VA to Add Medical Staff After 'Rust and Blood' Found on Surgical Instruments

The Manchester, N.H., Veteran Affairs Medical Center. Facebook photo
The Manchester, N.H., Veteran Affairs Medical Center. Facebook photo

At the Manchester, New Hampshire, VA Medical Center last year, surgeries were canceled when debris that appeared to be "rust and blood" was found on instruments doctors were about to use.

At the Washington, D.C., VA Medical Center last year, the staff ran out of sterilized instruments, and even bone marrow, and had to borrow them from neighboring hospitals.

At the Cincinnati VA Medical Center in 2016, inspectors found that the system was failing to provide doctors with equipment that was "free of bioburden [bacteria], debris, or both."

At the West Los Angeles VA Medical Center, 83 surgeries were cancelled in 2016 because of fly infestations in operating rooms.

Rep. Phil Roe, R-Tennessee, a medical doctor and chairman of the House Veterans Affairs Committee, said he found it amazing that the Veterans Health Administration within the VA was struggling to fulfill the "most basic function" of its hospitals: "to make sure you have sterile equipment."

"It's astonishing to me," Roe said at a hearing Wednesday before the Subcommittee On Oversight and Investigations.

Roe, who served two years in the Army Medical Corps, said he had performed or assisted in thousands of surgeries.

"I never even thought about it, was the equipment going to be sterile that I'm using today?" he said.

In response, Dr. Teresa Boyd, the VA's assistant under secretary for Health for Clinical Operations, acknowledged the problem but pointed to mitigating data on the surgical site infection rate.

Of the more than 424,000 surgeries scheduled at the VA in the past year, only 0.8 percent had to be cancelled because of concerns with equipment sterility, Boyd said. At the Washington, D.C., VA Medical Center, the rate was 1.09 percent.

That compared with surgical site infections rates of 1.41 percent nationally, and 1.9 percent in industry, she said.

However, Dr. John Daigh, Jr., assistant inspector general for Healthcare Inspections at the VA's Office of Inspector General, said there was still cause for concern regarding the VA's protocol for sterile equipment and ensuring the same standards across all its facilities.

The sterile equipment issue at the VA has been a recurring problem dating back to at least 2009 and has been documented in numerous reports from the Government Accountability Office, the VA's Office of Inspector General, the VHA's Office of Medical Inspector, and verified whistleblower complaints.

In 2009, more than 10,000 veterans at VA facilities in Florida, Georgia and Tennessee were put at risk for hepatitis because of concerns over the sterility of instruments used for colonoscopies.

Hospital officials at the time reported that tubing for endoscopes used repeatedly in the procedures had been rinsed but not disinfected.

At the hearing, Rep. Jack Bergman, R-Michigan, the subcommittee's chairman and a retired Marine lieutenant general, charged that failures in VA leadership allowed "safety protocols to go unnoticed and uncorrected."

He said the VHA's central office was unaware that medical centers were failing to submit timely Sterile Procedure Services reports, "suggesting that blame goes all the way to the top."

Boyd said the issue was being addressed at all levels of the VA. She also concurred with the findings of recent GAO reports, and said that a shortage of SPS staff was a contributing factor.

Last week, the VA reported that there were about 40,000 job vacancies at the VHA.

"It is imperative that we have not only trained and experienced front line staff" but also the leadership to direct them, Boyd said.

Beth Taylor, a registered nurse and the VA's deputy assistant under secretary for Health and Clinical Operations, also stressed the need for more staff in Sterile Procedure Services. She said a report on hiring would be filed by December and a plan should be ready in about six months.

"[The] current governance structure [at the VA] is simply not getting the job done," Bergman said.

He cited the Washington, D.C., VA Medical Center as the "poster child" for what has gone wrong at the VA in ensuring the provision of sterile equipment and operating rooms at its facilities.

The Washington VA center has been the subject of two scathing reports from the VA Office of Inspector General, released in 2017 earlier this year.

The latest IG report found "a culture of complacency among VA and Veterans Health Administration leaders at multiple levels who failed to address previously identified serious issues" at the Washington hospital and its two clinics.

"Veterans were put at risk because important supplies and instruments were not consistently available in patient care areas," the IG report said.

It added that equipment rooms where supplies were kept were filthy.

In his second week on the job in early August, VA Secretary Robert Wilkie visited the Washington facility, where he was told that plans were in place for "assuring reliable availability and sterilization of instruments for surgical procedures."

"We had a good visit today, and I appreciated hearing from facility and regional leadership on the important work that has been done to address the Inspector General's concerns, as well as plans for resolving all its remaining recommendations," Wilkie said in a statement following his visit.

-- Richard Sisk can be reached at

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