. Respiratory Therapist #2 notified Pulmonologist #1.

Patient #1 was admitted to ICU at 1:30 PM.
Review of the ICU Patient Notes indicated Patient #1 barely able to stand or sit on the bed. Patient #1's respiratory rate was between 34 to 40 breaths per minute with an oxygen saturation level 90%. Patient #1 using accessory muscles and was unable to talk. Respiratory Therapist #2 called for a nebulizer treatment. At 2 PM, Patient #1 continues to work to breathe, Pulmonologist #1 at the bedside. Registered Nurse #3 documented Patient #1 was unable to comprehend teaching secondary to extreme shortness of breath.

Documentation indicated att 2:10 PM, a nebulizer (Albuterol) treatment was administered. Patient #1's vital signs post treatment were recorded as a blood pressure 162/82, heart rate 162 beats per minute with respiratory rate of 36 breaths per minute with a 93%-91% oxygen saturation level. Respiratory Therapist #2 documented Patient #1 was improved after treatment.

Documentation indicated at 3:10 PM, by Pulmonologist #1 in a progress note indicated Patient #1 had status asmaticus with failed CPAP. Pulmonologist #1 indicated Patient #1 did not require mechanical ventilation at this time.

Review of the ICU Patient Notes indicated at 4 PM Patient #1 continued to work (to breathe). Patient #1's respiratory rate was 34 to 39 breaths per minute with an oxygen saturation level of 91%.

Review of the Respiratory Therapist #2 electronic Progress Note at 4:45 PM indicated Patient #1's vital signs were recorded as a blood pressure 154/69, heart rate 143 beats per minute and respirations 39 breaths per minute with an oxygen saturation level of 94%. Patient #1 remained on 55% Vente Mask with 6 liters of oxygen via nasal cannula.

Continued review of the ICU Patient Notes at 5 PM indicated Patient #1's condition not improving. Registered Nurse #3 said Pulmonologist #1 decided Patient #1 needed to be intubated. Registered Nurse #3 indicated an anesthesiologist would intubate Patient #1at the completion of a surgical case in the operating room.

There was no documentation of further contact with a physician.

Respiratory Therapist #2 documented in a late entry at 5 PM and 6 PM nebulizer treatments were administered to Patient #1. Patient #1's respiratory rate was 36 to 44 breaths per minute and oxygen saturation levels ranged between 90 to 92%. At approximately 6:10 PM, Patient #1 was changed to a non-rebreather mask and 6 liters of nasal cannula with a oxygen saturation level documented as 97%.

There was no documentation Pulmonologist #1 re-evaluated Patient #1 between 3:10 PM and 6:20 PM.

Pulmonologist #1 was interviewed in person on 02/09/11 at 9:50 Am. Pulmonologist #1 evaluated Patient #1 in the ED. Pulmonologist #1 said Patient #1 had a rapid heart rate of 170's to 180's and a low oxygen saturation level in the mid 90's. Pulmonologist #1 said Patient #1 was alert and conscious however not able to speak. Pulmonologist #! said Patient #1' ABG's had a low oxygen level and oxygen delivery was changed to a non-rebreather mask. Pulmonologist #! said Patient #1 improved and did not need to be intubated. Pulmonologist #1 said intubating Patient #1 would have placed the patient at risk for pneumonia. Pulmonologist #1 said Patient #1's lungs looked fairly good. Pulmonologist #1 said Patient #1 declined around 4 PM. Pulmonologist #1 said it was determined Patient #1 would have an elective intubation but it was not urgent. Pulmonologist #1 decided not to intubate Patient #1 because of a narrow throat and short tongue. There was no documentation of the Patient's oral cavity nor decision not to intubate. Pulmonologist #1 referred Patient #1 to anesthesia for intubation. Pulmonologist #1 said Anesthesiologist #1 came to the ICU and decided to transfer Patient #! into the operating room. Pulmonologist #1 said the OR was a more controlled environment and the intubation was not urgent. Pulmonologist #1 said Patient #1's oxygen saturation level was 97%. Pulmonologist #1 went to the operating room and assisted Anesthesiologist #1. Pulmonologist #1 said Anesthesiologist #! had no problem passing the endotracheal tube. Pulmonologist #1 said Patient #1 had inflamed airways and a lot of swelling with thick mucus. Pulmonologist #1 passed a bronchoscope. Pulmonologist #1 said Patient #1 started destating (dropping oxygen levels) and a code was called and despite a lengthy code Patient #1 expired.

Continued review of Patient #1's medical record indicated Anesthesiologist #1 examined Patient #1 on 01/31/11 at 6:20 PM. Anesthesiologist #1 arrived in ICU to assist with an urgent intubation of Patient #1 who was in acute respiratory distress. Anesthesiologist #1 indicated Patient #1's oxygen saturation levels on room air were recorded as 84% with a respiratory rate of 40's. Anesthesiologist #1 indicated Patient #1's tongue was swollen and Patient could not talk. Anesthesiologist #1 indicated Patient #1 was a Mallampati 4 (a nonvisual airway and difficult to intubate). At 6:40 PM, Anesthesiologist #1 indicated Patient needed to be taken to the operating room for an emergency airway.

Anesthesiologist #1 was interviewed in person on 02/09/11 at 12 PM. Anesthesiologist #2 was scheduled for elective cases until the evening of 01/31/11. Anesthesiologist #1 was called by RN #3 regarding Patient #1who needed an airway. Anesthesiologist #1 said the surgical cases were elective and if it had been known that the need to intubate was emergent the last case in the operating room could have been cancelled. Anesthesiologist #1 said after arrival into the ICU, Patient #1 was breathing at a rate of 40 to 60 breaths per minute with tight wheezes and oxygen saturation levels ranging 83 to 86%. The operating room was ordered be set up immediately. Anesthesiologist #1 said Patient #1 needed to be taken to the OR because of the anesthesia equipment and skilled staff available in the operating room. Anesthesiologist #1 said Pulmonologist #1 was in the ICU and later came to assist in the operating room. Anesthesiologist #1 said Patient #1 was at the point of not being able to breathe. Anesthesiologist #1 said the intubation was successful on the first attempt however, Patient #1' lungs prohibited any pressure applied to Ambu/aerate the lungs. Anesthesiologist #1 said despite the resuscitative efforts the Patient expired.

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Based on record review and staff interview, one of one applicable Patient's (#1) was not provided with the opportunity for prompt intubation and airway support management while in the Intensive Care Unit (ICU). Instead, the ICU staff called the operating room for Anesthesiologist #1 who was not immediately available.

The findings are as follow:

Refer to A-Tag 144.

The President of the Medical Staff was interviewed in person on 02/10/11 at 9 AM. The President of the Medical Staff said Patient #1 should havebeen intubated when the second set of ABG's were drawn at 1:15 PM. The President of the Medical Staff said neither the ED Physician or the Pulmonologist had been interviewed. The President of the Medical Staff said an ED Physician should have been called to intubate Patient #1, if the anesthesiologist was not available.

There was no documented evidence the Hospital had addressed the concerns regarding the medical management and lack at attempt of intubation for Patient #1 in the QA/PI Program.

Based on record review, physician and staff interview, Pulmonologist #1, Registered Nurse #3 and Respiratory Therapist #2 failed to adequately document Patient #1' change in medical condition and response to treatment in January 2011.

The findings are as follow:

Registered Nurse #3 documented on 01/31/11 at 5 PM Patient #1's condition was not improving. Registered Nurse #3 called Pulmonologist #1 who reported Patient #1 needed to be intubated.

Patient #1's medical record lacked a physician's assessment at the time of the Patient #1's change in condition. There was no documentation by Pulmonologist #1 that intubation was to be deferred to an anesthesiologist or the reasons why the physician chose to defer the care of Patient #1 to the anesthesiologist.

Pulmonologist #1 was interviewed in person on 02/09/11 at 9:50 Am. Pulmonologist #1 evaluated Patient #1 in the ED. Pulmonologist #1 said Patient #1 had a rapid heart rate of 170's to 180's and a low oxygen saturation level in the mid 90's. Pulmonologist #1 said Patient #1 was alert and conscious however not able to speak. Pulmonologist #1 said Patient #1' ABG's had a low oxygen level and changed to a non-rebreather mask. Pulmonologist #1 said Patient #1 improved and did not need to be intubated. Pulmonologist #1 said intubating Patient #1 would have placed the patient at risk for pneumonia. Pulmonologist #1 said Patient #1's lungs looked fairly good. Pulmonologist #1 said Patient #1 declined around 4 PM and the heart rate raised. Pulmonologist #1 said it was determined Patient #1 would have an elective intubation but it was not urgent. Pulmonologist #1 decided not to intubate Patient #1 because of a narrow throat and short tongue. There was no documentation of the Patient's oral cavity nor decision not to intubate. Pulmonologist #1 referred Patient #1 to anesthesia for intubation. Pulmonologist #1 said Anesthesiologist #1 came to the ICU and decided to transfer Patient #1 into the operating room. Pulmonologist #1 said the OR was a more controlled environment and the intubation was not urgent. Pulmonologist #1 said Patient #1's oxygen saturation level was 97%. Pulmonologist #1 went to the operating room and assisted Anesthesiologist #1. Pulmonologist #1 said Anesthesiologist #! had no problem passing the endotracheal tube. Pulmonologist #1 said Patient #1 had inflamed airways and a lot
of swelling with thick mucus. Pulmonologist #1 passed a bronchoscope. Pulmonologist #1 said Patient #1 started destating (dropping oxygen levels) and a code was called and despite a lengthy code Patient #1 expired.

Continued review of Patient #1's medical record indicated Anesthesiologist #1 examined Patient #1 on 01/31/11 at 6:20 PM. Anesthesiologist #1 arrived in ICU to assist with an urgent intubation of Patient #1 who was in acute respiratory distress. Anesthesiologist #1 indicated Patient #1's oxygen saturation levels on room air were recorded as 84% on room air and a respiratory rate of 40's. Anesthesiologist #1 indicated Patient #1's tongue was swollen and Patient could not talk. Anesthesiologist #1 indicated Patient #1 was a Mallampati 4 (a nonvisual airway and difficult to intubate. At 6:40 PM, Anesthesiologist #1 indicated Patient needed to be taken to the operating room as an emergency airway case

Anesthesiologist #1 was interviewed in person on 02/09/11 at 12 PM. Anesthesiologist #1 was scheduled for elective surgical cases until the evening of 01/31/11. Anesthesiologist #1 was called by RN #3 regarding a Patient(#1 who needed an airway. Anesthesiologist #1 said the cases were elective and if it had been known that the need to intubate Patient #1 was emergent, the last case in the operating room could have been cancelled.. Anesthesiologist #1 said after arrival into the ICU, Patient #1 was breathing at a rate of 40 to 60 breaths per minute with tight wheezes and oxygen saturation levels ranging 83 to 86%. The operating room was ordered to be set up immediately. Anesthesiologist #1 said Patient #1 needed to be taken to the OR because of the anesthesia equipment and skilled staff available in the operating room. Anesthesiologist #1 said Pulmonologist #1 was in the ICU and later came to assist in the operating room. Anesthesiologist #1 said Patient #1 was at the point of not being able to breathe. Anesthesiologist #1 said the intubation was successful on the first attempt however, Patient #1' lungs prohibited any pressure applied to Ambu/aerate the lungs Anesthesiologist #1 said despite the resuscitative efforts the Patient expired.

Between the hours of 4 PM to 6:20 PM, there was no documentation for Patient #1's response to treatment by either nursing or respiratory services.

Based on medical record review, physician and staff interview, Patient #1' emergent intubation was unnecessarily delayed because the anesthesiologist was in the operating room.

Refer to A- Tag 144.

The findings are as follow:

Patient #1, a non-surgical patient required emergent intubation while in the Intensive Care Unit.. Instead Patient #1 was brought into the operating room for intubation.

Registered Nurse #3 documented and said Anesthesiologist #1 was in the operating room with a patient and would arrive at the completion of the surgical case.

There were no other emergent provisions made to ensure Patient #1 was intubated in a timely manner. Instead, Between 4 PM and 6:20 PM, Patient #1' condition changed and there was no documentation Patient #1 was evaluated by a physician.

Anesthesiologist #1 was interviewed in person on 02/09/11 at 12 PM. Anesthesiologist #2 was scheduled for elective surgical cases until the evening of 01/31/11. Anesthesiologist #1 was called by RN #3 regarding Patient #1 who needed an airway. Anesthesiologist #1 said the surgical cases were elective and if it had been known that the need to intubate Patient #1 was emergent the last surgical case in the operating room could have been cancelled. Anesthesiologist #1 said after arrival into the ICU, Patient #1 was breathing at a rate of 40 to 60 breaths per minute with tight wheezes and oxygen saturation levels ranging 83 to 86%.The operating room was ordered to be set up immediately. Anesthesiologist #1 said Patient #1 needed to be taken to the OR because of the anesthesia equipment and skilled staff available in the operating room. Anesthesiologist #1 said Pulmonologist #1 was in the ICU and later came to assist in the operating room. Anesthesiologist #1 said Patient #1 was at the point of not being able to breathe. Anesthesiologist #1 said the intubation was successful on the first attempt however, Patient #1' lungs prohibited any pressure applied to Ambu/aerate the lungs Anesthesiologist #1 said despite the resuscitative efforts the Patient expired.

There was an unnecessary delay in Patient #1's intubation because there were no emergent provisions implemented for the lack of availability of the anesthesiologist who was in the operating room.