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The Albuquerque Veterans Affairs hospital is working to improve its processes after an October report found that nearly 170 surgeries were delayed or canceled there during a two-and-a-half year period due to unavailable sterile instruments and equipment.
An investigation by the VA Office of Inspector General found that from March 1, 2015, to Sept. 30, 2017, 169 surgeries were delayed or canceled for that reason.
Those include an instance in which an elderly patient receiving a hearing aid implant was pulled out of general anesthesia because the required surgical instruments were not available. Four hours later, the patient was again placed under anesthesia, and the surgery was completed.
The report found that, while no patients suffered adverse outcomes as a result of those delays and cancellations, three patients, including the patient mentioned above, were “exposed to increased risks for adverse clinical outcomes” due to the lack of prepared surgical equipment.
Every instrument that is used at the hospital, from tools used in podiatric procedures to scalpels used in heart surgery, must be sterilized by employees with the Sterile Processing Services department – made up of both VA and contracted employees – before they can be reused, said Albuquerque VA Medical Center Director Andrew Welch.
Each tool has a highly specific method for sterilization that can take up to 48 hours in some cases.
The investigation also found a lack of record-keeping concerning the training of SPS employees and low staffing levels.
Welch said he believes the hospital has already taken steps to correct many of the issues raised by the Office of Inspector General.
The SPS department has seen a 22 percent increase in personnel, as well as higher wages.
SPS pay was increased across the board at VAs nationally, Welch said.
“A lot of those have been added as support staff for quality and to assure that there’s a good underpinning for the daily workings,” said Pam Alexander, the chief nurse for Perioperative Services and SPS Operations. “I feel like that strengthened our department significantly.”
Alexander’s position was one of many created to address some of the issues raised in the report.
Also added were a reusable medical equipment educator, two quality assurance technicians and a quality assurance supervisor, among others.
Welch said that, while investigators were unable to locate some training records, he believes the training was completed by SPS employees.
The investigation stemmed from allegations made in May and June 2017, resulting in an unannounced site visit by an Inspector General team in September 2017.
VA Office of Inspector General spokesman Michael Nacincik said the OIG will begin tracking the status of its various recommendations three months after the release of the report.
Welch said that the complex logistics of SPS are a challenge for every health care institution and that the Albuquerque VA will continue to work toward improving its processes.
“The improvements in SPS never stop. You can never say we’re done, because the technology is evolving, the equipment is evolving, because sterile techniques are evolving, because how we do training is evolving. It is an ongoing quality improvement effort,” Welch said.