Breadcrumb

Alleged Chemotherapy Delay and Excessive Emergency Department Length of Stay

Report Information

Issue Date
Report Number
13-00488-26
VISN
State
Illinois
District
VA Office
Veterans Health Administration (VHA)
Report Author
Office of Healthcare Inspections
Report Type
Hotline Healthcare Inspection
Recommendations
3
Questioned Costs
$0
Better Use of Funds
$0
Congressionally Mandated
No

Summary

Summary
OIG conducted an inspection in response to a complainant’s allegations of a delay in chemotherapy treatment, excessive length of stay (LOS) in the Emergency Department (ED), and failure to perform a kidney ultrasound at the Jesse Brown VA Medical Center in Chicago, IL. We substantiated a delay in chemotherapy treatment, that the patient experienced excessive LOS in the ED on two occasions while awaiting admission, and that an inpatient kidney ultrasound was ordered but not performed. However, on both ED visits, the patient was promptly triaged and treated. We could not substantiate that the patient suffered adverse medical outcomes as a result of these delays. We found that there was no clearly defined process for monitoring oncology clinic patients awaiting inpatient beds after hours and that there was inconsistent patient handoff communication between oncology clinic staff and the ED triage nurses. We also identified problems in the Patient Flow Committee structure, membership, and communication of patient flow initiatives to the frontline staff. We made three 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 Facility Director ensure that length of stay in the emergency department is reviewed, and that action plans are developed to address excessive length of stay, and that action plans are implemented and monitored for compliance.
No. 2
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that the Patient Flow Committee meets as required by local policy, reviews membership to ensure inclusion of frontline staff, that follow-up reports are submitted, and that identified improvement processes are monitored and communicated to all involved staff.
No. 3
Closed and Implemented Recommendation Image, Checkmark
to Veterans Health Administration (VHA)
We recommended that the Facility Director ensure that action plans addressing the monitoring and handoff communication of oncology clinic patients waiting for after-hours admission are communicated to involved staff, implemented, and monitored for compliance.