Foster: VA sterilization issues too frequent

Reported incidents of improper equipment sterilization and procedures to protect veterans from contamination are growing too frequent at VA medical centers and clinics across the country, American Legion National Commander Jimmie Foster said today.

“Recent reports out of St. Louis, Mo., and Dayton, Ohio – along with a number of other incidents in the last three or four years – show that this problem is more system-wide than it is isolated,” Foster said. “VA Secretary Eric Shinseki has assured our staff that corrective measures are being taken to better ensure patient safety. We look forward to seeing his plan and helping however we can to assist in its implementation.”

Last week, the St. Louis, Mo., VA Medical Center suspended surgical procedures for several days while an investigation was conducted after an employee reported spots on surgical trays and a water stain on one surgical instrument at the facility. “We appreciate that it was a VA employee who reported this, which shows they are self-monitoring,” Foster said. “However, we are also disappointed and frustrated by the development, especially since we were just in St. Louis hearing about measures that had been taken to improve equipment cleanliness there.”

The American Legion’s System Worth Saving Task Force, which inspects VA medical facilities throughout the country before producing an annual report to Congress each year, visited the St. Louis VA Medical Center Jan. 12-13. There, members of the task force asked about sterilization procedural changes since letters were sent last year to about 1,800 veterans in the area, informing them that they may have been at risk of exposure to Hepatitus B, C, or even HIV. The task force was told that a number of corrective measures had been taken, including better compliance with manufacturer instructions for cleaning, disinfecting and sterilizing equipment, improved staff training, better monitoring and semi-annual self-assessments and action plans for areas in need of improvement.

“We believe the St. Louis VA Medical Center has been trying to establish procedures to prevent contamination since the problem last year,” Foster said. “But those procedures have clearly not yet been effective. VA has been dutiful in reporting the problems, but The American Legion wants to know how VA is going to solve them, not just in St. Louis, but throughout the country. And we want to know what we can do, as the largest veterans service organization, to help.”

Last week, VA also announced that more than 500 veterans were being contacted about potential hepatitus or HIV exposure after a Dayton, Ohio, clinic dentist admitted he had not always washed his hands or changed gloves between patients over an 18-year span. The clinic was offering free tests to those who may have been exposed. “The encouragement to get tested is strictly a precautionary measure,” a VA spokesman said. “It’s a very low risk that there’s any potential contamination.”

Reported sterilization discrepancies involving endoscopic procedures at facilities in Murfreesboro, Tenn., Augusta, Ga., and Miami, Fla., compelled VA to contact thousands of veterans after 2008, offering testing and treatment.

A 2009 report from the VA Inspector General’s Office concluded that the three facilities had not complied with management directives to employ a standardized approach on the re-use of endoscopic instruments. Following that, according an update posted on the VA website, the IG office completed a 129-facility investigation nationwide and found just one discrepancy – a typographical error. “VA is committed to transparency, sharing lessons learned from this process with the public sector and with the private health-care industry, with the intent of improving care for all patients,” the website reported.

Foster said he is confident that no one in VA is intentionally negligent about cleanliness and sterilization of equipment. “This is a problem that will get fixed quicker and better if we focus on real solutions, system-wide, rather than finger-pointing at any one facility. I look forward to seeing the secretary’s overall strategy and understanding how it will be put to work at the St. Louis VA Medical Center and all VA facilities throughout the country.”