Multiple Factors Cited in VA Deaths



In early September, the firm issued a scathing report about conditions throughout the VA Medical Center.

Among other things, the consulting firm found instances of emergency department triage being performed by a desk clerk; nurses not being able to readily identify or contact on-call residents, especially on nights and weekends; and doctors' orders not being followed.

The firm also found staffing shortages when it came to doctors, residents and interns. It found nursing education and certification levels that were below national standards. And the firm found that the hospital had difficulty in admitting patients due to a "daily house-wide gridlock," which sometimes resulted in patients being transferred to other hospitals until the VA hospital could take them back.

"The higher-than-expected ICU mortality rate at Lexington VA is likely the result of multiple factors, which, in concert, have a negative impact on the quality of care in multiple hospital units," the report says.

From Jan. 1 to July 23, 58 of 494 patients who had been treated in the VA hospital's intensive care unit died, according to the report. (According to the consulting firm, the intensive care unit mortality figures included people who died within 30 days of completing their stay in that unit.)

A safety climate survey done by the consultants indicated that two of three VA hospital intensive care unit staffers would not feel safe being treated as a patient. High percentages of staffers in other departments gave the same response.

Nurse charged in death

Since the report was issued, Maria K. Whitt, a former nurse at the VA hospital on Cooper Drive, has been charged in the 2006 death of a 90-year-old World War II veteran, who died of acute morphine intoxication in the hospital's intensive care unit. Whitt, 32, of Mount Sterling is accused of giving Jesse Lee Chain lethal doses of morphine Sept. 3, 2006. She has pleaded not guilty.

Two days after Whitt's arrest, a special agent in the U.S. Department of Veterans Affairs' Office of Inspector General testified at Whitt's detention hearing in federal court that at least two more patients died under suspicious circumstances while under her care.

Two-and-a-half weeks after the report came out, VA hospital registered nurse Jennifer Kay Angelini, 42, was found dead in a restroom on the hospital's sixth floor, which houses the intensive care unit. The Fayette County coroner's office is waiting for toxicology test results before ruling in her death.

Shortly after the Booz Allen Hamilton report was issued there was a major shakeup among top managers at the VA Medical Center, and the medical center began working with the consultants to implement a variety of changes.

Dr. Walter Divers, who, as chief of staff, oversaw the doctors at the medical center, and Melinda Washburn, who, as associate director for patient care services, oversaw the VA Medical Center's nurses, were moved into other roles at the center. They and Anita Stiles, who was moved out of her job as associate nurse executive for patient care services and into another position at the medical center, will continue to receive the same salaries they were making in their previous jobs — $130,001, $102,975 and $99,614.

Dr. Joe Pellecchia, chief of staff at the Huntington, W.Va., VA medical center, was brought to the Lexington VA Medical Center to serve as acting chief of staff. Greg Eagerton, associate director for patient care services at the Birmingham, Ala., VA medical center, was brought to the local VA medical center to serve as acting associate director for patient care services.

The management changes took effect Sept. 21.

An e-mail sent last week to the Herald-Leader from the Lexington VA Medical Center said recruiting for a new chief of staff had already begun.

Dr. Diane Knight, acting deputy chief medical officer for the group of VA medical centers that includes the one in Lexington, has been brought in to assist with recommendations made by Booz Allen Hamilton, a strategy and technology consulting firm that has done work for several federal government entities.

According to the e-mail, the local VA medical center is working to increase physician and nurse staffing; decrease the number of patients per nurse; lighten the administrative load of nurse managers; have a dedicated intensive care unit physician staff; and improve its patient incident reporting system, among other things.

"We are constantly engaged in process improvement opportunities and felt there would be value in a 'fresh eyes' approach. The consultants were asked to look at data, talk with employees, and provide feedback on areas where we had opportunities for improvement," the e-mail from the center's public affairs office said.

"Veterans can have confidence in the care we provide. We have over 1,700 dedicated employees who genuinely care about veterans and who take great pride in their work," said a follow-up e-mail sent to the Herald-Leader from the medical center on Friday. The e-mail noted that more than 30 percent of the medical center's workforce is comprised of veterans, and said that providing veterans with anything less than quality health care in a safe and compassionate environment was "simply unacceptable."

The Booz Allen Hamilton report lists 15 major contributing factors to the higher-than-expected mortality rate in the intensive care unit. Those factors involved several medical center departments.

The consultants found that the mortality rate for patients transferred to the intensive care unit within 48 hours of admission to other wards was 18 percent, four times higher than the mortality rate of patients directly admitted to the ICU.

Data for fiscal year 2008 shows a 25 percent death rate for patients transferred into the local VA hospital's intensive care unit from other wards. That compares with a national peer group mean of 17 percent, the report says.

The consultants found that patients were routinely placed in a higher level of care than necessary and that there was inadequate palliative and end-of-life care planning, which leads to "inappropriate ICU care."

The report found that the surgical intensive care unit was staffed with only one attending intensivist — or doctor who is trained in critical care — who was on duty on weekdays for three out of four weeks a month. The Society of Critical Care Medicine and other professional entities recommend that there be a full-time critical care doctor available on a timely basis in an intensive care unit 24 hours a day, every day, the report says.

The registered nurse-to patient ratio in the critical care unit at the VA hospital was better than the national benchmark of one nurse to 2.2 patients, according to the consultants. While the intensive care unit had a nurse-to-patient ratio that was above the national benchmark, other wards at the medical center had more patients per registered nurse than their national benchmarks, the report says.

Levels of training below national benchmarks

According to the report, only 36 percent of the medical center's intensive care unit nurses had a bachelor of science degree in nursing, while the national benchmark is 56 percent. Only 29 percent of the nurses in the hospital's emergency department had B.S. degrees in nursing, while the national standard is 59 percent; 43 percent of medical-surgical nurses had such degrees, just below the national standard of 44 percent.

According to the report, only 8 percent of the intensive care unit nurses had earned certification as critical care registered nurses, while the national standard for nurses with such certification is 42 percent. Only 14 percent of emergency department nurses had certification, compared with 33 percent nationally; four percent of the local hospital's medical-surgical nurses had certification, compared to 27 percent nationally.

Many of the VA Medical Center's staff physicians, residents and interns also have duties at the University of Kentucky Medical Center. Nationwide there are 107 medical schools in the country that are affiliated with VA medical centers.

UK Medical Center officials were not provided with a copy of the Booz Allen Hamilton report, and thus couldn't speak to it, said an e-mail attributed to UK College of Medicine dean Dr. Jay Perman.

"The VA is an active participant in the educational process, and like many universities across the nation, a number of our trainees gain a portion of their graduate medical education by rotating to our affiliated VA Medical Center. The specialty and the number of trainees who rotate to the VA is based upon the training requirements of the specialty, and upon agreement between the university and the VA on how those training requirements can best be met."


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