Healthcare Inspection - Alleged Inappropriate Treatment Oklahoma City VA Medical Center Oklahoma City, Oklahoma

The Office Of Inspector General reviewed allegations of inappropriate treatment in the Cardiac Intensive Care Unit (CICU) at the Oklahoma City VA Medical Center (medical center), Oklahoma City, OK. The purpose of the inspection was to determine the validity of allegations of inappropriate treatment concerning a patient admitted to the CICU in November 2005 with uncontrolled diabetes. He became septic (infected) and was placed on a ventilator. His condition deteriorated and several physicians and nurses performed an emergency amputation of his right lower leg at his CICU bedside. Several employee complainants alleged that performing the amputation in the CICU was inappropriate, several staff declined to be involved, it was performed without an anesthesiologist, and the patient was not receiving adequate pain management. We did not substantiate the allegations. We concluded that performing the emergency amputation in the CICU was not unreasonable or clinically inappropriate. The patient had necrotizing fasciitis, a potentially fatal medical emergency associated with systemic toxicity and shock, which necessitated timely and aggressive management. The patient was critically ill, his hemodynamic stability was tenuous, and the surgical team felt that moving the patient from CICU to the operating room was precarious. An anesthesiologist was present during the entire procedure and monitored the appropriateness of the patient’s sedation. CICU staff assisted with the procedure as needed. However, we concluded that the patient had previously called the facility’s Telcare program and reported pain and swelling in his right lower leg. Telcare is a component of primary care that provides 24-hour telephone triage and health care advice. A primary care nurse attempted to call the patient 2 days later, and the line was busy. Later that day the patient’s wife brought him to the emergency room. We did not find documentation of earlier attempts to contact the patient. We recommended the Veterans Integrated Service Network (VISN) and Medical Center Directors take actions to review the Telcare triage and response process to ensure that calls are appropriately prioritized and followed in an efficient and timely manner. The VISN and Medical Center Director agreed with the findings and provided acceptable improvement plans. We will follow up until all action plans have been completed.