OIG Seal
Department of Veterans Affairs, Office of Inspector General
Michael J. Missal, Inspector General

Report Summary

Title: Healthcare Inspection – Questionable Cardiac Interventions and Poor Management of Cardiovascular Care, Edward Hines, Jr. VA Hospital, Hines, Illinois
Report Number: 13-02053-119 Download
Issue Date: 4/8/2014
City/State: Hines, IL
VA Office: Veterans Health Administration (VHA)
Report Author: Office of Healthcare Inspections
Report Type: Healthcare Inspections
Release Type: Unrestricted

OIG conducted an inspection at the Edward Hines, Jr. VA Hospital in Hines, IL, at the request of Senator Richard Durbin and Congresswoman Tammy Duckworth concerning unnecessary cardiac interventions and poor management of cardiovascular care. We substantiated that two patients had questionable indications for coronary bypass surgery and that preoperative planning was inadequate for a patient who underwent coronary artery bypass surgery. We found that coronary interventions may have been inappropriate for nine patients who had undergone cardiac catheterizations during

2010–2013. We substantiated that there were operating room environmental and equipment deficiencies, hospital beds were often unavailable, there was poor bed utilization, and the facility did not monitor compliance with two of an affiliated academic institution’s contracts. We did not substantiate that a patient who died in the operating room received inappropriate care, the operation should not have been performed at the facility, and that preoperative planning was inadequate. We did not substantiate that there was inadequate staffing or medical support for cardiac surgery, patients had excessively long waits to be admitted from the emergency department, there were delays in or poor quality of echocardiography, non-board certified physicians were assigned to crucial management positions, care was inappropriately provided by trainees and non-physician providers, staff failed to adhere to written policies for the Surgical Intensive Care Unit, and that Surgical Intensive Care Unit physicians sometimes were at an affiliated academic institution during their VA tours of duty, or that there was a lack of fairness of Administrative Investigation Boards. OIG made four recommendations.