HospitalInspections.org

Based on review of the Emergency Department (ED) policies and procedures, medical records, staff interviews, current physician's roster, and ED call list, it was determined that the facility lacked an effective system to ensure that individuals from a referring hospital were accepted as an appropriate transfer who required the specialized capabilities or facilities if the receiving hospital had the capabilities or facilities if the receiving hospital had the capacity to treat the individual. This affected 1 of 21 sampled patients (#12). Refer to findings in tag A-2411.

Based on review of the Emergency Department (ED) policies and procedures, medical records, staff interviews, current physician's roster, ED call list, and the "Direct/Unscheduled Admission Form", it was determined that the facility lacked an effective system to ensure that individuals from a referring hospital were accepted as an appropriate transfer who required the specialized capabilities or facilities if the receiving hospital had the capacity to treat the individual. This affected 1 of 21 sampled patients (#12).


Findings were:

Patient #12's medical record from the transferring hospital was reviewed. The medical record revealed that on 8/10/2011 at 1230 p.m., patient #12 presented to the hospital via EMS (Emergency Medical Services) was placed on a stretcher, cardiac monitor, and an IV (Intravenous) line was started. Further review of the medical record revealed in part, "1:15 p.m. Labs (Laboratory) drawn.. 1:33 p.m. Pt (patient) vomited small amount of clear brown emesis...1:38 p.m. x-ray in with patient .. .Family at bedside... 2:20 p.m. Physician in to talk with pt and family...2:50 p.m. pt gone to x-ray for CT (Computerized tomography - a method of examining body organs by scanning them with x-rays) scan. 3:30 p.m. MD (medical doctor) made aware that pt is vomiting multiple times. MD also aware that unable to obtain B/P (blood pressure) on pt. 3:40 p.m. Family at bedside calls pt is standing at bedside very pale will not respond. . . pt placed back in bed. HR (heart rate ) ST (sinus tachycardia- an elevated Heart rhythm- normal heart is 60-100) 138. After lying pt flat she begins to respond MD at bedside 3:50 p.m. Dr.(ED Physician)___ speaks to Dr.___ and Dr. _____ states pt has to be admitted to Dr.___ ICU (Intensive Care Unit). 4:20 p.m. Dr. __in to assess pt and Dr.____ speaks to Dr.____ and Dr. ____ (ICU) and family pt is to be transferred. . . 4:35 p.m. Called Trinity Hospital in Augusta awaiting return call from Dr. _____. 4:40 p.m. 14 fr(french) NG (naso gastric) tube inserted . . . 600 ml (milliliters) of dark black to brown colored emesis received back. 5:21 p.m. Called Trinity Hosp.(hospital) Dr. ____ paged again... 5:29 p.m. Dr. ___ returns call states that he is Medical Dr (doctor) and give number to contact Dr.(Surgeon) ____ . Called Dr. _____ answering service awaiting call... 6:14 p.m. Called again Dr. (surgeon ____ to be paged again. 6:18 p.m. Dr. _____ (from transferring hospital ) speaking to Dr.____ (from trinity Hospital ) ... 6:20 p.m. Pt talking with family at bedside HR 112 .... on cardiac monitor B/P 100/56 con't (continue ) to monitor pt. 6:25 p.m. Dr.___ (surgeon) Has accepted pt to Trinity Hospital in Augusta, Ga. (Georgia). .. 6:38 p.m. Family aware transfer papers signed... 7:05 p.m. Report given to ___ RN and questions answered... 7:47 p.m. Trinity Hospital called about room assignment.. she(person from Trinity hospital) states Dr. (surgeon)____ never notified them that she was accepting the patient . She states that she will page Dr.(surgeon) _____. 7:55 p.m. _____(person from Trinity Hospital ) called and stated that Dr.(surgeon) ____ has refused to accept the pt due to the fact that the patient was still in our ER (emergency room- transferring hospital) and pt would be too late once the pt arrived at Trinity... 7:57 p.m. Dr. (surgeon)___ calls and states that it was not her responsibility to notify Trinity that she accepted the Pt., it was our responsibility. She further stated that by the time the pt. arrived in Augusta and she called in the surgery team that it would be after midnight and she was not going to stay up all night with this patient, She then spoke to Dr. ____ where she stated she refused to accept the pt (#12) until she knew if the pt had insurance. 8:03 p.m. (Another acute care hospital 's) xfer (transfer) center called for consult. .. 8:10 p.m. Face sheet faxed to the another acute care hospital ... 9:13 p.m. Pt accepted (by a physician)." Trinity hospital failed to accept an appropriate transfer (patient #12 on 8/10/2011) who required the hospital's specialized surgical capability and capacity to treat this patient, after a request was made by the transferring hospital.. The patient's medical record from the hospital that accepted patient #12 on 8/10/2011 was reviewed. Review of the "Discharge" dated 8/10/2011 revealed that patient #12 reason for hospitalization was Hypotension (abnormally low blood pressure) and Sepsis (severe illness in which the bloodstream is overwhelmed by bacteria). Further review indicated in part, "Upon arrival to the (hospital that accepted patient) in ED, the patient was given IV fluids for hypotension. She was intubated (is the placement of a flexible plastic or rubber tube into the trachea (windpipe) to maintain an open airway) for seizures then taken emergently to the OR (operating room) for exploratory laparotomy(is a method of abdominal exploration, a diagnostic tool that allows physicians to examine the abdominal organs). She was found to have"entirety of the stomach, small bowel, and colon frankly dead." The incision was then closed, and no further surgical intervention was made. She was admitted to the SICU (Surgical Intensive Care Unit) on multiple vasopressors (powerful class of drugs that induce vasoconstriction and thereby elevate Blood pressure) ... The pressors were then stopped. The patient's cardiac and hemodynamic status declined until the patient was pronounced dead at 11:25 on 8/11/2011 after cardiac arrest (occurs when the heart stops beating) and asystole (is a state of no cardiac electrical activity).

Review of the facility's Emergency Department (ED) policies and procedures entitled "Compliance with EMTALA", policy number T - 11, last effective date 01/10, revealed that if the facility had the specialized capabilities and the capacity to treat the patient it must accept the transfer of an individual requiring specialized capabilities. The policy indicated that "only the hospital - designated personnel and the emergency physician may accept the transfer of individuals on the hospital's behalf. The policy noted that the on-call physicians should not be permitted to accept or refuse transfers on the hospital's behalf." In addition, this policy required the facility to have available space and qualified personnel to treat the patient.

During interviews (#7 and #8) on 09/15/11 at 8:45 a.m. in the Conference Room, the Chief Nursing Officer (CNO) and the Administrative Director of Inpatient Services (ADOIS), both explained that the facility's process for handling request for transfers to the facility was for the transferring ED physician to call the on duty ED physician and ask for the specialty they needed. The ED staff were then to check the on-call log to see if the facility had an on-call physician for that specialty. If so, the ED staff were then to check with the Overhouse Supervisor (OHS) to find out if the facility had an available bed. Both interviewees explained that there was no problem with bed availability. Both interviewees stated that the facility's average daily census was 50 and that the Intensive Care Unit (ICU) had an average daily census of four (4). They stated that the facility had 90 beds with two (2) closed units and that the ICU had eight (8) beds. Both interviewees explained that if the ICU was full and an ICU bed was needed those patients' physicians could be contacted to see which ICU patient could be moved out of the ICU. The CNO stated that he/she believed that the problem with this case was that the transferring ED physician did not call the on duty ED physician but called the on-call surgeon instead. Both interviewees stated that the facility did not have a transfer center or a log of patients that were received as transfers from other facilities but did have a log of patients that the facility transferred to other facilities.

Review of the current "Physician Roster" revealed physician (interview #5) was listed as a medical doctor and physician (interview #6) was listed as a surgeon. Review of the facility's ED call list revealed physician (interview #6) was listed as the on-call surgeon on 08/10/11.

During interview (#2) on 09/14/11 at 11:30 a.m. in the ED Registrar's cubicle, the Registrar explained that if a facility called requesting to transfer a patient to the facility the transferring ED physician would call and speak directly to the ED physician on duty in the ED. The Registrar continued to say that if the patient was an inpatient that was to be directly admitted to a unit he/she would get the patient's name, date of birth, social security number, and fill out the "Direct/Unscheduled Admission Form" with information obtained from the transferring facility. Review of the "Direct/Unscheduled Admission Form" revealed that the staff were also to fill out the date and time of the call, the patient's estimated time of arrival, physician's name and telephone number, the patient's diagnosis, whether the patient was to be admitted as an inpatient, observation patient, outpatient, or ED patient, if orders were fax' d (FAXED) or coming with the patient, mode of arrival, assigned bed number, and the bed control representative's name. The Registrar stated that the facility did not have a transfer center or log of patients that were received as transfers from other facilities but did log the patient's they transferred out.

During interview (#3) on 09/14/11 at 11:40 a.m. in the ED Family Room, the RN explained that if a facility called requesting to transfer a patient, the transferring ED physician would talk to the ED physician on duty. The nurse stated that the ED physician would accept the patient and the ED staff would get a room ready for the patient after receiving report from the transferring facility's staff. The RN continued to say that some transfers were inpatients that were to be directly admitted as inpatients. The nurse stated that when patients were direct admits, the OHS determined whether the facility had an available bed and if so the OHS accepted the patient, and then the transferring physician would speak with a physician who had agreed to accept the patient. The nurse also stated that the facility did not have a transfer center or log of patients that were received as transfers from other facilities but did log the patient's they transferred out.


During interview (#4) on 09/14/11 at 11:40 a.m. in the Conference Room, the RN/OHS explained that he/she worked 08/10/11 from 7 :00 p.m. until 08/11/11 at 7:00 a.m. The OHS stated that he/she received a telephone call from a lady from another facility requesting a bed for a patient and that had informed him/her that the on-call surgeon (interview #6) had accepted the patient. The OHS also stated that he/she called admitting and they had not received orders or a call from the surgeon to inform them that the surgeon had accepted the patient. The OHS further stated that he/she then called the surgeon to see if the surgeon had accepted the patient. The OHS explained that he/she spoke with the surgeon and found out that the surgeon had accepted the patient but had changed his/her mind because it was getting late and the surgeon had surgery the next morning. The OHS stated he/she could not assign a bed without an accepting physician. The OHS stated that the facility had no Intensive Care Unit (ICU) beds available but had some beds were available on the medical/surgical unit. The OHS explained that he/she had a running tally of occupied beds which allowed him/her to know which beds were available. The OHS stated he/she could have called physicians to see which patient in the ICU could have been moved out of ICU and then opened a Stepdown Unit. The OHS stated that the person calling had not informed him/her that the patient was in the ED and that he/she thought the transfer was to be an inpatient to inpatient transfer. The OHS stated the correct process was for the transferring ED physician to call and speak to the ED physician on duty and ask if we have the type of specialist on-call that they need. The OHS continued to say that the ED then calls the OHS to find out if we have an available bed. The OHS stated the transferring facility then calls report and receives the assigned bed number. The OHS also stated that the facility did not have a transfer center or log of patients that were received as transfers from other facilities but did log the patient's they transferred out.

During interview (#5) on 09/14/11 at 5:00 p.m. in the Conference Room, the physician stated that on 08/10/11 he/she received a page from his/her answering service. The physician stated that he called the number listed and was told that they were looking for a surgeon and that he/she informed the caller that he/she was a medical doctor. The physician explained that he/she gave the caller the on-call surgeon's telephone number but that he/she was not aware that the patient was in the ED.

During interview (#6) on 09/14/11 at 6:30 p.m. in the Conference Room, the physician stated that on 08/10/11 he/she was the on-call surgeon. The physician explained that he/she received a call from another facility about 5:00 p.m. or 6:00 p.m. requesting to transfer a female patient that might need surgery. The physician stated he/she was informed that facility #3 (another local hospital in town) had refused the patient. The physician further stated that he/she told the caller that if they could put the patient in an ambulance "right now" and send the patient, he/she would accept the patient. The physician explained that he/she had been on call for the facility's ED and for facility #4's (another local hospital in town) ED. The physician stated that the OHS called me and informed me that it was the policy for the OHS to accept the patient if there was an available bed. The physician further stated that the transferring facility had made it sound like the patient might need an ICU bed. The physician stated that he/she received a call from facility #4 and was tied up in that ED with a patient from 8:30 p.m. until 11:00 p.m.