VA hospital visited by sterile processing team

WEST HAVEN — A VA team specializing in the maintenance of sterile conditions spent four days at the VA Connecticut Healthcare System hospital in West Haven last week — followed by a six-day visit by the national director of the program, the VA said Thursday.

The U.S. Department of Veterans Affairs issued a written statement about the visits in response to inquiries by Hearst Connecticut Media.

The statement does not mention any conclusions or recommendations that might have resulted from the visit — and the VA did not immediately respond to a request for them — but U.S. Sen. Richard Bluementhal, D-Conn., a member of the Senate Committee on Veterans Affairs, said he’ll be demanding answers in the days to come.

“The veterans of Connecticut deserve answers immediately and the VA has an obligation to provide them — and I will demand that the VA fulfill that obligation,” Blumenthal said Thursday evening.

“I’m aware of the situation and I take it very seriously, because any issue relating to sterile processing of equipment or other materials has to be concerning,” Blumenthal said. “So I will be demanding more specifics as to the findings of this visit and whether the recommendations for action are sufficient to assure unquestionable first-class facilities for Connecticut’s veterans. “

The West Haven VA was cited by the VA Inspector General’s office in 2014 for having dirty operating rooms as well as inadequate supervision and a high absentee rate.

But the VA said in the statement that the team that visited last week “was not from the VA Office of the Inspector General and the visit was not in relation to any prior VA OIG reports.”

The team from the National VA Sterile Processing Services, or SPS, program visited “to review the local program and offer recommendations for improvement and education to SPS staff,” the statement said.

“Thousands of local veterans choose to be treated at VA Connecticut because they know we provide exceptional health care that improves their health and well-being,” the VA statement said. “VA Connecticut continually assesses its clinical practices to ensure patient safety.

“Site visits by teams from VA headquarters happen frequently throughout the health care system nationally and are designed to ensure VA facilities maintain a state of continuous quality improvement,” the statement read.

“We anticipate future visits from the national SPS team as we work to implement the team recommendations,” the VA said.

The New Haven Register has submitted a request under the Freedom of Information Act for the conclusions of the SPS site team and its recommendations. The VA had not provided them as of the close of business Thursday.

Blumenthal said that while he doesn’t yet know the specifics, “This issue may be symptomatic of a larger challenge, which relates to the aging of the overall healthcare facility, which has been deeply concerning for some time.

“We’ve been advocating for greater investment and giving priority to the West Haven VA for complete renovation and rebuilding,” he said.

Back in 2014, the VA Inspector General concluded that “terminal cleaning procedures in the (VA operating room) are not performed appropriately and the hospital’s Environmental Management Services, or EMS, “has insufficient staff resources assigned to the OR.”

That report resulted from at least one unannounced inspection. It came four months after tests at the West Haven VA hospital found “low, but detectable levels” of Legionella bacteria in its water sources. That bacteria was found to have been “confined to one building” and was found “in about five faucets.”

The 2014 Inspector General’s report found that hospital EMS staff at that time did not “utilize standard operating procedures ... or checklists for cleaning that are consistent with recognized industry standards.

“Patients with infectious diseases who may require special precautions” at that time were “scheduled for surgical procedures throughout the day along with patients who are not infectious,” the report said.

“OR staff,” meanwhile, were “not always made aware of an infectious patient’s precaution status prior to the arrival of the patient,” it said.

Inspector General investigators at that time “substantiated that terminal cleaning of the OR is not performed appropriately and that a shortage of trained EMS staff assigned to the OR and an incomplete SOP and checklist inconsistent with recognized industry standards were contributing factors,” the report said.

With regard to supervision, the 2014 report found that “during an unannounced evening inspection of the OR, we saw no EMS staff for almost an hour, when two staff members should have been present,” the report stated. “EMS supervisors we spoke to could not explain the absence of employees during this time.”

At the time of the 2014 inspection, the VA’s EMS department had an authorized staffing of 125, with 38 vacancies, the report said, but facility managers reported “that on an average workday, 19 percent of EMS staff did not report to work.”