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Healthcare Inspection – Out of Operating Room Airway Management Concerns, W.G. (Bill) Hefner VA Medical Center, Salisbury, North Carolina

Report Information

Issue Date
Report Number
13-04005-296
VISN
State
North Carolina
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
6
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted an inspection in response to allegations regarding out of operating room airway management (OOORAM) at the W. G. (Bill) Hefner VA Medical Center (the facility) in Salisbury, NC. We substantiated that the facility’s local policy for OOORAM was not updated as required and, when a new policy was implemented, it did not contain all the components required by Veterans Health Administration (VHA) Directive 2012-032. We also substantiated that the facility’s OOORAM training and competency assessments were not consistently completed as required, not enough staff were authorized to perform OOORAM and some staff performed OOORAM without authorization, highly portable video laryngoscopes were not always immediately available, and required analysis after patient care events involving intubation by unauthorized facility staff did not always occur. We did not substantiate there was an unacceptable number of “Code Blues” (an emergency situation announced in a hospital to indicate a patient requires immediate resuscitation) and found the facility reviewed events where cardiopulmonary resuscitation was attempted as required. During the course of this review, we found the facility had not updated the scope of practice for a non-licensed independent practitioner who was authorized to perform OOORAM. We recommended that the Facility Director ensure the facility’s OOORAM policy is updated to include all VHA requirements, that processes be strengthened to complete OOORAM training and competency requirements as outlined by VHA and local policies, that processes be strengthened to provide OOORAM coverage as required, that highly portable video laryngoscope equipment is immediately available, that an analysis is performed for the five identified patient care events in our report, and that the scope of practices are updated for non-licensed independent practitioners who perform OOORAM.

Open Recommendation Image, SquareOpenClosed and Implemented Recommendation Image, CheckmarkClosed-ImplementedNot Implemented Recommendation Image, X character'Closed-Not Implemented
No. 1
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that the facility’s out of operating room airway management policy is updated to include all Veterans Health Administration requirements.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that processes be strengthened to complete out of operating room airway management training and competency requirements as outlined by Veterans Health Administration and local policies.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that processes be strengthened to provide out of operating room airway management coverage as required.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that highly portable video laryngoscope equipment is immediately available
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that analysis of the five patient care events identified in this report is completed as required.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that the scopes of practice are updated for non-licensed independent practitioners who perform out of operating room airway management.