The case of a child who died of severe trauma after a questionable transfer from Memorial Hospital Central’s emergency department to Children’s Hospital in Colorado Springs was part of a state review that led Children’s to relinquish its license.
Children’s Hospital officials say that the decision to relinquish the license was made to improve coordination at Memorial.
A joint investigation, begun in March by federal and state health authorities, concluded Wednesday with two reports citing violations of the hospitals’ license requirements.
Children’s Hospital failed to meet state trauma statutes, which resulted in “negative patient outcomes related to delays in care of pediatric patients,” one report states. Children’s failed to provide specialty treatment and appropriate patient transfer and care, the report continues.
Memorial didn’t comply with license terms, investigators found, and that “failure resulted in a delay of treatment for a pediatric patient who required pediatric neurosurgery services.”
Memorial inappropriately transferred the patient from its emergency department to Children’s pediatric intensive care unit, “even though pediatric neurosurgery services weren’t available.”
Optimal care would have included timely transport to Children’s main hospital location in Aurora, the report says.
Children’s and Memorial officials, in a joint media briefing Wednesday in Colorado Springs, said the technical failures didn’t alter the two children’s ultimate outcomes.
“Yes, one of those children died,” said Dr. Joan Bothner, Children’s chief medical officer, “but the (regulatory issues) didn’t affect the health outcome. The child had devastating injuries.”
Bothner said foggy weather in January prevented a helicopter flight that would have taken the patient to more specialized care in the Denver area. The child was transferred instead to Children’s ICU at Memorial.
“That was the best place for that child to be,” Bothner said. “As the night went on … it became apparent the child needed urgent surgery.”
The next day, after the surgical procedure was performed by a non-pediatric neurosurgeon, the child was transported to Children’s in Aurora.
The child’s subsequent death, Bothner said, “wasn’t due to any of the care at Memorial or a delay in that care.”
But the report says there was not documentation as to why ground transportation was delayed for three hours and 15 minutes before surgery. Transfer finally took place 17 hours after the child’s admission to the hospital.
A second pediatric patient was treated, the report says, without documentation that a pediatric neurosurgeon at a designated trauma facility was ever consulted.
And, despite wording in the reports to the contrary, officials at the Colorado Department of Public Health and Environment, contacted after the briefing, said that the issues identified did not affect the health outcomes of any patient.
Dr. Patrick Faricy, Memorial’s chief medical officer, said that although the process-related issues did not harm these patients, they could under other circumstances.
That’s why changes were being made.
Children’s Hospital in Colorado Springs and Memorial Hospital Central have been operating under two licenses and brands, but share a building.
On June 4, Children’s will relinquish its license but will continue operating the pediatric unit at Memorial under a management-services agreement with Memorial’s parent, University of Colorado Health. UCHealth provides adult patient care at that location.
Going forward under one license (Memorial’s), Children’s president and CEO Jena Hausmann said, all patients will have one electronic health record and bills from one source. And children admitted to Memorial’s ER will no longer have to be discharged from Memorial and readmitted to Children’s.
A further result of the state and federal investigation was that Memorial Hospital voluntarily surrendered a waiver from the state health department to treat the most complex pediatric trauma cases. They now will be transferred to Children’s in Aurora or Rocky Mountain Hospital for Children in Denver. This will affect fewer than an estimated 120 patients a year, Faricy said.
Children will continue to be cared for at Memorial by the same pediatric professionals from Children’s.
“In no way are we cutting pediatric services we provide to patients in Colorado Springs and southern Colorado,” said Memorial CEO George Hayes.
