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SAN JOAQUIN GENERAL HOSPITAL 500 W HOSPITAL ROAD FRENCH CAMP, CA 95231 May 9, 2016
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on staff interviews and facility document and record reviews, the General Acute Care Hospital (GACH) failed to ensure that an on-call physician, an obstetrician/ gynecologist (MD 1), responded to the Emergency Department (ED) to address the needs of a critically ill patient (Patient A) in severe septic shock in a reasonable amount of time on 8/11/14.

The failure of the on call physician consultant to respond to Patient 1's Emergent Medical Condition for four hours, forty five minutes may have contributed to the death of Patient A.

Findings:

Patient A was admitted on [DATE], two days after an uncomplicated birth at the GACH with complaints of vaginal bleeding, nausea, vomiting and loss of vision. A document reviewed titled Initial Nursing Assessment noted Patient A's admission vital signs, taken at 12:51 p.m., were: blood pressure (bp): 81/56 (norm is 100/60 to 140/90), pulse (p): 110 (norm is 60-100), temperature (t): 36.6 centigrade (97.8 F), and respirations: 18 (12-20 is norm). This document also identified that Patient A had a pale appearance and was lethargic (sluggish).

Patient A was seen by a Physician's Assistant (PA 1) (trained to practice medicine on a team under the supervision of physicians and surgeons) at 1:10 p.m. PA 1 documented on the ED Chart that Patient A said she had vaginal bleeding, "a lot" since 5 a.m., soaking 4 pads in an hour and also complained about a foul odor.

PA 1 ordered a blood test and the results were returned at 1:30 p.m. The result was that the White Blood Cells (WBCs) were at 41.5, a very high result indicating an infectious process (normal range is 4.5 -11.0). The diagnoses documented by PA 1 on the document titled Emergency Department Chart, page 2 were 1. Septic Shock, 2. DIC (a serious coagulation conditon in which blood clots form in small blood vessels), 3.Endometritis (ionflammatory conditon of the lining of the uterus), 4. Retained products of conception. The start time on this document was 1:10 p.m. PA 1 documented a call for an OB Gyn consult to MD 1 at 2:50 p.m. MD 1 called back at 3 p.m. and had PA 1 repeat the blood tests and ordered an ultrasound to be done of the pelvis of Patient A. The second blood test, completed at 5 p.m., showed that the WBC count was then 52.5. PA 1 documented another call to MD 1 at 6 p.m., but there was no response time noted on the record and MD 1 did not come to the ED to see Patient A. An ED Nursing Progress Note at 4:35 p.m. documented Patient A's blood pressure as 84/55 and the pulse was 98. At 6 p.m. the nurse documented that Patient A was waiting for the OB consult. At this time there had been a 3 hour plus time lapse from the first call PA 1 made requesting a consult.

At 7: 30 p.m. nursing documentation indicated that an ED MD was at the bedside to examine the patient. The OB Gyn consultant had still not inquired about or seen Patient 1. At that time Patient A's blood pressure was 87/systolic and heart rate was 130 (normal range is 60-100). At 7:35 p.m. MD 1 was documented as being at the bedside to see Patient A for the first time (four and three quarters hours after consult request).

On 5/7/15 at 12:45 p.m. an interview was conducted with the ED Manager (EDM) regarding expected response times for MDs called for consultation in the ED. The EDM stated she would expect a response time of 15- 30 minutes for a physician to physician discussion or an actual patient visit.

On 5/21/15, at 2:03 p.m., the Medical Director of the ED was interviewed by phone. When asked about the expected response time to a call from the ED he said "I think the Hospital bylaws have a 30 minute standard."

On 5/14/15 at 8:05 a.m. a phone interview was conducted with the MD 1. MD 1 said the "ED response time depends on what is needed, a phone consult for advice versus an actual patient visit, "I can't really generalize a time". MD 1 acknowledged if it was urgent he could be there in minutes as" OB is right above the ED". When asked about the documented request to the call regarding Patient A, with the initial WBC count so high, why he did not see the patient? MD stated he wanted to repeat the WBC's. MD 1 acknowledged the "ED called back about 4 hours later. Got the Ultrasound and WBC and the D&C (a surgical procedure to clean out the uterus) was done about 4-5 hours after admission."

On 5/14/15, at 3:10 p.m., a phone interview was conducted with the PA. The PA stated that with Patient A's blood pressure being low and her pulse being high she was concerned about getting fluids into the patient then doing the physical exam and possibly utilizing antibiotics. The PA said she conferred with the ED MD and after getting the initial blood work back with the high WBCs she paged MD 1 at 2:50 p.m. The PA informed the OB about getting fluids into the patient and "he wanted to know about the band count" (bands are immature WBC's count and can indicate impending infection. Norm is 0-5, Patient A's bands were 13 on the first count at 1:30 p.m. and 9 on the second count at 5 p.m.). The PA stated she did not recall what the MD 1's issues were with the white count and why he wanted it to be redone, "He [MD 1] didn't want to admit her to the hospital until the band count was rechecked."

When the PA was asked about how long it was between the first contact with the OB and when he came to see the patient she stated "hours." The PA further stated "after the initial contact and care went on I tried to page him (MD 1) again, more than 3 times without a response. I waited about 10-15 minutes between pages. Generally we wait about 15 minutes for a call back."

In review of the Medical Staff Bylaws, Rules and Regulations, dated 3/12/13, there was no reference to the use of or roles of on call physicians who are used for consults. There was no definition of what a reasonable amount of time for response would be.

The Deputy Director of Standards and Compliance (DDSC), in an interview on 5/7/15 at 10 a.m., acknowledged a facility investigation had been conducted and there were needs identified to address the on call physician response time to an Emergent Medical Condition.

The DDSC, in an interview on 6/9/15, stated there were no policies and procedures written to define the responsibilities of the on call physician to respond, examine and treat patients with an Emergency Medical Condition.