Alleged Deficiencies in Out of Operating Room Airway Management Processes at the Colmery-O’Neil VA Medical Center within the VA Eastern Kansas Health Care System, Topeka, Kansas

The VA Office of Inspector General (OIG) conducted a healthcare inspection to address care and process issues for an Emergency Department patient and out of operating room airway management processes (OOORAM). The OIG substantiated that an advanced practice registered nurse caused airway trauma while unsuccessfully attempting intubation. However, the bleeding was minor and of no lasting impact. OIG staff determined that the other aspects of the subject patient’s emergency care were appropriate. The OIG substantiated the advanced practice registered nurse did not document the failed intubation attempts in the patient’s health record. The OIG team concluded that the advanced practice registered nurse should have personally documented the procedure in the patient’s health record. The OIG substantiated that an Emergency Department provider documented a brief normal neurological examination and determined that this was adequate given the emergent circumstances. The OIG did not substantiate that the patient was inadequately sedated prior to receiving paralytics for the intubation. The OIG concluded that the patient received a sedative medication for seizures, which is also used for intubation. Furthermore, the patient was unresponsive and therefore did not likely need additional sedatives. The OIG found the facility was not in compliance with tracking competency assessments for OOORAM providers, and leaders addressed OOORAM issues when they became aware of deficiencies and were working to implement new processes for OOORAM provider privileging. The OIG team identified that providers’ credentialing information was not consistently uploaded into VetPro and determined Cardiopulmonary Resuscitation Committee minutes were lacking in documentation of discussion related to resuscitative events, data analysis, and actions proposed for improvements. OIG inspectors made seven recommendations related to OOORAM documentation, review of OOORAM policy, OOORAM training and competency, credentialing, VHA OOORAM policy implementation, documentation in VetPro, and committee review of resuscitative events.