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ST. VINCENT'S MEDICAL CENTER 2800 MAIN ST BRIDGEPORT, CT 06606 May 8, 2018
VIOLATION: ON CALL PHYSICIANS Tag No: A2404
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on a review of clinical records, interviews and policy review, for one (1) of twenty (20) records reviewed for emergency room care and services (Patient #1), the hospital failed to ensure that the on-call hand surgeon evaluated the patient when s/he presented to the ED with a left traumatic 3rd digit amputation through the middle phalanx and concomitant injuries to the 2nd and 4th digits. The finding includes the following:

Patient #1, a [AGE] year old (MDS) dated [DATE] at 7:32 PM via EMS after sustaining an injury while using a table saw. The patient had a past medical history of diabetes, coronary artery disease, hypertension and myocardial infarction. Review of MD #1's assessment dated [DATE] at 7:28 PM indicated that the patient was working with a table saw when a piece of wood threw the blade back and took the distal phalanx of his/her third finger and tips of the 2nd and 4th fingers. The lacerations were jagged in nature and bone was exposed on digits 2-4. Review of the radiological report dated 4/22/18 at 8:12 PM identified that there were amputation deformities of the distal second and third digits with absence of the distal phalanx of the third digit as well as the tuft of the distal second phalanx. There is probable involvement of the distal tip of the middle third phalanx. The distal interphalangeal joint (DIP) of the third digit is disrupted.

Review of MD #1's progress note at 8:17 PM reflected that an emergent consult to the on-call hand surgeon, MD #2, was made, the case was described and MD #2 advised MD #1 to call hospital #2 for transfer for consideration of re-implantation as MD #2 does not perform re-implants. The note further reflected that MD #1 called hospital #2 and spoke with MD #3 about the case. MD #2 and MD #3 discussed the case and per MD #2, MD #3 would evaluate the patient. The patient was subsequently transferred to hospital #2 at 9:44 PM for evaluation of the traumatic hand injury.

Review of the clinical record from hospital #2 dated 4/22/18 identified that the patient was transferred from hospital #1 after a table saw injury with amputation of the left 3rd finger and damage to the 2nd and 4th. The ED physician evaluated the patient at 10:37 PM and requested a plastic surgery consult. Consultation identified that the patient was evaluated and given the mechanism of injury, zone of injury, and patient's significant comorbidities, replantation versus revision amputation were explained to the patient ultimately pursuing revision amputation. The patient subsequently had the wound closed in the ED and no re implantation based on the risks and benefits reviewed. The patient was discharged home on 4/23/18 at approximately 3:10 AM.

Interview with MD #1 on 5/7/18 at 1:30 PM stated his main goals were to get a plan to address the patient's fingers, pain control and obtain baseline bloodwork. Upon the patient's arrival to the ED, he called the on-call hand surgeon MD #2, who indicated that the patient should be transferred since she does not do re-implantations. MD #1 stated that when he spoke with the potential receiving physician (MD #3), he stated MD #2 should see and evaluate the patient prior to transfer and this could be a case of EMTALA. After speaking to MD #3, MD #1 called MD #2 again who felt that coming in to evaluate the patient would delay the process and felt this was not an EMTALA as the patient was being transferred to a higher level of care. The patient was subsequently transferred to acute care hospital #2 on 4/22/18 at 9:44 PM.

Interview with MD #2 on 5/8/18 at 8:30 AM verified that she was called on 4/22/18 about a patient who had a distal phalanx amputation. MD #2 indicated she felt that the patient should be evaluated for microsurgery and this was not performed at the facility. MD #2 stated she reviewed a picture of the patient's hand sent to her and that she did not come into the ED to evaluate patient as this would delay potential treatment. MD #2 further stated that the receiving hospital indicated they would not refuse the patient however did request that she evaluate the patient and review options, risks and benefits. MD #2 indicated that she responded to the call, however, did not go to the ED to evaluate the patient as she felt that would delay the care.

Review of the clinical record lacked documentation that identified Patient #1 was evaluated by MD #2, the on-call hand surgeon, despite MD #1's and the receiving hospitals request to do so.

Review of the EMTALA policy indicated that the on-call physician must come to the ED when requested by the ED physician, another physician, a nurse or any hospital worker making the request on behalf of the physician or nurse. If requested, the on-call physician must come to the ED to see a patient that is being transferred to another institution before the transfer and must communicate with the receiving physician.

Review of the facility Rules and Regulations indicated that Consultations shall show evidence of the consultations review of the patient's record, pertinent findings on examinations of the patient and the consultant's opinion and recommendations.