Federal Report Sheds Light On VA Hospital Concerns

By Brien McElhatten

June 18, 2010 Updated Mar 9, 2010 at 11:24 PM EDT

FORT WAYNE, Ind. (Indiana's NewsCenter) - A federal investigation substantiates reports of resource mismanagement at the VA hospital.

The 17-page document released on March 2nd, highlights problem areas with the VA Northern Indiana Health Care System. The report traced complaints of "persistent instrumentation problems with operating room sets and peel packages; ongoing reusable medical equipment issues; supply processing and distribution stocking and dating of supplies; pharmacy stocking of operating rooms, post anesthesia care unit, endoscopy unit medications and management issues."

The investigation, conducted by the VA Office of Inspector general, substantiated some, but not all of the complaints made by staff members. It found that surgical instrument sets were returning improperly from a VA sterilizing facility in Marion. Some tools were marked with water spots, while tool packages occasionally contained the wrong tools or missing instruments. Investigators discovered that several technicians were unable to identify basic pieces that make up those kits.

Hospital Assistant Director Helen Rhodes says the employees were new at the time of the investigation, and that pictures of the tools and properly assembled tool kits have been issued to them to prevent recurrences.

In addition to improperly packaged tool sets, instruments like endoscopes occasionally returned from sterilization covered in water spots, prompting dozens of surgeries to be postponed in the summer of 2009.

"We made sure filters were changed and we had preventative maintenance checks done," explained Rhodes. "Just a lot of different variables to make sure we could help identify the causes."

The northern Indiana VA system serves thousands of veterans across the area. In 1995, the Marion facility combined management with the Fort Wayne hospital. According to officials, that may be partially to blame for the problems. Since the Fort Wayne facility lacks sterilization equipment, surgical instruments and tools are sent via truck to the Marion complex to be cleaned and repackaged for use. Officials admit that the constant back-and-forth may have been an aggravating factor.

"We've had some revisions to equipment and everything and we feel that we have satisfactorily resolved that," continued Rhodes. "At no point was the safety of our patients ever at risk."

Improperly packaged instruments were not the only focus of the
investigation.

Complaints surrounding the management of the OR staff were also brought to light. The report substantiated the allegation that the OR nurse manager was, at the time, responsible for providing coverage in other areas of the hospital, thereby making her unavailable to guide operating room staff. The lack of leadership on those occasions worried some staff members officials say, and in response, the OR nurse no longer "fills in" in other areas of the hospital when assigned to work in the operating room.

Allegations that pharmacy technicians removed expired medications without replacing them were found to be unsubstantiated.
Hospital officials say they are following the recommendations made by investigators.

Documents show that numerous "test runs" of instruments have shown improvement. Officials note that tool sets now come back clean and properly assembled, after staff education programs were completed. Labeling systems and stock monitoring protocols have also been developed and are being implemented.

Officials say they were aware of the concerns before the report was made and have been working to rectify them.

The report sheds light on a VA system that is heavily taxed by an influx of new patients. Service members in the guard and reserve are coming back from Iraq and Afghanistan and are now eligible for treatment. That adds thousands of patients to an already busy system.

A new medical facility planned for Fort Wayne should help matters. Planned for 2014, the 190,000 square foot facility is double the size of the current hospital and should alleviate some of the congestion.

Meanwhile, until the new medical center is operational, Rhodes says her staff will continue to make improvements.
"We are going to do whatever it takes to safeguard the safety of our veterans."




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