Veterans are not Guinea Pigs: Investigation of Patient Death Finds Deficient Care at VA Hospital
This article reports that the emergency department triage may have resulted in delay in care. They reported: The emergency department triage of a patient who later died at a Florida VA facility was “deficient and mismanaged,” according to a new report issued by the VA Office of Inspector General. The actual report (https://www.oversight.gov/sites/default/files/oig-reports/VA/VAOIG-20-03535-146.pdf) titled: “Delay in a Patient’s Emergency Department Care at the Malcom Randall VA Medical Center in Gainesville, Florida” From the Inspector General’s report:
“In summer 2020, the OIG received an anonymous complaint alleging that a patient’s care was delayed and mismanaged in the facility’s Emergency Department, resulting in the patient’s death. The complainant also alleged that facility leaders ignored complaints of inadequate nurse staffing levels in the Emergency Department”
The report speaks to that the Veterans Health Administration (VHA) uses a five tier Emergency Severity Index (ESI) triage system by registered nurses performing triage in VHA emergency departments. ESI level 1 is used for patients who need immediate lifesaving intervention whereas ESI levels 3, 4, and 5 are used for patients who can wait to be seen.
Both the article and VHA IG report described a 60-year-old patient only days post op, who arrived at the ED with constant abdominal pain of 8 out of 10, labored breathing, and pale complexion in addition to having had the recent abdominal procedure, according to the OIG report. However, the patient was assigned an emergency severity index (ESI) level 3 (meaning they could wait to be seen) by a nurse, evaluated by a nurse practitioner, and returned to the waiting room. Ok, right there! I’m not an ED or triage expert, but even in my limited trained brain, if your put good and bad on a continuum, this way over on the bad side. You can list right off the bat a series of dangerous differentials that would need to immediately be ruled out. However the first error found that the patient was incorrectly triaged, and I would hate to be this RN. During the next hour, the patient yelled, “I cannot breathe,”
We all know about this reference, but to have something like this happen to anyone, let alone a Veteran is incomprehensible. Why are Veteran’s always subject to less than standard care? Less competent providers? The report and article then state “nurse provided supplemental oxygen via nasal canula. Just over an hour after the patient arrived at the facility’s Emergency Department, the patient fell forward out of a chair and a code blue was initiated. The patient was taken to an examination room and was noted to be unresponsive and cyanotic with agonal breathing. The patient was admitted to the Surgical Intensive Care Unit and died later that day.” I would really hate to be this RN. Not only incorrectly triaging the patient, then not recognizing a deteriorating condition providing only supplemental oxygen.
I would also hate to be the nurse practitioner, the provider who saw the patient. Again, why was there not a physician seeing a Veteran? I hate that it’s always Veterans who seem to suffer needlessly. I’m not here to bash non-physician providers, but the IG report says: “The nurse practitioner reported reviewing the patient’s EHR briefly and saw the surgeon’s note asking the patient to present to the facility’s Emergency Department for evaluation. However, the nurse practitioner did not contact the facility surgeon upon the patient’s arrival and assessment. Although communication between facility Emergency Department staff and surgical staff is not required, it may have improved the patient’s Emergency Department triage.” Ultimately, a CT scan completed after the patient’s deterioration but prior to death indicated extensive thrombus in the aorta with blood supply being cut off from multiple organs, according to the report.
The VHA IG report states that: “Placing patients in emergency department rooms, instead of the waiting room, allows for intravenous access to be started, vital signs to be monitored, and for a physician to be assigned to assess the patient.” However: “The OIG was unable to determine if the patient would have been seen by a physician prior to the code if assigned an ESI level 2 and placed in a room.”
It’s not just the VA. My father was in a private, for profit hospital for 5 days and was never seen by a doctor from the hospitalist service, just a midlevel, who admitted to me that the admitting hospitalist had never seen him. There was a pulmonologist consulted who did visit (a couple times, I have the EOB so I know it wasn’t everyday) but he only communicated with me when I called his cell phone (which I had from before I retired). He was also seen by a midlevel who was supposed to do a palliative care consult. She spent 10 minutes on the phone telling me he wasn’t “ready for hospice.” He died within a week of that “consult.”
Do we even need a Veteran’s Administration anymore? I mean for healthcare. Would we be better off giving them Medicare and letting them choose their own care? Maybe running VA hospitals limited to rehabilitation and psychiatry? Maybe offering the psych/rehab services to the civilian population as well, to maintain baseline services, with ability to expand after conflicts. And maybe I should not say “would WE be better off”, maybe I should be saying would the VETERANS be better off?
I work in this system. They are slowly replacing all MDs in NFL/VISN8 VAs with NPs. And that ER is a joke, it exists to obstruct care.
Horrendous story. I say again, if you can, you do. If you can’t, you work at the VA.
So disgusting. The Veterans give the best of themselves, take supreme risks and then are treated as the worst of us. I rotated through a VA hospital in the late 80’s. This could be a story from then but without the publicity. I guess nothing has changed.