HospitalInspections.org

Based on medical record review, incident reports review, AHA guidelines review, and staff interviews, it was determined the hospital failed to ensure the immediate availability of services, equipment, personnel, and resources of other hospital departments to emergency patients for 1 of 9 ED patients (Patient #7) whose records were reviewed. This caused a delay in care for a patient who presented to the ED with a heart attack. Findings include:

According to Journal of the American Heart Association 2019, (https://www.ahajournals.org/doi/10.1161/jaha.119.012188) reviewed 11/22/22, "In patients with ST segment-elevation myocardial infarction, timely reperfusion therapy with door to balloon (D2B) time <90 minutes is recommended by current guidelines. The current study showed that there was continuous association between shortening D2B time and reduced risk of 1 year mortality."

Patient #7 was 55 year old male admitted to the ED on 11/06/22 at 1:04 AM with a heart attack. His medical record included a note from the Cardiologist stating, "There was an unacceptable delay in the cardiac Cath Lab and myself being called due to failure of the communication center." Patient #7's medical record documented the door to balloon time was 116 minutes, which exceeded the hospital's goal of 60 minutes, and the ACC's goal of 90 minutes.

An incident report for Patient #7 was reviewed. It included, "A STEMI was called and interventional MD contacted at 0114 for emergent LHC and cath lab activation. Access center attempted to call staff using cath lab extension numbers instead of home phone numbers but there was no cath lab staff on site with it being 0115. First staff member was not contacted until 0152 therefore door to balloon time was not for neither [sic] the 60 min PMC goal nor the 90 min ACC goal."

On 11/16/22 beginning at 12:54 PM, the Access center employee was interviewed about the delay in notifying the cath lab team for Patient #7. She stated the ED physician told her to call the cath lab. She stated she called the cath lab and did not receive an answer due to the cath lab not being staffed during night shift. She stated she emailed her supervisor to see what to do and did not receive a response until the next day. When asked why she called the cath lab directly rather than calling the on-call staff due to it being the middle of the night, she stated, "It was my first day being on my own and it had not come up in training yet."

Surveyors requested competencies for the Access center employee who was interviewed. The facility was unable to provide documentation the Access center employee was trained on notifying the cath lab team after hours. The VP of Quality was interviewed on 11/16/22 at 2:46 PM and confirmed there were no competencies or proof of orientation to the access center, including activation of the on call system, for the employee.

The CV Quality Coordinator and the CV Services Manager were interviewed together on 11/16/22 beginning at 9:23 AM. They stated the hospital follows AHA and ACC guidelines. They both confirmed that there was a delay in care for Patient #7. They stated that the Access center employee was new and did not know the process to call the cath lab team in at night. CV Quality Coordinator and CV Services Manager were asked why 90 minutes was the goal of door to balloon time for a patient having a heart attack. They both replied, "time is muscle." When asked about how the delay in response time to the cath lab could effect affect Patient #7, The CV Services Manager stated patients can lose heart muscle, and have problems a year later. The CV Quality Coordinator said the ACC goal of door to balloon time was less than 90 minutes because after 90 minutes there could be heart damage.

On 11/16/22 beginning at 10:35 AM, Patient #7's Cardiologist was interviewed. He confirmed that, "time is very important." He stated when he arrived at the cath lab, no other staff were present. He had to call each cath lab employee into the hospital. He stated Patient #7 did not suffer, but could have.

The facility failed to ensure the immediate availability of services, equipment, personnel, and resources of other hospital departments to emergency patients.