The investigation continues into the origin of stains on a sterilized tray that halted operations in the surgical unit at the John Cochran Division of the St. Louis VA Medical Center.
While surgical operations remain suspended, the VA held a surprise show-and-tell last week (Feb. 16) by opening up its surgical and dental facilities to select media.
Present was a team of experts, including Cochran’s Medical Director Rima Ann Nelson; Surgery Chief, Dr. Michael Crittenden; Chief Engineer Keith Repko; regional and national VA representatives; and Charles Hancock, an independent sterilization consultant.
Two other independent consulting groups have also been part of the investigation of processes involved in sterilization, but thus far, no definitive conclusions have been announced.
“What we do know is that it is not blood and it’s not bodily fluids that would put any of our patients’ safety at risk of infection,” said Medical Director Rima Ann Nelson.
Investigators are looking at chemicals or equipment as a possible source.
“We have tested the water; we have tested the team; we have tested the instruments; we have tested the processes; we have tested the washers; the sterilizer; the steam quality.
Through all of this, we have found nothing that could be hazardous,” said Keith Repko, chief engineer.
In addition, Repko said the VA has added steam filters, cleaned everything thoroughly and brought in vendors to thoroughly clean the sterilizers.
The cause of the water spots remain a mystery.
“In fact, we’ve had two independent labs analyze wipes, analyze the instrument panel, analyze the chemicals, analyze the supplies,” Repko said.
Three consultants are reviewing what the VA has done and are making recommendations.
“Now we are talking ions and metals and chemistry and chemicals,” Nelson said.
“I’ve looked at the procedures that are used here in the reprocessing of reusable medical devices, and they meet or exceed the national standards,” said Charles Hancock, the sterilization consultant.
Dozens of surgeries have been rescheduled or performed at other medical facilities and paid for by the VA, although officials would not speculate at what cost.
The VA stressed no veterans are endangered by the latest problem discovered in the sterilization services.
“To date we have found nothing that would put any patient at risk, but we truly want to understand what this is and we’ll resume when we truly understand what this is,” said Dr. Michael Crittenden, surgery chief.
Cochran officials said the most difficult part of the probe is losing the confidence of the veterans Cochran serves.
“I really want us to regain the trust of our veterans,” Nelson said.
The Joint Commission, the hospital and health facility national accreditation agency, also made an onsite visit earlier in the day. The VA said their report is not expected until at least 10 days.
“We would like to open as soon as we can, but we will not reopen until we know the cause, we’ve corrected whatever it was that caused the situation, and we can insure their safety,” Nelson said.
To read the VA’s full statement on the surgical tray investigation, go to www.stlouisva.gov.
Anonymous veteran survey
U.S. Senator Claire McCaskill has implemented an anonymous veteran satisfaction survey on her Senate website that veterans can fill out online; print a hard copy to fill out and return; or to find resources or request a meeting.
McCaskill said the VA has promised to respond to any questions or issues within 30 days of receiving a report.
Veterans can visit http://mccaskill.senate.gov/vhep to participate.
