JPS patient dies after policy slows move to ER

A man staying at the mental health unit of John Peter Smith Hospital died after the staff summoned an ambulance to take him to the emergency room instead of calling for doctors a parking lot away.

The ambulance took 15 minutes to arrive, while the hospital could have had an emergency team at his side in little more than five minutes.

The hospital violated state law by its actions, an investigation by the Texas Department of State Health Services found. JPS' policy for emergency care at the psychiatric facility amounted to performing CPR and calling 911, and that was flawed, state investigators reported.

Resuscitation services offered at the main hospital should have been available at Trinity Springs Pavilion, said Carrie Williams, a spokeswoman for the health services department.

"What should have occurred ... was notification to JPS' STAT team in the main hospital, which responds to calls for resuscitation," she said.

Late last month, the state fined the hospital, the hub of the taxpayer-supported Tarrant County Hospital District, $7,500.

JPS had argued against a penalty and tried to prove that summoning an ambulance was faster by timing the transportation of a mannequin on a stretcher.

The mannequin won.

"If they're not two separate hospitals, you can't call an outside ambulance to transfer a patient from one part of the facility to the other," said Neal Adams, the hospital district's general counsel. "We are under one license -- Trinity Springs psych hospital and the main hospital -- therefore we could not get around that rule."

Neither JPS nor the state would identify the patient, citing state and federal privacy laws.

But apparently he was Jerry Hammer of Arlington, a Trinity Springs patient and former Temple University professor.

His family had been puzzled about a $500 bill for ambulance services, especially since Hammer was living about 360 feet from the hospital.

Deborah French, Hammer's niece, said JPS told her that calling an ambulance was normal procedure. French said she wasn't told how much time elapsed before it arrived.

"I think it's pretty sad when you're in a hospital and you have to call an ambulance for emergency services," French said.

Minutes count

One possible hiccup in JPS' policy was that ambulance services may assume that a patient at a hospital -- a place full of doctors and nurses -- is already receiving medical attention.

"The assumption that our system makes in that case is that it's not as urgent for us to get there because it's not like you're at home and there's no trained medical person there," said Jack Eades, executive director of MedStar.

That may be why it took MedStar 15 minutes to arrive at Trinity Springs, where the hospital operates 70 beds. Response times averaged between seven and 10 minutes in August, when Hammer died, Eades said.

On Aug. 13, staff members at Trinity Springs noticed that the man was in acute cardiopulmonary distress.

French said someone walking by Hammer's room noticed that her uncle had collapsed.

At 5:45 p.m., staff members phoned 911 to request an ambulance and began CPR.

They didn't try to take the man via elevators and a corridor to the main hospital's emergency room because that would have been a trip of more than 1,000 feet, Adams said.

"That patient was transferred much quicker by ambulance than [by] going through the hospital," Adams said.

Or maybe not.

Based on JPS' simulation using a mannequin, it would have taken the emergency resuscitation team 5 minutes, 5 seconds to reach the patient. Moving the patient on a stretcher to the ER would have taken 6 minutes, 43 seconds, the simulation showed.

Overall, the patient would have received care and been moved to emergency room within 12 minutes -- three minutes before the ambulance arrived at 6 p.m.

And it isn't clear how long it took to load and transport the patient in the ambulance. Hammer died at 6:20 p.m., according to Tarrant County medical examiner's records.

State investigators learned about the death because JPS reported it to its accrediting agency, Adams said. JPS was initially assessed a fine of $15,000 out of a maximum $25,000.

"They reduced the fine ... to $7,500 because they realized we truly had the patient's safety in mind," Adams said.

JPS changed its policy after the state investigated. The policy now states that people "found in acute cardiopulmonary distress at Trinity Springs Pavilion will have initial stabilizing treatment and basic life support performed. They will be transported to the Emergency Department by stretcher via the service tunnel with necessary interventions provided continuously en route."

But Dr. Wayne Williams, a JPS board member, said the old policy may have been just as sensible.

"Depending upon what the emergency is ... the 911 guys have better equipment than a STAT team would have," Williams said. "STAT teams basically are set up to handle cardiac arrests more than anything else."

Left with questions

French said she was told that her uncle died because a blood clot traveled to his lungs. But Hammer's family can't help but wonder why he died with medical care so close.

Hammer, 62, went from high school dropout to a Ph.D., then sold real estate. Toward the end of his life he stuck notes to cabinets to remind him of tasks. The family believes that he may have had Alzheimer's disease or dementia at the time of his death.

Along with unanswered questions, they're also left with a bill.

"The man was there for a month, they killed him, and now they're charging him $80,000," she said.

About two months after Hammer died, the hospital district put a lien on his Arlington home.

News researcher Marcia Melton and staff writer Anthony Spangler contributed to this report.