Department of Veterans Affairs
 

Office of Inspector General
 

Healthcare Inspection
 

Quality of Care in the Intensive Care Unit
 

VA Northern Indiana Health Care System
 

Fort Wayne, Indiana
 

Report No. 10-02816-200 June 20, 2011
 VA Office of Inspector General
 

Washington, DC 20420
 
To Report Suspected Wrongdoing in VA Programs and Operations:
 

Telephone: 1-800-488-8244
 

E-Mail: vaoighotline@va.gov
 

(Hotline Information: http://www.va.gov/oig/contacts/hotline.asp)
 
Quality of Care in the Intensive Care Unit, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

Executive Summary
 

The VA Office of Inspector General Office of Healthcare Inspections (OHI) conducted 

an inspection to determine the validity of allegations regarding quality of care at the VA 

Northern Indiana Health Care System (the facility) in Fort Wayne, IN. 

An anonymous complainant alleged that a physician was responsible for several patient 

deaths and that no action was taken following peer review assessments; a patient 

(Patient 1) died because the physician delayed transfer to a community hospital; and in 

March 2010, three ventilators were in simultaneous operation in violation of policy, with 

no backup ventilators available for emergencies. 

During the course of this inspection, the OHI received additional allegations regarding 

the physician. First, the physician allegedly prescribed medication which “fried a 

patient’s kidneys” and disregarded computer notification warnings about the use of a 

medication for the patient (Patient 2). Second, the physician allegedly removed a patient 

(Patient 3) from a ventilator prematurely and the patient needed to be transferred to a 

community hospital. 

An additional allegation was that a patient (Patient 4) with a large blood clot in his leg 

was inappropriately transferred from the Marion campus to the Fort Wayne campus, and 

his care was poorly managed after transfer. 

We found inadequate management, documentation, and review of Patient 1’s 

cardiopulmonary arrest and inadequate Intensive Care Unit (ICU) monitoring of 

Patient 2. We also found that Patient 3 should not have been accepted in transfer from a 

community hospital. We identified no quality of care issues in the care of Patient 4. 

We did not substantiate that the physician was responsible for patient deaths, delayed 

transfer of Patient 1, inappropriately prescribed a medication for Patient 2, or prematurely 

removed Patient 3 from a ventilator. 

We substantiated that in March 2010 there were two intervals when three patients in the 

ICU received mechanical ventilator therapy concurrently. We did not substantiate that 

there were no backup ventilators in the facility or that the use of three ventilators 

simultaneously was in violation of facility policy. 

During a 6-month period, we found 23 days with time periods ranging from 4 to 15 hours 

during which there were no staff in the facility with demonstrated competence in out-ofoperating room (OR) airway management. 

VA Office of Inspector General i 
Quality of Care in the Intensive Care Unit, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

In addition, we found that Medical Officers of the Day were routinely providing care to 

patients in the emergency department and to inpatients, including the ICU, contrary to 

Veterans Health Administration (VHA) policy. 

We recommended that the System Director: 

	 Ensure that peer review assessments of the care issues identified for Patients 1–3 

are conducted and that action is taken as necessary. 

	 Confer with Regional Counsel regarding adverse event disclosure to the family of 

Patient 1. 

	 Ensure that care provided in response to cardiopulmonary arrests is documented 

and reviewed in accordance with facility policy. 

	 Ensure that staff with demonstrated competence and clinical privileges or scope of 

practice are available at all times to provide out-of-OR airway management. 

	 Ensure that ICU physician coverage complies with VHA policy. 

The VISN and System Directors concurred with the inspection results. We will follow 

up on the planned actions until they are complete. 

VA Office of Inspector General ii 
DEPARTMENT OF VETERANS AFFAIRS
 

Office of Inspector General
 

Washington, DC 20420
 

TO:	 Director, Veterans In Partnership (10N11) 

SUBJECT:	 Healthcare Inspection – Quality of Care in the Intensive Care Unit, VA 

Northern Indiana Health Care System, Fort Wayne, Indiana 

Purpose 

The VA Office of Inspector General (OIG) Office of Healthcare Inspections (OHI) 

conducted an inspection to determine the validity of allegations regarding quality of care 

at the VA Northern Indiana Health Care System, Fort Wayne, IN. 

Background 

The VA Northern Indiana Health Care System, part of Veterans Integrated Service 

Network (VISN) 11, is comprised of two campuses located in Fort Wayne and Marion, 

IN. The Fort Wayne campus (the facility) has 22 medical/surgical and 4 intensive care 

unit (ICU) beds. The Marion campus provides long term care and acute and chronic 

psychiatric care, serving as the psychiatric referral hospital for veterans throughout the 

state of Indiana. The Fort Wayne and Marion campuses are located approximately 

56 miles apart. 

An anonymous complainant contacted the OIG Hotline Section on May 19, 2010. The 

complainant alleged that: 

	 A physician (Physician X) at the facility was responsible for several patient deaths 

during the past 2 years and that no action was taken following peer review 

assessments. 

	 In March 2010, a patient (Patient 1) died because Physician X delayed transfer to a 

community hospital. 

	 In March 2010, three ventilators were in simultaneous operation in violation of 

policy, with no backup ventilators available for emergencies. 

VA Office of Inspector General 1 
Quality of Care in the Intensive Care Unit, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

During the course of this inspection, the OHI received the following additional 

allegations: 

	 Physician X prescribed medication which “fried a patient’s kidneys.” The patient 

(Patient 2) was transferred to a community hospital for emergency dialysis and 

died. 

	 Physician X disregarded computer notification warnings about the use of 

theophylline for Patient 2. 

	 Physician X removed a patient (Patient 3) from a ventilator prematurely, and the 

patient needed to be transferred to a community hospital. 

	 A patient (Patient 4) with a large blood clot in his leg was inappropriately 

transferred from the Marion campus to the Fort Wayne campus, and his care was 

poorly managed after transfer. 

Scope and Methodology 

We conducted onsite inspections on July 26–28 and September 20–23, 2010. We 

reviewed facility and Veterans Health Administration (VHA) policies, committee 

minutes, quality management data and documentation, and other applicable facility 

documents. Also, we evaluated facility data from the VHA Inpatient Evaluation Center. 

We interviewed employees and managers with knowledge of or the responsibility for 

administrative controls related to these allegations. 

We conducted the inspection in accordance with Quality Standards for Inspection and 

Evaluation published by the Council of Inspectors General on Integrity and Efficiency. 

Case Summaries 

Patient 1 

The patient had a history of myocardial infarction, congestive heart failure, carotid artery 

disease, and diabetes mellitus. He had previously undergone coronary artery bypass 

surgery, carotid artery surgery, and placement of an implantable cardioverter 

defibrillator. 

The patient was admitted to the facility in early March 2010 after presenting with 

shortness of breath and chest pressure. Echocardiography revealed “markedly decreased 

left ventricular systolic function.” He improved following intravenous (IV) treatment 

with a diuretic and was discharged home after 3 days. 

Ten days after discharge, the patient presented to the facility emergency department (ED) 

with 2–3 days of worsening shortness of breath and less than 1 day of left calf swelling 

and pain. Computed tomography (CT) of the thorax showed no evidence of pulmonary 

VA Office of Inspector General 2 
Quality of Care in the Intensive Care Unit, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

embolism. The patient was admitted to the general medical ward and treated with IV 

fluids and the antibiotic ceftriaxone for possible pneumonia. 

On the following morning, after the patient’s blood pressure (BP) was found to be low 

(86/50 mm Hg), the rate of IV fluids was increased and two of the patient’s usual 

medications (furosemide and carvedilol) were discontinued. Also on that morning, 

laboratory personnel reported that blood cultures obtained in the ED on the previous 

afternoon were growing gram positive cocci, and antibiotic therapy was changed to 

piperacillin/tazobactam and clindamycin. 

The patient was transferred to the ICU and evaluated by surgical consultants, who noted 

that there was no crepitation of the left leg on physical examination and that 

ultrasonography obtained that day had revealed no evidence of deep vein thrombosis. 

The consultants indicated that the patient had “cellulitis with sepsis” and recommended 

the addition of a third antibiotic, vancomycin. Because of persistent hypotension, the 

patient was also treated with dopamine. 

Nursing documentation describes that the patient became increasingly lethargic and had 

decreased urine output, and that the patient’s family requested transfer to another facility. 

A nursing report was called to a local community hospital, but at that time no bed was 

available. Approximately 1 hour later, the receiving hospital was ready to accept the 

patient and ambulance transportation was initiated. Approximately 30 minutes later, the 

patient’s breathing was judged to be ineffective, and a code blue was called. The cardiac 

rhythm recorded at the time the patient deteriorated was ventricular tachycardia. The 

physician who responded wrote that the patient “did not have a pulse or BP during the 

code.” Advanced Cardiac Life Support protocols were reportedly implemented “for 

about 40 minutes,” but the patient did not survive. The death certificate states that death 

was due to “streptococcus pyogenes septic shock and congestive heart failure.” 

Patient 2 

The patient was transferred from a community hospital to the facility in mid-february 

2009 with severe chronic obstructive pulmonary disease and pneumonia. On hospital day 

(HD) 2, he was moved to the ICU for continuous nebulizer treatment and closer 

monitoring. He received IV fluids only as necessary for administration of an antibiotic, 

but these were discontinued by HD 3. Nursing documentation indicated that he was 

eating less than half of each meal. During the hospitalization, physicians received routine 

electronic notifications warning of the potential for interactions among the patient’s 

medications. 

On HD 6, he was noted to have mental status changes and decreased urine output. 

Laboratory tests revealed markedly worsened kidney function when compared with the 

most recent tests 5 days earlier. A private nephrologist was consulted and the patient was 

transferred to a community hospital for urgent hemodialysis. 

VA Office of Inspector General 3 
Quality of Care in the Intensive Care Unit, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

The patient died 3 days later. Medical records obtained from the private hospital 

revealed that the patient had worsening respiratory distress but had “regained his normal 

renal function.” The death certificate states that death was due to “end-stage chronic lung 

disease.” 

Patient 3 

The patient was transferred to the facility from a community hospital in mid-October 

2009 for continued treatment of acute respiratory failure and sepsis. He was morbidly 

obese and had recently been treated with chemotherapy for non-Hodgkin’s lymphoma. 

At the time of transfer, he was intubated and receiving IV medication to maintain a 

normal BP. He was admitted to the facility ICU and treated with broad spectrum 

antibiotics. Over the next few days, his condition gradually improved. 

On the morning of HD 5, the patient expressed that he wished to have the endotracheal 

tube (ETT) removed. That afternoon, a respiratory therapist (RT) wrote that the “patient 

became anxious coughing up pink frothy mucus via ETT.” The RT was unable to pass a 

suction catheter and notified Physician X of a possible kink in the ETT. Physician X 

ordered that the patient be extubated and placed on BiPAP.1 The patient subsequently 

developed respiratory distress, and an anesthesiologist was notified of the need for 

emergent intubation. The anesthesiologist was unable to intubate, noting “significant 

airway edema” and that “the decision was made to transfer patient to a facility with 

backup for a surgical airway due to risk of increasing airway edema and loss of airway 

with continued airway manipulation.” Later that evening, the patient was transferred to a 

community hospital (different from the original transferring hospital) and successfully 

intubated. 

At the community hospital, the patient was extubated the following day, hospitalized an 

additional 3 days, and transferred back to the facility. He was then discharged home after 

1 day. At the time of this report, 17 months after discharge, the patient was ambulatory 

and attending clinic visits at the facility. 

Patient 4 

The patient presented to the urgent care clinic at the Marion campus in late September 

2010 with 4 days of pain involving his entire left leg. His medical history was significant 

for hypertension, diabetes mellitus, arthritis, and a remote history of left leg deep vein 

thrombosis. Ultrasonography at a local hospital revealed extensive left proximal iliac 

vein thrombosis, and the patient was treated with the anticoagulant enoxaparin and 

transferred to the Fort Wayne facility. At Fort Wayne, he was admitted to a general 

1 BiPAP is a form of positive airway pressure commonly used in critically ill patients. The patient wears a sealed 

mask by which oxygen is delivered at a higher pressure during inspiration than during expiration. 

VA Office of Inspector General 4 
Quality of Care in the Intensive Care Unit, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

medical ward and then to the ICU because he was considered to be at high risk for 

pulmonary embolism. 

Approximately 6 hours after admission, the patient developed chest pain and shortness of 

breath, and CT revealed bilateral pulmonary emboli. With remobilization occurring 

despite anticoagulation, the patient was felt to require placement of an inferior vena cava 

(IVC) filter, and he was transferred to a community hospital. An IVC filter was placed 

without complication and the patient was discharged home after 3 days. At the time of 

this report, 7 months later, the patient was ambulatory and attending clinic visits at the 

facility. 

Inspection Results 

Issue 1: Quality of Care for Specific Patients 

In the care of Patient 1, we found inadequate management of cardiopulmonary arrest. At 

the time of arrest, the patient’s initial cardiac rhythm was ventricular tachycardia. 

Although this abnormal rhythm should have been treated with immediate electrical 

cardioversion, we found no evidence that this treatment was provided for at least 

20 minutes. 

Facility policy2 states that the ICU Nurse Manager or Nursing Officer of the Day, during 

non-administrative hours, is responsible for coordinating a critique of code blue 

management with those involved in the code as soon as possible. Findings and 

recommendations are to be reported to the Critical Care Committee (CCC). The CCC is 

to review critiques of medical codes and out-of-operating room (OR) airway data.3 

In this case, concurrent documentation of code activities was inadequate and there was no 

post-code assessment. Further, the CCC did not review available cardiac rhythm 

recordings. 

Patient 2 was inadequately monitored during his ICU stay. The patient was eating 

poorly, physicians documented no clinical assessment of his fluid requirements during 

3 days in the ICU, and there was no laboratory assessment of kidney function. 

Patient 3 should not have been accepted in transfer from the community hospital. 

At the time of transfer, he required mechanical ventilation and IV medication for BP 

support. Moving such a patient between facilities subjects the patient to risks that are 

appropriate only if the receiving facility can provide critical services not otherwise 

available. 

We identified no quality of care issues in the care of patient 4. 

2 VA Northern Indiana Health Care System Policy Number 11-46, Emergency Response Code Blue, April 25, 2008. 3 VA Northern Indiana Health Care System Policy Number 11-07-10, Critical Care Committee, February 17, 2010. 

VA Office of Inspector General 5 
Quality of Care in the Intensive Care Unit, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

Issue 2: Quality of Care Provided by Physician X 

We did not substantiate that Physician X was responsible for patient deaths. A review of 

deaths at the facility during fiscal years (FYs) 2009–2010 revealed no association with 

patient care management by Physician X. Further, reports for the facility generated by 

VHA’s Inpatient Evaluation Center for quarters 3 and 4 of FY 2010 revealed no excess 

mortality. 

We did not substantiate that Physician X delayed transfer of Patient 1, inappropriately 

prescribed theophylline for Patient 2, or prematurely removed Patient 3 from a ventilator. 

Physician X received notifications and considered the possibility of interactions between 

Patient 2’s medications. However, we identified no inappropriate use of medications, 

and no untoward consequences resulted from the combination of medications prescribed. 

Issue 3: Out-of-Operating Room Airway Management 

A facility anesthesiologist is on call to assist with airway management in out-of-OR 

settings during non-administrative hours, but this physician does not remain in the facility 

and is only required to arrive within 1 hour of being contacted. To ensure that competent 

staff are always available to provide airway management in out-of-OR settings, facility 

policy requires the Chief of Staff to assess the number and type of clinical staff whose 

expected duties include these procedures.4 We found that no assessment had been 

completed. 

The facility hired contract physicians to work as Medical Officers of the Day5 (MODs). 

The MOD contract in effect from February 1, 2010, through January 31, 2011, stipulated 

that MODs complete a written test on emergency airway management and demonstrate 

competence in emergency airway management to facility staff. 

A review of the training records and credentialing and privileging files of the 10 MODs 

who provided medical coverage at the facility during non-administrative hours revealed 

that only 2 of the MODs had passed the written test, had demonstrated competency, and 

were privileged to perform out-of-OR airway management. 

Facility RTs who agreed to provide out-of-OR airway management were provided 

opportunities to establish competence. At the time of our review, 14 RTs were employed 

at the facility and 6 (43 percent) of them were identified as being competent to perform 

out-of-OR airway management. There were no RTs who were deemed competent to 

perform out-of-OR airway management assigned to work the evening shift at the time of 

our review. 

4 VA Northern Indiana Health Care System Policy Number 11-51, Out-of-Operating Room Airway Management,
 

August 6, 2008.

5 The Medical Officer of the Day is a designated responsible physician who is physically present in an inpatient
 

facility during periods when the regular medical staff is not on duty. These periods generally include evenings,
 

nights, weekends, and holidays, but may be required in other circumstances.
 

VA Office of Inspector General 6 
Quality of Care in the Intensive Care Unit, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

We reviewed MOD and RT schedules for March–August 2010. We found 23 days with 

time periods ranging from 4 to 15 hours during which there were no staff in the facility 

deemed competent to perform out-of-OR airway management. 

Issue 4: Critical Care Issues 

ICU Physician Staffing. Facility policy states that all physicians with ICU privileges will 

share an on-call schedule covering 24 hours a day, 7 days a week, to assure that one 

physician with ICU privileges is always available for consultation.6 Physicians without 

specific ICU privileges, including MODs, can admit patients to ICU. When a practitioner 

without ICU privileges admits patients to ICU, he/she is to contact the attending 

physician to discuss the clinical condition and treatment plan. 

At the time of our review, the facility had 10 contract MODs and only 4 of them had 

privileges to provide ICU care. Management of ICU patients within the first 24 hours of 

admission was largely provided by MODs, many of whom lacked privileges to provide 

ICU patient care and whose primary responsibility was to provide patient care in the ED. 

According to VHA policy, a properly trained, experienced, credentialed, and privileged 

emergency physician must be present in the ED at all times and must not be expected to 

cover the inpatient unit or respond to emergencies outside of the ED.7 

The facility hired contract physicians to work as MODs. One MOD was scheduled to 

work from 4:30 p.m. to 8:00 a.m., Monday through Friday. On Saturday and Sunday, 

one MOD was scheduled to work a 12-hour shift (8:00 a.m.–8:00 p.m. or 

8:00 p.m.–8:00 a.m.). Most of the time the MOD was on duty, he/she was the only 

physician in the facility. 

The MOD contract stated that the care of inpatients during non-administrative hours is 

the responsibility of the MOD, and that he/she should visit all wards, including ICU, and 

personally see all seriously ill patients and other patients as requested by charge nurses or 

staff physicians. 

Ventilator Management. We substantiated that in March 2010 there were two intervals 

when three patients in the ICU received mechanical ventilator therapy concurrently. We 

did not substantiate that there were no backup ventilators in the facility; three portable 

ventilators were available for use in the event there was a need for another due to 

mechanical failure or additional patient care requirements. 

6 VA Northern Indiana Health Care System Policy Number 11-16, Intensive Care Unit (ICU), January 26, 2007. 7 VHA Directive 2010-010, Standards for Emergency Department and Urgent Care Clinic Staffing Needs in VHA 

Facilities, March 2, 2010. 

VA Office of Inspector General 7 
Quality of Care in the Intensive Care Unit, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

We did not substantiate that the simultaneous use of three ventilators was in violation of 

facility policy. We found no guidance limiting the number of ventilators that can be used 

concurrently. 

Conclusions 

We found inadequate management, documentation, and review of Patient 1’s 

cardiopulmonary arrest and inadequate ICU monitoring of Patient 2. We also found that 

Patient 3 should not have been accepted in transfer from a community hospital. We 

identified no quality of care issues in the care of patient 4. 

We did not substantiate that Physician X was responsible for patient deaths. We also did 

not substantiate that Physician X delayed transfer of Patient 1, inappropriately prescribed 

theophylline for Patient 2, or prematurely removed Patient 3 from a ventilator. 

During a 6-month period, we found 23 days with time periods ranging from 4 to 15 hours 

during which there were no staff in the facility with demonstrated competence to perform 

out-of-OR airway management. 

MODs were routinely providing care to patients in the ED and to inpatients, including the 

ICU, contrary to VHA policy. 

We substantiated that in March 2010 there were two intervals when three patients in the 

ICU received mechanical ventilator therapy concurrently. We did not substantiate that 

there were no backup ventilators in the facility or that the use of three ventilators 

simultaneously was in violation of facility policy. 

Recommendations 

Recommendation 1. We recommended that the System Director ensure that peer review 

assessments of the care issues identified for Patients 1–3 are conducted and that action is 

taken as necessary. 

Recommendation 2. We recommended that the System Director confer with Regional 

Counsel regarding adverse event disclosure to the family of Patient 1. 

Recommendation 3. We recommended that the System Director ensure that care 

provided in response to cardiopulmonary arrests is documented and reviewed in 

accordance with facility policy. 

Recommendation 4. We recommended that the System Director ensure that staff with 

demonstrated competence and clinical privileges or scope of practice are available at all 

times to provide out-of-OR airway management. 

VA Office of Inspector General 8 
Quality of Care in the Intensive Care Unit, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

Recommendation 5. We recommended that the System Director ensure that ICU 

physician coverage complies with VHA policy. 

Comments 

The VISN and System Directors concurred with the inspection results (See Appendixes A 

and B, pages 10–14, for the full text of the Directors’ comments). We will follow up on 

the planned actions until they are complete. 

JOHN D. DAIGH, JR., M.D.
 

Assistant Inspector General for
 

Healthcare Inspections
 

VA Office of Inspector General 9 
Quality of Care in the Intensive Care Unit, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

Appendix A 

VISN Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 May 2, 2011 

From:	 Director, Veterans In Partnership (10N11) 

Subject:	 Healthcare Inspection – Quality of Care in the Intensive Care 

Unit, VA Northern Indiana Health Care System, Fort Wayne, 

Indiana 

To:	 Director, Chicago Office of Healthcare Inspections (54CH) 

Thru:	 Director, Management Review Service (10B5) 

Attached is the response from VA Northern Indiana 

Healthcare System to the Quality of Care in the ICU at Ft. 

Wayne. If you have any questions, please contact Kelley 

Sermak, Acting QMO, at 734-222-4302. 

Michael S. Finegan
 

Director, Veterans In Partnership (10N11)
 

VA Office of Inspector General 10 
Quality of Care in the Intensive Care Unit, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

Appendix B 

System Director Comments 

Department of 

Veterans Affairs Memorandum 

Date:	 April 28, 2011 

From:	 Director, VA Northern Indiana Health Care System (610A/4) 

Subject:	 Healthcare Inspection – Quality of Care in the Intensive Care 

Unit, VA Northern Indiana Health Care System, Fort Wayne, 

Indiana 

To:	 Director, Veterans In Partnership (10N11) 

1. The Leadership has reviewed the draft inspection report of 

the Review of Quality of Care conducted by the Office of 

Healthcare Inspections. Our response to the 

recommendations is attached. 

2 We appreciate the completeness of the review that was 

conducted for these cases involving Veterans treated in the 

Intensive Care Unit. We concur with the recommendations 

and have implemented changes to increase patient safety in 

the Intensive Care Unit. 

(original signed by:)
 

Helen Rhodes, Acting Director for and in the absence of:
 

Daniel Hendee, FACHE, Director
 

Director, VA Northern Indiana Health Care System (610/A4)
 

VA Office of Inspector General 11 
Quality of Care in the Intensive Care Unit, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

Director’s Comments
 

to Office of Inspector General’s Report
 

The following Director’s comments are submitted in response to the 

recommendations in the Office of Inspector General’s report: 

OIG Recommendations 

Recommendation 1. We recommended that the System Director ensure 

that peer review assessments of the care issues identified for Patients 1–3 

are conducted and that action is taken as necessary. 

Concur: Target Completion Date: June 30, 2011 

Facility’s Response: 

Peer reviews were completed on each of these patients. These Internal 

Peer Reviews have been sent for External Peer Review in order to validate 

Internal Peer Review findings. 

Status: Initial Facility Peer Reviews Completed on May 20, 2010. 

External Peer Reviews Results and Peer Review Committee Reviews 

should be completed by June 30, 2011. 

Recommendation 2. We recommended that the System Director confer 

with Regional Counsel regarding adverse event disclosure to the family of 

Patient 1. 

Concur: Target Completion Date: June 30, 2011 

Facility’s Response: 

Regional Counsel was conferred with on April 21, 2011, regarding adverse 

event disclosure to the family of Patient 1. It was decided that an 

institutional disclosure was not warranted at this time but would be 

reevaluated after completion of an External Peer Review. 

Status: Completed initial conference on April 21, 2011. External Peer 

Review Results and Peer Review Committee Reviews should be completed 

by June 30, 2011. 

VA Office of Inspector General 12 
Quality of Care in the Intensive Care Unit, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

Recommendation 3. We recommended that the System Director ensure 

that care provided in response to cardiopulmonary arrests is documented 

and reviewed in accordance with facility policy. 

Concur: Target Completion Date: May 31, 2011 

Facility’s Response: 

VA NIHCS complies with VA NIHCS Policy 11-46-11, Emergency 

Response Code Blue, and VHA Directive 2008-063. Cardiopulmonary 

resuscitative events and their immediate Code Critiques are monitored on a 

monthly basis by the Acute Care Committee (formerly, the Critical Care 

Committee) for completeness and quality of care. Codes are critiqued by 

the code team members and then reviewed by an Intensive Care Unit RN 

for recommendations which are forwarded to the Patient Safety Manager 

(this is transitioning to Quality Management) who prepares the code report 

for the monthly review by the Acute Care Committee and compiles data per 

the directive for trending in a quarterly Cardiopulmonary report. Issues and 

non-compliance are identified, recorded, and sent out to appropriate 

managers for action. Actions are followed up by Patient Safety 

(transitioning to Quality Management) who reports the data to the 

committee for tracking and trending. The Acute Care Committee 

aggregates and analyzes the data looking for opportunities for improvement 

and reports go to the Clinical Executive Board. 

In the March 2010 code review, the code was not documented according to 

facility policy and records could not be found. The code members were 

questioned regarding their recollection of the event. The lack of 

documentation issue for this code was discussed during the April 2010 

Critical Care Committee and the decision was made to make the ICU Nurse 

Manager responsible to ensure that code records and code critiques are 

completed according to VA NIHCS policy. During the July 2010 OIG 

review, the code record and strips were found. These were then reviewed 

by the Critical Care Committee at their August 2010 meeting. In an effort 

to provide oversight into tracking the code blue responses and appropriate 

documentation, Quality Management will discuss all code blue events on 

an ongoing basis during morning report. Quality Management will track 

follow-up of all code blue events by placing the information on the morning 

report tracking log and will ensure that all documentation is completed 

according to VA NIHCS policy. This oversight will also include ensuring 

that the code blue documentation and strips have been scanned into the 

medical record. 

VA Office of Inspector General 13 
Quality of Care in the Intensive Care Unit, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

Status: Open 

Recommendation 4. We recommended that the System Director ensure 

that staff with demonstrated competence and clinical privileges or scope of 

practice are available at all times to provide out-of-OR airway management. 

Concur: Target Completion Date: January 20, 2011 

Facility’s Response: 

All Fort Wayne MODs covering the ICU have established competencies 

with out-of-OR airway management and have been credentialed and 

priviledged to do so. A second MOD was added for non-administrative 

hours, including holidays, so that one is available at all times to provide 

out-of-OR airway management. 

Status: Completed. 

Recommendation 5. We recommended that the System Director ensure 

that ICU physician coverage complies with VHA policy. 

Concur: Target Completion Date: October 12, 2010 

Facility’s Response: 

A second MOD was added for non-administrative hours, including 

holidays, so that ICU physician coverage complies with VHA policy. 

Status: Completed. 

VA Office of Inspector General 14 
Quality of Care in the Intensive Care Unit, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

Appendix C 

OIG Contact and Staff Acknowledgments 

OIG Contact For more information about this report, please contact the 

Office of Inspector General (202) 461-4720 

Acknowledgments Verena Briley-Hudson, NP, Chicago Regional Director 

Roberta Thompson, LCSW, Team Leader 

Paula Chapman, CTRS 

Jerome Herbers, Jr., MD 

JoDean Marquez, RN 

Jennifer Reed, RN 

Wachita Haywood, RN 

Judy Brown, Program Support Assistant 

VA Office of Inspector General 15 
Quality of Care in the Intensive Care Unit, VA Northern Indiana Health Care System, Fort Wayne, Indiana 

Appendix D 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Director, Veterans In Partnership (10N11) 

Director, VA Northern Indiana Health Care System (610/A4) 

Non-VA Distribution 

House Committee on Veterans’ Affairs 

House Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

House Committee on Oversight and Government Reform 

Senate Committee on Veterans’ Affairs 

Senate Appropriations Subcommittee on Military Construction, Veterans Affairs, and 

Related Agencies 

Senate Committee on Homeland Security and Governmental Affairs 

National Veterans Service Organizations 

Government Accountability Office 

Office of Management and Budget 

U.S. Senate: Sherrod Brown, Daniel Coats, Richard G. Lugar, Rob Portman 

U.S. House of Representatives: Dan Burton, Joe Donnelly, Robert E. Latta, Mike Pence, 

Todd Rokita, Marlin Stutzman 

This report is available at http://www.va.gov/oig/publications/reports-list.asp. 

VA Office of Inspector General 16