Deficiencies in Communication for a Patient with a Spinal Cord Injury at the Charlie Norwood VA Medical Center in Augusta, Georgia

The VA Office of Inspector General (OIG) conducted a healthcare inspection at the Charlie Norwood VA Medical Center (facility) in Augusta, Georgia, to assess allegations that a spinal cord injury (SCI) patient was inappropriately admitted to an inpatient SCI unit following surgical treatment of femur and tibia bone fractures. Allegations included that the patient was not consistently monitored for blood pressure or laboratory results, had significant postoperative bleeding requiring transfer to the critical care unit (CCU), and had multiple blood transfusions. The OIG identified a concern related to a lack of communication between an orthopedic surgeon and the SCI interdisciplinary team. The OIG did not substantiate that the patient’s postoperative admission to the SCI unit was inappropriate. Postoperative SCI patients are admitted to the SCI unit unless there are complications during surgery or other concerns. The patient met post-anesthesia care unit discharge criteria, and several facility SCI staff were familiar with the patient’s care. The patient experienced significant postoperative bleeding, which resulted in the patient’s transfer to a higher level of care and multiple blood transfusions. However, the OIG determined this event was not a result of the patient’s admission to, or the postoperative care provided on, the SCI unit. SCI nurses’ close monitoring of the patient and timely initiation of a rapid response contributed to the patient’s successful recovery. The OIG identified a lack of communication between the surgeon and SCI staff related to the outpatient management of the patient’s leg fractures prior to surgery. Establishing a process to ensure improved communication and coordination between the Surgery Service and the SCI Service may benefit SCI patients with surgical needs. The OIG made one recommendation to the Facility Director related to establishing a process to optimize communication.