Surgical Service Care Deficiencies in the Critical Care Unit at the Charlie Norwood VA Medical Center in Augusta, Georgia

The VA Office of Inspector General (OIG) conducted a rapid response healthcare inspection at the Charlie Norwood VA Medical Center in Augusta, Georgia, to assess allegations from an anonymous complainant that deficiencies in care coordination between facility staff and remote telemedicine intensive care unit (tele-ICU) staff resulted in deaths, injuries, or poor outcomes for patients in the critical care unit (CCU) after general surgery residents were withdrawn. The names of six patients were included in the complaint. The OIG substantiated that deficiencies in care coordination existed between facility staff and tele-ICU staff after the residents were withdrawn but was unable to determine that the withdrawal resulted in deaths, injuries, or poor outcomes for patients identified in the complaint. The OIG found that facility leaders were aware of the potential withdrawal of the residents but did not take actions to ensure that effective processes were in place and failed to be proactive in developing, disseminating, and ensuring effectiveness of relevant algorithms. The OIG also found a combination of a misunderstanding of the tele-ICU program and a lack of facility staff engagement with tele-ICU staff to assist with co-management of monitored patients contributed to challenging and impaired communication processes. The tele-ICU was not integrated into facility quality management processes and facility staff and tele-ICU staff did not report, and therefore patient safety staff did not evaluate, tele-ICU patient safety events. Six recommendations were made to the Facility Director related to communication and coordination, on-call processes, medicine and surgery staff responsibilities, patient safety reporting training, quality review collaboration processes, and orientation and competency training. Two recommendations were made to the Veterans Integrated Service Network 10 Tele-ICU Medical Director related to patient safety reporting training and coordination of patient care reviews.