INDIANAPOLIS — The Roudebush VA Medical Center usually performs hundreds of surgeries every month, but 13 Investigates has learned some of those surgeries have been put on hold – and a special incident response team has been mobilized – to address a safety concern involving the hospital’s surgical instruments.
The VA says the problem was first discovered last month as nurses and surgeons prepared to perform operations inside the Indianapolis VA hospital. A regional spokesman for the Department of Veterans Affairs tells 13News that staff “identified abnormalities in sterilized instruments” at Roudebush. An executive at the VA hospital further explained that surgical instruments required to perform medical procedures on veterans did not look as clean as they should.
“There were water spots that seemed to have a little bit of a white ring around them and then they also noticed a few brown spots,” explained Roudebush VAMC chief nursing executive Christie Artuso, who said many of the abnormal spots were the size of a pinhead. “We started to see several of these in a single day, and so at that point in time … we stopped immediately processing instruments here.”
Artuso said the hospital immediately set up a large incident management team (IMT), including 20 to 30 staff from various departments within the Roudebush VA Medical Center, to figure out the cause of the problem and how to address it.
The VA insists “there have been no negative patient outcomes as a result of this situation” because all trays of surgical instruments are inspected before every surgery.
“Any time any small change was noted in a tray, the entire tray was moved out, so we never used any of these instruments of patients,” Artuso told 13News.
But the discovery of unsterile surgical instruments has resulted in significant disruptions at Indiana’s busiest VA hospital, which is still struggling to fully understand the problem, mitigate its impact and return to normal operations.
Suspending sterilizations, delaying surgeries
Executives at Roudebush quickly decided to suspend operations at the hospital’s Sterile Processing Service (SPS) once the sterilization problem was discovered on April 10.
The SPS oversees sterilization of reusable surgical instruments used within the VA hospital. Without the ability to sterilize instruments needed for surgeries, the incident management team started looking to other VA hospitals for help.
For the past six weeks, Roudebush has been relying on VA medical centers in Marion, Fort Wayne, Dayton and Cincinnati to sterilize all of its surgical instruments so that it can continue to perform some of its scheduled operations. The process involves decontaminating the instruments after each surgery in Indianapolis, then trucking the instruments to other facilities for sterilization – often very late at night when the other VA hospitals are not using their sterilization machines – before driving the instruments back to Indianapolis.
The time-consuming process has impacted the number of surgeries performed at the Roudebush VA Medical Center.
Prior to shutting down the Roudebush Sterile Processing Service, doctors performed a total of 541 operations at the Indianapolis VA hospital in March. A Roudebush spokeswoman said the hospital was operating in March at peak capacity. In April, the number of operations dropped to 335 (a 43% decrease) and only 235 surgeries have been performed during the first three weeks of May, according to statistics provided by the VA.
“We’re trying to coordinate them based on the availability of our instrumentation,” explained Artuso.
She said to date, 116 medical procedures have been rescheduled due to the limited availability of sterilized instruments, with another 77 veterans currently in the process of rescheduling other operations. An additional 54 veterans were referred to “community care,” which allows them to schedule their surgeries at other hospitals (at VA expense).
“All of us are focused on the best possible care for our veterans and not delaying any of that care,” Artuso said, adding that most scheduled medical procedures were delayed only a few days.
Disruption, frustration
Other workers at the Roudebush VA Medical Center tell 13News the disruption to some veterans and their families has been profound.
Two staff members, who spoke to 13 Investigates on the condition of anonymity because they are not authorized to speak publicly about issues inside the VA medical center, said some veterans have been required to reschedule their surgeries multiple times over the past six weeks – sometimes with little advance notice.
“It’s disrupted everything. It’s been chaos,” said one of the Roudebush workers. “The delays are a big concern, and sending patients out to community care just causes some [patients] to start from scratch to get their operation scheduled. That can mean a 30-day or 45-day waiting time to get rescheduled for a surgery.”
“I think everyone’s frustrated, and we have no idea when this is going to end,” the other staff member told 13News.
Roudebush executives say the hospital’s patient care coordinators have been working with individual patients to present alternative options and to reschedule delayed procedures within a reasonable time frame, while continuing to prioritize cases based on clinical severity.
The VA hospital told 13 Investigates “all patients whose scheduled procedure has been impacted by the … interruption may elect to receive this procedure at a community facility” other than the Roudebush VA Medical Center.
The VA says it cannot estimate the cost of the disruption until after the SPS is fully restored.
Searching for the cause
Roudebush executives are still trying to determine exactly what caused the hospital’s sterilization process to go awry. They believe there is no single issue that is responsible for the problem, but rather multiple issues that created a “perfect storm” necessitating a shutdown of the Sterile Processing Service.
Artuso said an investigation points to the possibility that highly-acidic water in Roudebush’s steam injection system produced the white and brown spots detected on surgical instruments. She told 13News that engineers have installed a new steam injection system, as well as new filters, valves and pipes in an attempt to remedy the problem.
The VA says it has also taken additional steps to bring its SPS back online as soon as possible:
- Installation of four new sterilizers
- Complete cleaning of all sterilizer chambers
- Re-plumbing the reverse osmosis water system used to purify water
- Installation of higher quality sterilizer filters
- Installation of equipment to manage steam pH
- Increased the frequency of preventive maintenance of all sterilizers
- Reconditioning of all surgical instruments
- Established a water testing contract
A hospital spokeswoman said Roudebush executives are optimistic that the SPS will be fully operational by early June, but at this point, no one at the VA Medical Center is willing to set a firm date for facility operations and patient surgeries to return to normal.
Artuso said once the SPS is back online, Roudebush will re-sterilize its entire inventory of surgical instruments – all 30,000 of them.
“I am very grateful that we have a team that will stop the line and that will recognize when something doesn’t look right,” she said. “We adhere to very strict standards, and we owe that to our veterans.”