Strict new policies to ensure veteran safety led to investigation after a VA employee reported spots on trays and on surgical instrument.
The Department of Veterans Affairs acted swiftly and correctly to temporarily suspend surgeries earlier this month at the John Cochran VA Medical Center in St. Louis after stains and water spots were noticed on some medical trays and one surgical instrument, American Legion National Commander Jimmie Foster said.
“The spots were reported to hospital officials by an employee acting diligently on more stringent self-monitoring policies now in place throughout the VA health-care system,” Foster said. “We believe VA is taking very seriously its need to provide the cleanest, safest possible care for our nation’s veterans. Self-reporting of any possible threat to that safety – even a questionable water spot – is an important part of VA’s commitment to transparency.”
The American Legion’s System Worth Saving Task Force inspected the St. Louis facility Jan. 12-13 and received a report from the hospital’s Reusable Medical Equipment Committee, which was formed after some 1,800 veterans in the St. Louis area last year were called in to be tested for possible Hepatitis B, C and HIV exposure after improper sterilization of dental equipment was discovered in a VA dental clinic. The clinic was closed following the revelation, the chief of dental service was removed from VA employment, and a new state-of-the-art facility with tighter oversight requirements was opened to replace it.
Two weeks after the meeting between the System Worth Saving Task Force and the St. Louis VA officials, however, the hospital suspended surgeries after an employee reported the spots to supervisors. The hospital responded quickly, investigating all equipment in the facility, while making arrangements elsewhere for patients in immediate need of surgery, according to a follow-up report from the health-care system.
The Legion’s System Worth Saving Task Force has closely scrutinized VA performance on medical equipment sterilization procedures since a 2009 VA Inspector General’s Office report revealed the potential for contamination due to the cleaning procedures of reusable endoscopy and colonoscopy instruments. The report noted that in 2004, 2,000 veterans in California were notified by VA that an endoscope reprocessing machine had malfunctioned; in 2005, 200 veterans in Pennsylvania were notified when VA colonoscopes were found to have been inadequately disinfected.
The VA Inspector General’s investigation – which focused on facilities in Tennessee, Florida and Georgia where problems had been reported in the media – led to systemwide directives to reduce the risk of exposure caused by VA medical equipment. Included among were improved supervision, closer compliance with manufacturer’s recommendations for cleaning reusable equipment, better training, self-monitoring and inspections.
“VA responded to these problems by looking in the mirror and holding the whole system to a higher standard than ever before,” Foster said. “And that’s a good thing. Our nation’s veterans deserve the best possible standard of care and safety. The American Legion is dedicated to helping VA fulfill that commitment.”
The American Legion’s System Worth Saving Task Force was established eight years ago when more than 300,000 veterans were waiting 30 days or longer for primary-care appointments with their VA doctors. The task force, which includes American Legion volunteers and staff, inspects approximately 50 VA health-care facilities a year, interviewing hospital officials on such issues as access, adequate staffing, quality of care, facility space and cleanliness. The inspections are assembled into an annual report that is submitted to Congress, the White House and VA Central Office.