Multiple factors cited in Lexington VA deaths

October 13, 2009 by Bob Higgins · Leave a Comment

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Lexington’s Veterans Affairs Medical Center had a 25 percent death rate in 2008 for patients transferred into its intensive care unit from other wards. Photo: Pablo Alcala

By Jennifer Hewlett Kentucky.com

Insufficient nurse staffing levels, a lack of communication and planning, and significant gaps in key leadership roles may have contributed to a higher-than-expected mortality rate among patients treated in the intensive care unit at Lexington’s Veterans Affairs Medical Center on Cooper Drive, according to a consulting firm.

The high mortality rate prompted local and regional VA officials to call in the McLean, Va., based Booz Allen Hamilton consulting firm to investigate and issue recommendations.

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.)