Some Sterility

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Over a hundred years ago, a physician named Joseph Lister pioneered the concept of sterile instruments during surgery. At the time he doused his instruments with carbolic acid, now known as phenol, and this became the first widely used surgical antiseptic.

Yet, somehow the VA is unable to reliably assure patients scheduled for operation, that the utmost efforts have been undertaken to ensure the scalpels and clamps and retractors the surgeons use are clean.

This month we look at concerns raised by whistleblowers at the New Mexico VA Healthcare System. This is documented in a report by the VA Office of inspector General (OIG) and is available to the public. We also have employee knowledge of how VA sterile processing systems work, or in this case, don’t work.

An anonymous call came in to the OIG that alleged employees were tampering with sterile equipment processes, surgical procedures were delayed due to lack of sterilized instrument sets and leadership was aware of the issues but took no action. Apparently, this happened because of a staff shortage — a contract for sterile processing employees had recently been canceled.

The VA OIG did their usual investigation which involved interviewing staff, checking records, and making sure policies were being followed. They weren’t able to find any tampering of instruments but this is suspect. We’ve heard from VA employees about how the OIG truly operates: they show up, often unannounced, with a clipboard and begin checking boxes on their to-do list. If, in their plain view, there isn’t an open set of surgical instruments that are obviously altered or corrupted, then the evidence is considered ‘inconclusive.’ Case closed.

In fairness to the OIG, they are often overworked, having to investigate nearly every VA for a multiple of causes, and do not have access to the same set of medical experts found in the private sector. Instead, they often rely on Veterans Health Administration (VHA) which is dubious as we’ve seen that the VA does a poor job of policing itself.

On this visit they noted that two years prior in 2015, a witness testified that a co-worker would invalidate the sterility seal on an assembled tray of surgical instruments. However, the facility director ignored this allegation because it was ‘not conclusive.’ We wonder if that director has ever visited a surgical operating room in their hospital or works primarily ‘from the desk.’ In any case, two years passed and similar allegations surfaced so the problem obviously had not gone away.

The OIG did verify on their revisit in 2017 that about ten percent of the surgical sets had missing instruments, though a description was lacking as to the missing instrument. Really? So the surgeon has to guess one out of ten times what’s in or not in the set while the patient is anesthetized. I wouldn’t want to be patient number ten on a busy day.

A cryptic comment on the OIG report is worth discussing. “While damaged sets were not identified during the OIG’s on-site inspection, the seal of a sterile set was inadvertently broken … which allowed the OIG to examine the contents of that sterile set.” So the OIG was reluctant to inspect any sterile surgical sets unless they somehow fell open? This doesn’t seem like a very thorough inspection especially when the one set that fortuitously broke open was found to lack instruments necessary for a laparotomy. They even admit this may have resulted in a canceled surgery.

The surgeons the OIG interviewed freely admitted major problems with sterile processing. Good for them. And to their credit, the OIG recommending an abundance of improvements — all of which the Director is responsible for implementing.  The target date for these varied from a generous three to six months from the time the report was generated. For our veterans sake, let’s hope the Director fixes the problem sooner.


Prof. Sam

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