Mismanagement of Emergency Department Care of a Patient with Acute Coronary Syndrome at the Robert J. Dole VA Medical Center in Wichita, Kansas

The VA Office of Inspector General (OIG) conducted an inspection to evaluate allegations that coordination and quality of care issues contributed to a delay in transfer and led to a patient death shortly after transfer from the Robert J. Dole VA Medical Center (facility) in Wichita, Kansas, to a community hospital. The OIG substantiated that coordination and quality of care issues in the management of a patient who presented to the facility’s Emergency Department with acute coronary syndrome (ACS) symptoms contributed to the patient’s death. The Emergency Department physician mismanaged the patient’s care by failing to initiate a timely transfer to a hospital capable of providing percutaneous coronary intervention (PCI). The patient presented to the Emergency Department in early 2019 with ACS symptoms. The physician contacted a facility cardiologist who advised transfer to a community hospital capable of PCI. The physician made two calls to a community hospital to initiate the transfer. The first call was to contact the patient’s personal community cardiologist. The second call, placed 50 minutes after the patient’s arrival to the facility Emergency Department, was to the on-call cardiologist at the community hospital who accepted the patient for admission. During transport, the patient became unstable and died soon after arriving at the community hospital. The OIG concluded that failure to transfer the patient for PCI within 30 minutes of arrival limited the patient’s chances for the best possible outcome. The facility conducted a review of the patient’s care but did not determine any contributing factors that led to the transfer delay or take actions to improve the emergent transfer process. The OIG made one recommendation to the Veterans Integrated Service Network Director related to peer review and nine recommendations to the Facility Director related to staff training, interfacility transfers, policy updates, committee oversight, and institutional disclosure.