Combined Assessment Program Summary Report - Evaluation of Emergency Airway Management in Veterans Health Administration Facilities

Report Information

Issue Date
Report Number
16-00969-257
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Comprehensive Healthcare Inspection Program
Recommendations
7
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
The purpose of the evaluation was to assess compliance with selected Veterans Health Administration requirements related to emergency airway management performed outside of a facility’s operating room. The VA Office of Inspector General (OIG) performed this evaluation in conjunction with 55 Combined Assessment Program reviews conducted from October 1, 2014, through September 30, 2015. Although OIG noted high compliance in many areas, including that facilities’ policies incorporated most required components, facilities designated a subject matter expert consistent with Veterans Health Administration requirements, and videolaryngoscopes were readily accessible in designated facility locations, OIG identified opportunities for improvement and made seven recommendations.

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 Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure facilities’ policies include plans for managing difficult airways.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facility clinical managers provide all required initial training for designated employees who will perform airway management and ensure initial competency assessment includes all required testing and demonstration and that facility managers monitor compliance.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facility clinical managers include all required elements in airway management competency reassessments and that facility managers monitor compliance.
No. 4
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility clinical managers ensure competent clinicians provide emergency airway management during all hours of patient care unless the facility is exempt and that facility managers monitor compliance.
No. 5
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, ensure that facility clinical managers conduct root cause analyses when clinicians without demonstrated airway management competency perform emergency intubations and that facility managers monitor compliance.
No. 6
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility clinical managers ensure scopes of practice for non-licensed independent practitioners who perform airway management include a statement related to airway management and that facility managers monitor compliance.
No. 7
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Under Secretary for Health, in conjunction with Veterans Integrated Service Network and facility senior managers, require that facility Chiefs of Staff ensure clinicians complete required training and experience within a short timeframe after recommending airway management privileges and that facility managers monitor compliance.