Healthcare Inspection – Alleged Mismanagement in the Cardiac Catheterization Laboratory, VA Maryland Health Care System, Baltimore, Maryland

OIG conducted an inspection in response to allegations regarding the cardiac catheterization laboratory (CCL) at the Baltimore VA Medical Center, Baltimore, MD. The allegations related to mismanagement of CCL patient emergencies and CCL staffing. We did not substantiate allegations that a patient died because CCL staffing was insufficient to perform an urgent case and leadership delayed transferring the patient to the University of Maryland medical center. We also did not substantiate allegations that the CCL nurse manager, intensive care unit nurses, and Anesthesia Service ignored CCL staff requests for help during a cardiac emergency. We did substantiate that CCL staff were correctly told not to call the rapid response team for help because the CCL is considered an outpatient clinic and the rapid response team is limited to responding to inpatient situations only. We did not substantiate that the facility did not follow “standard of care requirements” since there are no definitive national or VHA standards for minimal staffing of the CCL. However, we found that the facility did not consistently meet national and local policy requirements for staffing during CCL procedures involving moderate sedation. Changes implemented at the facility in April 2013 required two registered nurses be present for all CCL procedures. The facility acknowledged ongoing efforts to evaluate the cost-benefit of CCL in-house operations due to low volume of procedures performed in the CCL. Incidental to our inspection, we found that staff were unclear about the roles of the code blue and rapid response teams, as well as the process for obtaining anesthesiologist assistance in the event of an emergency in the CCL. We made three recommendations.