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VA hospitals cancel surgeries over ‘rust and blood’ on unsterilized instruments

Surgical instruments (Armin/WikiCommons)
September 08, 2018

VA hospitals across the country have been found to be lacking adequate functionality and could be hazardous to patients and doctors.

Last year, the Manchester VA Medical Center in New Hampshire was forced to cancel surgeries due to surgical instruments being contaminated with what appeared to be rust and blood, reported this week.

Also last year, the VA Medical Center in Washington, D.C. had to borrow bone marrow and sterilized surgical instruments from nearby hospitals because they ran out.

In 2016, a Cincinnati VA Medical Center inspection revealed that the hospital was unable to provide surgical equipment that was “free of bioburden [bacteria], debris, or both.”

In 2016, 83 surgeries were canceled at the West Los Angeles VA Medical Center due to a fly infestation in the operating rooms.

In 2009, more than 10,000 veterans at VA facilities in Florida, Georgia, and Tennessee were put at risk for hepatitis due to the sterility of instruments used for colonoscopies.

Rep. Phil Roe, a medical doctor and chairman of the House Veterans Affairs Committee, said he was stunned that the Veterans Health Administration (VHA) within the VA was struggling to fulfill the “most basic function” of its hospitals: “to make sure you have sterile equipment.”

“It’s astonishing to me. I never even thought about it, was the equipment going to be sterile that I’m using today,” Roe said.

Dr. Teresa Boyd, the VA’s assistant undersecretary for Health for Clinical Operations responded with: “Of the more than 424,000 surgeries scheduled at the VA in the past year, only 0.8 percent had to be canceled because of concerns with equipment sterility. The rate was 1.09 percent compared with surgical site infections rates of 1.41 percent nationally, and 1.9 percent in industry.”

Dr. John Daigh, Jr., assistant inspector general for Healthcare Inspections at the VA’s Office of Inspector General said the VA’s protocol for sterile equipment is concerning and it should be ensuring the same standards across all its facilities.

Complaints regarding sterile equipment issues at the VA have been documented since 2009, including those from the Government Accountability Office, the VA’s Office of Inspector General, the VHA’s Office of Medical Inspector, and verified whistleblower complaints.

Rep. Jack Bergman, the subcommittee’s chairman and a retired Marine lieutenant general, said it is failures in VA leadership that allow this problem to go unnoticed and uncorrected.

Medical centers are supposed to submit timely Sterile Procedure Services (SPS) reports. The VHA’s central office did not know that this protocol wasn’t being followed.

Boyd said that a shortage of SPS staff was a contributing factor in the issue, which is being addressed at all levels of the VA.

The VA said there are about 40,000 current job vacancies at the VHA.

“It is imperative that we have not only trained and experienced front line staff” but also competent leaders, Boyd said.

“[The] current governance structure [at the VA] is simply not getting the job done,” Bergman said.

Bergman said the Washington, D.C., VA Medical Center is the “poster child” for what has gone wrong at the VA in ensuring the provision of sterile equipment and operating rooms at its facilities.

The latest IG report found “a culture of complacency among VA and Veterans Health Administration leaders at multiple levels who failed to address previously identified serious issues” at the Washington hospital and its two clinics.

The report stated: “Veterans were put at risk because important supplies and instruments were not consistently available in patient care areas and equipment rooms where supplies were kept were filthy.”

VA Secretary Robert Wilkie visited the Washington facility in early August. He said: “We had a good visit today, and I appreciated hearing from facility and regional leadership on the important work that has been done to address the Inspector General’s concerns, as well as plans for resolving all its remaining recommendations.”