LEXINGTON, Ky. -- 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, Ky.'s, Veterans Affairs Medical Center, 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. It noted that the death rate among the hospital's ICU patients was much higher than in other facilities.
"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.
Since the report was issued, Maria K. Whitt, a former nurse at the VA hospital, 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, Ky., 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.
But the report found a host of other problems at the center. Among them: 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.
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.
Read the full story at Kentucky.com
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