The troubled Atlanta Veterans Affairs Medical Center continues to run at diminished capacity after shutting down operating rooms in late September for all but emergency surgery, say people familiar with the matter.
Some days as many as four of the nine operating rooms are still not functioning and full capacity is not scheduled to be restored through at least February at the largest hospital in the Southeast for military veterans, according to internal VA emails reviewed by The Atlanta Journal-Constitution.
Recent problems include safety violations during surgical processes, gnats in one operating room, lack of proper surgical tools in one case and a strong chemical odor in one operating room, according to two hospital employees who spoke on condition of anonymity.
The VA said in an emailed response Friday to the AJC that it had increased capacity and six operating rooms have returned to full service. It said all nine rooms have not been in service for a decade, but provided no details about the level of capacity at which they are functioning. The Atlanta facility “remains dedicated to ensuring the highest quality care for Veterans,” the email added.
The agency said later Friday that two gnats were found in one operating room, which was cleaned immediately. It said the chemical odor was identified in an operating room and “appropriate action” was taken, with no impact to patient care.
The VA said last month it planned to resume normal operations by early November. The 400-plus-bed hospital on Clairmont Road in Decatur and its outlying clinics serve about 120,000 area military veterans. It has been wracked by a string of incidents that exposed mismanagement and dangerous practices.
The lengthy slowdown is an indication of extraordinary problems, experts say.
“It is very unusual,” said Jeff Peters, CEO of Surgical Directions, a Chicago health care consulting group. Most hospitals get operating rooms back up in days, he added.
The problems will add to waiting times for veterans. Even before the partial shutdown, surgery dates at the hospital could take three months or more, according to employees.
Violations of surgical protocols may have caused two injuries to staff, according to a November email reviewed by the AJC that went out to surgery section chiefs and acting chief of surgery. Protocols require at least two staff members to accompany patients from surgery to recovery in case the patient wakes up and becomes agitated. That did not happen after two recent surgeries. In each incident most of the staff had already left the operating room. Two staff members still attending were injured to the point of requiring surgery themselves.
In a response late Friday, the VA said there have been no injuries after surgeries or violation of operating room protocol that would result in employee injury.
Also, no surgery is supposed to start before the full team is in the room. “There are concerns that at times, the surgical technician is not present, scrubbed and ready to go” when the patient is being anesthetized, according to another email.
Emails described a patient being put under in late October before pre-operative procedures had been completed, and a safety violation about a month ago when surgical tools and equipment were being cleaned and broken down before a patient left an operating room.
The VA said late Friday all staff are present before the start of each operation.
When the VA began canceling non-emergency surgeries, it began rescheduling patients and farming out surgeries to some non-VA providers. During its first two weeks under the protocol in October, it sent 100 patients to non-VA facilities for surgery and performed 130 in-house. It has not shared updated numbers.
The Atlanta hospital has posted low scores in recent years on quality of care provided, including one star last year, the lowest-possible score.
This year, it got the lowest scores for employee and patient satisfaction among the nation’s 140 VA medical facilities. Also, a September VA inspector general’s report said the facility has the most difficulty in recruiting workers, with doctors and nurses topping the list.
National VA leadership appointed a new hospital director last spring to try to resolve some of the problems.
On Sept. 16, national leaders also put regional director Leslie Wiggins, who had previously managed the hospital, on administrative leave after an incident in which a dying veteran in the Atlanta complex was found covered in ant bites. Wiggins left the service in October.
After the incident, the regional medical director based in metro Atlanta was assigned to administrative duties pending a review of quality and safety of care issues. Seven staff members were reassigned to non-patient care.
The interim regional director, Scott Isaacks, was assigned from a VA hospital in Charleston that posted four- and five-star scores in recent years. Five is the highest score in the system.
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