Traumatic Brain Injury Services and Leaders’ Oversight at the Southeast Louisiana Veterans Health Care System in New Orleans

The VA Office of Inspector General (OIG) conducted an inspection at the request of Chairman Mark Takano, House Committee on Veterans’ Affairs, to assess allegations that facility staff failed to adequately evaluate and treat Traumatic Brain Injury (TBI) for patients who served in Operation Enduring Freedom/Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND) at the Southeast Louisiana Health Care System in New Orleans. The OIG did not substantiate the allegations that the facility polytrauma program failed to adequately evaluate and treat TBI for patients who served in OEF/OIF/OND. The OIG reviewed data from the Veterans Health Administration (VHA) Support Service Center and found the facility screening rate generally met or exceeded VHA’s national benchmark. The OIG conducted an independent electronic health record (EHR) review to determine if patients who had a positive initial TBI screen conducted at the facility from October 1, 2017, through September 30, 2020, received a Comprehensive Traumatic Brain Injury Evaluation (CTBIE), and if the CTBIE was completed within 30 days. The OIG reviewed 327 EHRs and found 243 CTBIEs were completed, with 172 of them completed within 30 days. The OIG found scheduling challenges, primarily patient causal factors, contributed to why CTBIEs were not timely completed. Of the 243 CTBIEs completed, 181 patients were diagnosed as having a TBI. Clinical services were initiated for 162 of the 175 patients where services were indicated. The OIG found that the plans of care were thorough and found several areas in which facility staff exceeded VHA standards. The OIG did not identify adverse clinical outcomes for patients whose CTBIE was not timely completed or where clinical services were indicated but not initiated. The OIG found that facility leaders also oversaw two EHR reviews of the assessment and evaluation of facility TBI patients. The OIG made no recommendations.