Department of Veterans Affairs 

Office of Inspector General 

Healthcare Inspection

Out-of-Operating Room Airway

Management in Veterans Health

Administration Medical Centers

Report No. 08-01130-173 July 29, 2008

VA Office of Inspector General 

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

Call the OIG Hotline – (800) 488-8244 
Out-of-Operating Room Airway Management in Veterans Health Administration Medical Centers 

Executive Summary

The VA Office of Inspector General reviewed Veterans Health Administration (VHA) 

medical centers to assess compliance with VHA Directive 2005-031, Out-ofOperating Room Airway Management, dated August 8, 2005. This subject is 

important since not all facilities have 24-hour anesthesia coverage; therefore, other 

clinical staff must be competent in airway management. In addition, VHA recognizes 

that direct observation of care provided to actual patients is required. The directive 

addresses appropriate competencies of practitioners who perform urgent and emergent 

airway management outside of VHA operating rooms and the use of devices to 

confirm successful tube placement. 

We requested specific documentation regarding out-of-operating room airway 

management from all medical centers with authorized inpatient beds. We reviewed 

each local policy’s compliance with the VHA Directive, discrepancies between local 

policy and local practice, and compliance with required provider-specific data 

analysis and facility committee oversight. We also identified best practices. 

Despite the fact that the National Center for Patient Safety provided all facilities a 

sample policy that met Directive requirements, facilities deleted elements or made 

changes that altered the intent of the Directive as developed locally. When 

considering compliance with all six required policy elements, 71 of 120 facilities 

(59 percent) included all six elements. The balance (49 facilities, or 41 percent) 

included some but not all required elements. There were only 17 of 120 facilities 

(14 percent) that captured provider-specific competency data for all providers 

performing airway management; and only 6 of 120 facilities (5 percent) documented 

committee oversight of aggregate and provider-specific data. This is necessary, since 

without provider-specific data and oversight, medical centers would be unable to 

verify provider competency to perform certain procedures. Only three facilities 

complied with all requirements of the Directive that we reviewed. 

We identified areas to improve the out-of-operating room airway management 

program and patient safety. We recommended that VHA require facilities to apply for 

a waiver from the Directive if they do not perform out-of-operating room airway 

management; maintain policies that comply with all elements of VHA Directive 

2005-031; and collect provider-specific and aggregate data for airway management 

and discuss results at their designated oversight committee. 

VA Office of Inspector General i 
DEPARTMENT OF VETERANS AFFAIRS

Office of Inspector General

Washington, DC 20420

TO: Under Secretary for Health (10) 

SUBJECT: Healthcare Inspection – Out-of-Operating Room Airway Management 

in Veterans Health Administration Medical Centers 

Purpose 

The Department of Veterans Affairs, Office of Inspector General (OIG), Office of 

Healthcare Inspections (OHI) conducted an inspection of selected Veterans Health 

Administration (VHA) medical centers to assess compliance with VHA Directive 2005­

031, Out-of-Operating Room Airway Management, dated August 8, 2005. This Directive 

addresses appropriate competencies of practitioners who perform urgent and emergent 

airway management outside of VHA facility operating rooms (ORs), and the use of 

devices1 to confirm successful endotracheal tube2 placement. 

Background 

Recent OIG reports3 and a number of findings in recent Combined Assessment Program 

(CAP) reports address deficiencies in the area of provider privileging, specifically 

whether VHA appropriately verifies the current competence of providers to perform 

certain procedures. Clinical competency cannot be assumed simply because training has 

been provided. Providers who have been trained in Advanced Cardiac Life Support 

(ACLS) are not necessarily competent to perform airway management, even though it is 

part of the training. VHA recognizes that in order to ensure competency, direct 

observation of care provided to actual patients is required. 

Airway management is the process of ensuring a patent pathway to the lungs in order to 

maintain adequate oxygenation. Generally, this process occurs in the OR prior to 

induction of an anesthetic agent that paralyzes a patient’s ability to maintain normal 

1 Devices such as carbon dioxide (CO2) monitors or esophageal detection devices. 2The flexible plastic tube in the mouth and then down into the trachea (the airway); the purpose is to ventilate the

lungs. 3 Healthcare Inspection – Quality of Care Issues VA Medical Center, Marion, Illinois, No. 07-03386-65, issued

January 28, 2008.

Healthcare Inspection – Quality of Care and Patient Safety Issues, Martinsburg VA Medical Center, Martinsburg 

West Virginia, No. 07-02191-147, issued June 18, 2007. 

VA Office of Inspector General 1 
Out-of-Operating Room Airway Management in Veterans Health Administration Medical Centers 

breathing. Anesthesia staff are highly trained and experienced to provide this service, 

and do so on a daily basis. The requirement for emergency airway management arises 

outside of the OR when patients experience respiratory distress. Because not all medical 

facilities have 24-hour anesthesia coverage, other clinical staff must be competent in 

airway management. Risk for adverse outcomes increases when staff are not well trained 

or competent to perform emergency airway support. A major challenge is the proper 

placement of an endotracheal tube. This tube, which is inserted through the mouth or 

nose into the trachea, is the most commonly used method to maintain an artificial airway. 

If inserted incorrectly, the patient will not receive proper oxygenation, which could result 

in brain damage or death. Emergency intubations should be performed by clinical staff 

with demonstrated experience and skill. 

In the 1990’s, the American Society of Anesthesiologists (ASA) and the American 

Association of Nurse Anesthetists separately initiated reviews of closed anesthesia 

malpractice claims to identify causes of poor patient outcomes and identify potential 

corrective actions to reduce adverse events.4 Data from these reviews indicated that 

respiratory events accounted for the majority of all claims filed and for 85 percent of 

claims for death and brain damage. The most common events were due to inadequate or 

difficult ventilation and esophageal versus endotracheal intubations. The reviewers were 

unable to determine the causes of inadequate ventilation but in the cases of esophageal 

intubations, providers relied on auscultation5 to verify placement of the tube.6 As a result 

of these reviews, use of inexpensive and effective devices to confirm endotracheal tube 

placement are supported by the American College of Emergency Physicians, ASA, the 

National Association of Emergency Medical Service Physicians, and the American Heart 

Association. 

In 2002, the National Center for Patient Safety (NCPS) conducted a survey of VHA 

facilities that confirmed the requirement of emergency airway management outside the 

OR.7 Results of this survey indicated an estimated 11,007 cases a year of non-OR 

intubations in VHA medical facilities. Twelve percent of these were unusually difficult. 

According to the survey, most facilities reported multiple disciplines provided airway 

management, including staff physicians, residents, and respiratory therapists. Only 

45 percent of facilities reported that anesthesia staff was available after regular/day tours 

of duty. Additionally, 30 percent reported using no adjunctive devices to confirm proper 

tube placement. 

4 Caplan, R. A., Posner, K. L., Ward, R. J., and Cheney, F. W. (1990, May). Adverse respiratory events in

anesthesia: a closed claims analysis. Anesthesiology. 72 (5), 828-833. 5 Auscultation is the technical term for listening to the internal sounds of the body, usually using a stethoscope; the

word is based on the Latin verb auscultare "to listen." 6 MacRae, M. G. (2007, August). Closed claims studies in anesthesia: a literature review and implications for

practice. AANA J. 75 (4), 267-275. 7 Stalhandske, E. J., Bishop, M. J., and Bagian, J. P. The Department of Veterans Affairs emergency airway

management initiative. Unpublished manuscript.

VA Office of Inspector General 2 
Out-of-Operating Room Airway Management in Veterans Health Administration Medical Centers

VA Office of Inspector General 3

These findings led to the development of VHA Directive 2005-031, mandating each

inpatient facility develop a written policy by December 1, 2005, defining the:

 Practice settings and circumstances that allow endotracheal intubations outside the

OR and the designated clinical staff who have these duties.

 Process for confirming competence of those who provide out-of-operating room

airway management.

 Device used to confirm tube placement.

 Process for collection and comparison of provider specific data on airway

management, with periodic review of both aggregate and provider specific data by

a designated committee.

If inpatient facilities use community paramedics to respond to emergencies, then they

must submit a waiver request to the Office of Patient Care Services, VA Central Office.

Directors of facilities that only provide outpatient care need to ensure that the standard

for providing airway management is through community assistance, and no waiver is

required. However, if they perform emergency airway management, a policy to address

competency of staff performing those procedures should be consistent with the Directive.

Scope and Methodology

Our inspection assessed VHA medical facility compliance with selected elements of

Directive 2005-031 that related to provider competency. The review was limited to

inpatient facilities. We evaluated VHA required policy and procedure elements,

reviewed medical facility processes and documentation of provider competency, and

identified best practices.

On February 27, 2008, we electronically submitted a request for documentation

pertaining to out-of-operating room airway management to medical center directors of

VHA facilities with authorized inpatient beds. Their responses were required by

March 21, 2008. Specifically, we requested that the medical facilities provide us the

following information from fiscal year (FY) 2006, FY 2007, and FY 2008 through

February 28, 2008: (1) facility policy addressing out-of-operating room airway

management; (2) list of providers permitted to provide airway management outside the

OR and their occupation category; (3) any provider specific quality data concerning

airway management for all individuals listed; and (4) minutes of the designated oversight

body that reviews aggregate and/or provider specific data regarding airway management.

We requested information from medical center directors of the 131 facilities that we

identified as having inpatient beds. Four did not respond and four had received waivers.

(See Appendix B, pages 14–17, for facility list). We analyzed and aggregated materials

received from the remaining 123 facilities to identify findings in this report.
Out-of-Operating Room Airway Management in Veterans Health Administration Medical Centers

VA Office of Inspector General 4

Our inspection covered the following areas:

 Implementation of out-of-operating room airway management policy by

December 1, 2005, that includes requirements for the following six elements:

o (1) A statement that assessed the number and type of clinical staff whose

expected duties include endotracheal intubation and airway management in

a non-OR setting.

o (2) Process for confirming provider competence.

o (3) Documentation of procedural skills including successful endotracheal

intubation of a patient and successful ventilation of an unconscious patient

using a bag and mask and either an oral or nasopharyngeal airway.

o (4) Use of a device to confirm tube placement along with auscultation.

o (5) Provider-specific data analysis, compared against aggregate data for

those privileged to perform airway management.

o (6) Designated committee periodic review of data.

 Evaluation that providers permitted by the facilities to provide airway

management matches policy statement describing occupations of clinical staff

with these duties.

 Presence or absence of provider-specific data for all individuals listed by the

facility.

 Evaluation that minutes from designated body reflect review of provider-specific

data compared to aggregate data regarding out-of-operating room airway

management.

 Identification of best practices.

We conducted the inspection in accordance with Quality Standards for Inspections

published by the President’s Council on Integrity and Efficiency.
Out-of-Operating Room Airway Management in Veterans Health Administration Medical Centers 

Inspection Results 

We noted deficiencies in compliance with Directive 2005-031. Our inspection 

demonstrated that less than 3 percent of VHA facilities complied with all the selected 

requirements that we reviewed. We evaluated compliance with required facility policy 

elements, provider specific and aggregate data, and committee oversight. Specific 

findings are discussed in the remainder of this report. 

Issue 1: Facility Policy Review 

The first part of our review related to specific facility policy components. VHA 

published Directive 2005-031 on August 8, 2005. Each inpatient facility was required to 

have a written policy in effect by December 1, 2005, and NCPS provided an example of a 

facility-level policy that met Directive requirements on their website. 

We received electronic responses from 127 facilities with inpatient beds. Five were on 

the waiver list, but one provided a policy and had providers performing out-of-operating 

room airway management, so we included them in the data analysis. The other four were 

not included in the data analysis because they had waivers and submitted policies that 

confirmed their practice of calling 911 for emergency response. The final denominator 

for policy review was 123 facilities. 

Policy Implementation 

Of the 123 facilities remaining, 122 submitted a local policy. Two facility policies stated 

that they called 911 for all emergencies, but they had not requested a waiver. Four 

policies were still in draft format and not formally approved at the time of our review. 

Forty-nine of the 122 policies (40 percent) complied with the December 1, 2005, 

deadline. 

Some facilities were confused regarding the “inpatient facility” designation in the 

Directive. The one facility that did not submit a policy informed us they did not have 

inpatient beds, only nursing home care unit (NHCU) beds. We confirmed with program 

officials at Anesthesia Service, VA Central Office, that the Directive also applies to 

NHCUs. If NHCUs use 911 emergency services, they should request a waiver. 

However, if VA providers perform emergency airway management in NHCUs, the 

Directive would apply. 

Policy Requirements 

We excluded the two facilities that called 911 from the remainder of the policy 

requirement review, because they did not have any providers who performed out-ofoperating room airway management. We evaluated the remaining 120 local policies to 

determine whether they contained selected requirements specified in Directive 2005-031 

VA Office of Inspector General 5 
Out-of-Operating Room Airway Management in Veterans Health Administration Medical Centers 

regarding provider competency. Those requirements (in italics) and results are described 

below: 

1. Provisions for out-of-operating room airway management that reflect the 

specific practice settings and circumstances of that facility, including an 

assessment of the number and type of clinical staff whose expected duties would 

include endotracheal intubation and airway management in a non-operating room 

setting. 

One hundred five of the 120 policies (88 percent) included a statement regarding clinical 

staff expectations. The NCPS sample policy included a statement that the Chief of Staff 

would provide an assessment of the number and type of clinical staff expected to perform 

non-operating room airway management. If that statement was in policies, or if they 

specified the exact number and type of staff, we determined they complied with the 

Directive. VA Central Office Anesthesia staff confirmed that the intent of the Directive 

was to limit the number of providers who perform emergency intubations so that they 

could perform enough procedures to maintain proficiency. 

2. A process for confirming the competence of those who perform airway 

management that includes initial competency for privileging or establishing scope 

of practice and ongoing demonstration of competency for reappraisal, renewal of 

privileges, and scope of practice. 

The policy review demonstrated that 113 of 120 policies (94 percent) contained a 

description of the process for confirming competency of providers. 

3. Documentation of procedural skill including successful endotracheal 

intubation of a patient and successful ventilation of an unconscious patient using a 

bag and mask and either an oral or nasopharyngeal airway. 

The requirements for competency include cognitive and procedural skills. Facility 

policies included details on procedural skill assessment for 106 of the 120 policies 

(88 percent). 

The Directive clearly states that ACLS certification is not adequate because the training 

is on mannequins. The Directive requires actual patient experience. One policy we 

reviewed stated that because there were so few intubations at the facility, mannequins 

could be used to demonstrate competency. This violates the intent of the Directive. 

In the policies we reviewed, the locally required minimum number of procedures per 

provider ranged from 1 to 15. Some smaller facilities created partnering experience with 

larger, VHA tertiary care medical centers. Their providers traveled to those larger 

facilities for OR intubation experience. Other providers documented experience at 

private, community medical centers to meet their minimum requirements. 

VA Office of Inspector General 6 
Out-of-Operating Room Airway Management in Veterans Health Administration Medical Centers 

4. Use of device, along with auscultation, to confirm tube placement. 

Of the policies reviewed, 112 of 120 (93 percent) required the use of a device to confirm 

placement. Failure to properly intubate the trachea and ventilate a patient can result in 

permanent damage or death. VHA requires the use of devices to monitor tube placement. 

5. Provider-specific data analysis compared to aggregate data from providers 

with comparable clinical privileges. 

The Directive requires that facilities include in their policy a statement that providerspecific emergency airway management data will be compared to aggregate data to assist 

in the determination of competency. Ninety-four of the 120 policies (78 percent) 

included this statement. 

6. Designated committee oversight. 

Facilities are also required to designate a committee that will be responsible for 

reviewing provider-specific and aggregate data. Ninety of the 120 policies (75 percent) 

designated committee oversight. 

Overall, when considering compliance with all six required policy elements, 71 of 120 

facilities (59 percent) included all six elements. The balance (49 facilities, or 41 percent) 

included some but not all required elements. 

Issue 2: Discrepancies Between Policy and Practice 

The remainder of the inspection compared local policy requirements to actual facility 

practice. We requested the names and occupational categories of providers who were 

allowed to perform emergency out-of-operating room airway management. Occupational 

categories included physicians, registered nurses (including certified registered nurse 

anesthetists), respiratory therapists, physician assistants, dentists, emergency medical 

technicians, and medical residents. We then compared that list to the facility policy. 

There were discrepancies between those categories listed in policies compared to the list 

of providers. For example, a physician assistant was on the list of providers but the 

policy stated that only physicians could perform intubations. Another facility stated their 

practice was to call 911 unless a clinician was “compelled” to intubate. However, they 

listed 20 physicians who were allowed to intubate. Even so, in FY 2007 there had only 

been one intubation by a facility physician. Yet another facility listed 112 physicians 

who were allowed to emergently intubate. VA Central Office Anesthesia staff confirmed 

that the intent of the Directive was to limit the number of providers who perform 

emergency intubations so that they would perform enough procedures to maintain 

proficiency. 

VA Office of Inspector General 7 
Out-of-Operating Room Airway Management in Veterans Health Administration Medical Centers 

Issue 3: Provider-Specific Data and Committee Oversight 

The final part of the review related to the requirement for provider-specific and aggregate 

data analysis. We requested any provider-specific quality data concerning emergency 

airway management for all individuals on the list of permitted providers. We reviewed 

the provider data to determine if there was data for each individual on the list. Only 17 of 

the 120 facilities (14 percent) had captured data for all providers. Some had partial data, 

for example, respiratory therapist data but not physician data. Several facilities submitted 

documentation of training and initial competence but their information did not provide 

evidence of ongoing competency or provide information that can be used during the 

clinical reprivileging process. The 17 facilities that complied with the requirement 

collected data on those providers who had performed emergency intubation, the number 

of attempts, the success of intubation, and any complications. That data was then 

compared to facility aggregate data to determine individual competency. 

We also asked for the minutes of the designated oversight committee that reviewed both 

aggregate and provider-specific data concerning intubation and airway management. 

Only 6 of 120 facilities (5 percent) provided minutes with documentation of required 

data. While some facilities provided minutes with documentation of emergency 

resuscitation events, the minutes did not include provider-specific data. 

We identified best practices at the James E. Van Zandt VA Medical Center, Altoona, PA, 

and the Huntington VA Medical Center, Huntington, WV, where committees compared 

statistical data and were able to identify the need for provider retraining or were able to 

verify competency for providers performing out-of-operating room airway management. 

Conclusions 

Some facilities that did not have acute care beds were confused regarding the 

implementation of the Directive. Because they only had NHCUs, the designation 

“inpatient facility” led to misinterpretation of requirements. If those facilities call 911 for 

emergency response, they need to apply for a waiver. If their providers perform out-ofoperating room airway management, they must comply with the Directive. 

Despite the fact that NCPS provided a sample policy, facilities had deleted required 

elements or made changes that altered the intent of the Directive. When considering 

compliance with all six required policy elements, 71 of 120 facilities 

(59 percent) included all six elements. The balance (49 facilities, or 41 percent) included 

some but not all required elements. There was variation regarding the minimum number 

of procedures locally required to establish and maintain competency. 

We identified best practices at facilities that maintained provider-specific information on 

the number of procedures performed and outcomes (successful intubations, number of 

attempts, complications). Committees then compared that information to facility 

VA Office of Inspector General 8 
Out-of-Operating Room Airway Management in Veterans Health Administration Medical Centers 

aggregate data and discussed opportunities to improve clinical practice. That information 

was then used for reprivileging or renewal of scope of practice. The Hampton VA 

Medical Center, Hampton, VA, initiated incident reports if unauthorized providers 

performed intubation. Managers then discussed those incidents with the individuals and 

their supervisors. 

The majority of facilities did not comply with provider-specific data collection for use in 

the reprivileging process. This review validated OIG’s concern that medical centers are 

not able to verify provider competence to perform certain procedures. Without providerspecific information, facilities cannot measure performance and outcome or assess the 

competency of an individual provider’s ability to perform emergency airway 

management. 

There were 3 of the 120 facilities (less than 3 percent) that complied with all the 

Directive requirements that we reviewed. These were the James E. Van Zandt VA 

Medical Center, Altoona, PA; the Huntington VA Medical Center, Huntington, WV; and 

the Northern Arizona VA Health Care System, Prescott, AZ. 

Recommendations 

Recommendation 1. The Under Secretary for Health will ensure that VHA requires 

facilities that do not perform out-of-operating room airway management to apply for a 

waiver from VHA Directive 2005-031. 

Recommendation 2. The Under Secretary for Health will ensure that VHA facilities that 

perform out-of-operating room airway management maintain policies that comply with 

all elements of VHA Directive 2005-031. 

Recommendation 3. The Under Secretary for Health will require VHA facilities to 

collect provider specific and aggregate data regarding out-of-operating room airway 

management and discuss results at the designated oversight committee. 

Comments 

The Under Secretary for Health agreed with our findings and recommendations and 

provided acceptable improvement plans. (See Appendix A, pages 10–13, for the full text 

of the comments.) We will follow up on planned actions until they are completed. 

 (original signed by:)

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

Assistant Inspector General for

Healthcare Inspections

VA Office of Inspector General 9 
Out-of-Operating Room Airway Management in Veterans Health Administration Medical Centers 

Appendix A 

Under Secretary for Health Comments 

Department of 

Veterans Affairs Memorandum 

Date: June 27, 2008 

From: Under Secretary for Health (10) 

Subject: Healthcare Inspection – Out-of-Operating Room Airway 

Management in Veterans Health Administration Medical Centers 

To: Assistant Inspector General for Healthcare Inspections (54) 

1. I have reviewed the draft report, and I concur with the report and 

recommendations. Although some Veterans Health Administration 

(VHA) facilities reviewed demonstrated compliance with all 

requirements of VHA Directive 2005-031, Out-of-Operating Room 

Airway Management, not all facilities were compliant. We will use 

the results of your audit to reinforce compliance with the Directive. 

2. The requirement for provider-specific and aggregate data analysis 

is essential for performance measurement and assessment of an 

individual provider’s ability to perform emergency airway 

management, and should include a review of that analysis by an 

oversight committee. To increase facility compliance with this 

component, Patient Care Services (PCS) provided facilities with a 

Clinical Patient Record System reminder dialog template using 

health factors (Endotracheal Intubation Procedure Note), which will 

facilitate both the provider-specific and aggregate data analysis. 

Further, oversight committee review of provider-specific and 

aggregate data will be emphasized when dialog template instructions 

are issued to the field next month, and will be addressed, as 

necessary, at the next meeting of the Under Secretary for Health’s 

Coordinating Committee for Quality and Safety. 

3. To further ensure compliance with VHA policy concerning outof-operating room airway management, PCS will collaborate with 

the Deputy Under Secretary for Health for Operations and 

Management (DUSHOM) to reinforce compliance at the upcoming 

VISN Chief Medical Officer’s conference call scheduled for June 

VA Office of Inspector General 10 
Out-of-Operating Room Airway Management in Veterans Health Administration Medical Centers 

30, 2008. Patient safety, specific training, demonstrated 

competency, provider-specific aggregate data analysis, and waiver 

requirements will be emphasized. PCS and the DUSHOM will work 

together to develop and issue a survey to the field to assess the 

current state of facility compliance with the Directive, and are tasked 

with ensuring corrective action is taken where necessary. 

4. Thank you for the opportunity to review the draft report and for 

incorporating our technical comments in the final report. If you 

have any questions, please contact Margaret M. Seleski, Director, 

Management Review Service (10B5) at (202) 461-8470. 

 (original signed by:)

Michael J. Kussman, MD, MS, MACP 

Attachment 

VA Office of Inspector General 11 
Out-of-Operating Room Airway Management in Veterans Health Administration Medical Centers 

Under Secretary for Health Comments 

to Office of Inspector General’s Report 

The following Under Secretary for Health’s comments are submitted in 

response to the recommendations in the Office of Inspector General’s 

report: 

OIG Recommendations 

The Under Secretary for Health will: 

Recommendation 1. Ensure that VHA requires facilities that do not 

perform out-of-operating room airway management to apply for a waiver 

from VHA Directive 2005-031. 

Concur In process Target Completion Date: September 30, 2008 

Patient Care Services (PCS) will collaborate with the Deputy Under 

Secretary for Health for Operations and Management (DUSHOM) to 

reinforce the need for VHA facilities to fully comply with VHA Directive 

2005-031 at the upcoming VISN Chief Medical Officers’ conference call 

scheduled for June 30, 2008. Facilities’ use of community services as first 

responders to emergency airway management will be discussed, with 

additional emphasis on the policy requirement that application and receipt 

of a waiver be complete before utilizing that option. 

PCS and the DUSHOM will also work together to develop and issue a 

survey to the field by June 30, 2008, to assess the current state of facility 

compliance with the Directive. Assessment of survey responses and 

development of appropriate action for non-compliant facilities will be 

completed by September 30, 2008. 

Recommendation 2. Ensure that VHA facilities that perform out-ofoperating room airway management maintain policies that comply with all 

elements of VHA Directive 2005-031. 

Concur In process Target Completion Date: September 30, 2008 

Patient Care Services (PCS) will collaborate with the Deputy Under 

Secretary for Health for Operations and Management (DUSHOM) to 

reinforce the need for VHA facilities to fully comply with VHA Directive 

2005-031 at the upcoming VISN Chief Medical Officer’s conference call 

VA Office of Inspector General 12 
Out-of-Operating Room Airway Management in Veterans Health Administration Medical Centers 

scheduled for June 30, 2008. Patient safety, specific training, demonstrated 

competency, and provider-specific aggregate data analysis, as required by 

the policy, will be emphasized. 

PCS and the DUSHOM will also work together to develop and issue a 

survey to the field by June 30, 2008, to assess the current state of facility 

compliance with the Directive. Assessment of survey responses and 

development of appropriate action for non-compliant facilities will be 

completed by September 30, 2008. 

Recommendation 3. Require VHA facilities to collect provider specific 

and aggregate data regarding out-of-operating room airway management 

and discuss results at the designated oversight committee. 

Concur In process Target Completion Date: July 15, 2008 

Provider-specific and aggregate data analysis is required by VHA Directive 

2005-031. In May 2008, VHA facilities were given a CPRS reminder 

dialog template using health factors (Endotracheal Intubation Procedure 

Note). Patient Care Services (PCS) is currently working on providing 

facilities with instructions on how to retrieve the health factors data from 

this new template, which will facilitate both the provider-specific and 

aggregate data analysis. When PCS distributes the instructions to the field, 

they will also emphasize the requirement of designated oversight 

committee review of the provider-specific and aggregate data. This 

requirement will also be addressed, as necessary, at the next meeting of the 

Under Secretary for Health’s Coordinating Committee for Quality and 

Safety. The dialog template instructions for retrieving the data from 

Vista/CPRS will be completed and issued to the field no later than July 15, 

2008. 

VA Office of Inspector General 13 
Out-of-Operating Room Airway Management in Veterans Health Administration Medical Centers 

Appendix B 

List of Medical Centers 

Facilities That Responded to Request 

Aleda E. Lutz VA Medical Center, Saginaw, MI 

Alexandria VA Medical Center, Pineville, LA 

Amarillo VA Health Care System (Thomas E. Creek VA Medical Center), 

Amarillo, TX 

Asheville VA Medical Center, Asheville, NC 

Atlanta VA Medical Center, Decatur, GA 

Bath VA Medical Center, Bath, NY 

Battle Creek VA Medical Center, Battle Creek, MI 

Bay Pines VA Healthcare System, Bay Pines, FL 

Beckley VA Medical Center, Beckley, WV 

Birmingham VA Medical Center, Birmingham, AL 

Boise VA Medical Center, Boise, ID 

Butler VA Medical Center, Butler, PA 

Canandaigua VA Medical Center, Canandaigua, NY 

Carl Vinson VA Medical Center, Dublin, GA 

Central Alabama Veterans Health Care System, Montgomery and Tuskegee, AL 

Central Arkansas Veterans Healthcare System, John L. McClellan Memorial 

Veterans Hospital, Little Rock, AR; and Eugene J. Towbin Healthcare Center, 

North Little Rock, AR 

Central Texas Veterans Health Care System, Olin E. Teague Veterans’ Center, 

Temple, TX; and Waco VA Medical Center, Waco, TX 

Charlie Norwood VA Medical Center, Augusta, GA 

Cheyenne VA Medical Center, Cheyenne, WY 

Chillicothe VA Medical Center, Chillicothe, OH 

Cincinnati VA Medical Center, Cincinnati, OH 

Clement J. Zablocki VA Medical Center, Milwaukee, WI 

Dayton VA Medical Center, Dayton, OH 

Durham VA Medical Center, Durham, NC 

Edward Hines, Jr. VA Hospital, Hines, IL 

Erie VA Medical Center, Erie, PA 

Fargo VA Medical Center, Fargo, ND 

Fayetteville VA Medical Center, Fayetteville, AR 

Fayetteville VA Medical Center, Fayetteville, NC 

G.V. (Sonny) Montgomery VA Medical Center, Jackson, MS 

Grand Junction VA Medical Center, Grand Junction, CO 

Harry S. Truman Memorial Veterans’ Hospital, Columbia, MO 

Hunter Holmes McGuire VA Medical Center, Richmond, VA 

Huntington VA Medical Center, Huntington, WV 

Iowa City VA Medical Center, Iowa City, IA 

VA Office of Inspector General 14 
Out-of-Operating Room Airway Management in Veterans Health Administration Medical Centers 

Iron Mountain VA Medical Center, Iron Mountain, MI 

Jack C. Montgomery VA Medical Center, Muskogee, OK 

James A. Haley Veterans’ Hospital, Tampa, FL 

James E. Van Zandt VA Medical Center, Altoona, PA 

James H. Quillen VA Medical Center, Mountain Home, TN 

James J. Peters VA Medical Center, Bronx, NY 

Jesse Brown VA Medical Center, Chicago, IL 

John D. Dingell VA Medical Center, Detroit, MI 

John J. Pershing VA Medical Center, Poplar Bluff, MO 

Jonathan M. Wainwright Memorial VA Medical Center, Walla Walla, WA 

Kansas City VA Medical Center, Kansas City, MO 

Lebanon VA Medical Center, Lebanon, PA 

Lexington VA Medical Center, Lexington, KY 

Louis A. Johnson VA Medical Center, Clarksburg, WV 

Louis Stokes VA Medical Center, Cleveland, OH 

Louisville VA Medical Center, Louisville, KY 

Marion VA Medical Center, Marion, IL 

Martinsburg VA Medical Center, Martinsburg, WV 

Memphis VA Medical Center, Memphis, TN 

Miami VA Healthcare System, Miami, FL 

Michael E. DeBakey VA Medical Center, Houston, TX 

Minneapolis VA Medical Center, Minneapolis, MN 

New Mexico VA Health Care System, Albuquerque, NM 

North Chicago VA Medical Center, North Chicago, IL 

North Florida/South Georgia Veterans Health System, Gainesville and Lake City, 

FL 

Northern Arizona VA Health Care System, Prescott, AZ 

Northport VA Medical Center, Northport, NY 

Oklahoma City VA Medical Center, Oklahoma City, OK 

Overton Brooks VA Medical Center, Shreveport, LA 

Philadelphia VA Medical Center, Philadelphia, PA 

Phoenix VA Health Care System (Carl T. Hayden Veterans Medical Center), 

Phoenix, AZ 

Portland VA Medical Center, Portland, OR 

Providence VA Medical Center, Providence, RI 

Ralph H. Johnson VA Medical Center, Charleston, SC 

Richard L. Roudebush VA Medical Center (Indianapolis VA Medical Center), 

Indianapolis, IN 

Robert J. Dole VA Medical Center, Wichita, KS 

St. Cloud VA Medical Center, St. Cloud, MN 

St. Louis VA Medical Center, John Cochran Division and Jefferson Barracks 

Division, St. Louis, MO 

VA Office of Inspector General 15 
Out-of-Operating Room Airway Management in Veterans Health Administration Medical Centers 

Salem VA Medical Center, Salem, VA 

Salisbury - W.G. (Bill) Hefner VA Medical Center, Salisbury, NC 

Sheridan VA Medical Center, Sheridan, WY 

Sioux Falls VA Medical Center (Royal C. Johnson Veterans Memorial Medical 

Center), Sioux Falls, SD 

South Texas Veterans Health Care System, San Antonio, TX 

Southern Arizona VA Health Care System, Tucson, AZ 

Spokane VA Medical Center, Spokane, WA 

Stratton VA Medical Center, Albany, NY 

Syracuse VA Medical Center, Syracuse, NY 

Tennessee Valley Healthcare System, Alvin C. York (Murfreesboro) Campus and 

Nashville VA Medical Center, Nashville, TN 

Togus VA Medical Center, Augusta, ME 

Tomah VA Medical Center, Tomah, WI 

Tuscaloosa VA Medical Center, Tuscaloosa, AL 

VA Ann Arbor Healthcare System, Ann Arbor, MI 

VA Black Hills Health Care System, Fort Meade and Hot Springs, SD 

VA Boston Healthcare System, Brockton, Jamaica Plain, and West Roxbury, MA 

VA Caribbean Healthcare System, San Juan, PR 

VA Central California Health Care System, Fresno, CA 

VA Central Iowa Health Care System, Des Moines and Knoxville, IA 

VA Connecticut Healthcare System, Newington and West Haven, CT 

VA Eastern Colorado Health Care System, Denver, CO 

VA Eastern Kansas Health Care System, Leavenworth (Dwight D. Eisenhower 

VA Medical Center) and Topeka (Colmery-O’Neil VA Medical Center), KS 

VA Greater Los Angeles Healthcare System, Los Angeles, CA 

VA Gulf Coast Veterans Health Care System, Biloxi, MS 

VA Illiana Health Care System, Danville, IL 

VA Loma Linda Healthcare System, Loma Linda, CA 

VA Long Beach Healthcare System, Long Beach, CA 

VA Maryland Health Care System, Baltimore and Perry Point, MD 

VA Montana Health Care System, Fort Harrison, MT 

VA Nebraska Western Iowa Health Care System, Grand Island, Lincoln, and 

Omaha, NE 

VA New Jersey Health Care System, East Orange and Lyons, NJ 

VA NY Harbor Healthcare System, Brooklyn and New York, NY 

VA North Texas Health Care System: Dallas VA Medical Center, Dallas, TX; and 

Sam Rayburn Memorial Veterans Center, Bonham, TX 

VA Northern California Health Care System, Mather, CA 

VA Northern Indiana Health Care System, Fort Wayne and Marion, Indiana 

VA Palo Alto Health Care System, Livermore, Menlo, and Palo Alto, CA 

VA Office of Inspector General 16 
Out-of-Operating Room Airway Management in Veterans Health Administration Medical Centers 

VA Pittsburgh Healthcare System, University Drive, Highland Drive, and H.J. 

Heinz III Progressive Care Center, Pittsburgh, PA 

VA Puget Sound Health Care System, Seattle and American Lake Division at 

Tacoma, WA 

VA Roseburg Healthcare System, Roseburg, OR 

VA Salt Lake City Health Care System, Salt Lake City, UT 

VA San Diego Healthcare System, San Diego, CA 

VA Sierra Nevada Health Care System, Reno, NV 

VA Western New York Healthcare System, Batavia and Buffalo, NY 

West Palm Beach VAMC, West Palm Beach, FL 

West Texas VA Health Care System, Big Spring, TX 

White River Junction VA Medical Center, White River Junction, VT 

Wilkes-Barre VA Medical Center, Wilkes-Barre, PA 

William S. Middleton Memorial Veterans Hospital, Madison, WI 

Wilmington VA Medical Center, Wilmington, DE 

Facilities That Did Not Respond to Request 

San Francisco VA Medical Center, San Francisco, CA 

VA Pacific Islands Health Care System, Honolulu, HI 

Washington DC VA Medical Center, Washington, DC 

Wm. Jennings Bryan Dorn VA Medical Center, Columbia, SC 

Facilities with Waivers 

Coatesville VA Medical Center, Coatesville, PA 

Edith Nourse Rogers Memorial Veterans Hospital, Bedford, MA 

Northampton VA Medical Center, Leeds, MA 

VA Hudson Valley Health Care System, Castle Point Campus, Castle Point, NY 

and Franklin Delano Roosevelt Campus, Montrose, NY 

Facility with Waiver but Provided Airway Management and Had Policy 

Hampton VA Medical Center, Hampton, VA 

VA Office of Inspector General 17 
Out-of-Operating Room Airway Management in Veterans Health Administration Medical Centers 

Appendix C 

OIG Contact and Staff Acknowledgment 

OIG Contact Virginia L. Solana, Director 

Kansas City Regional Office of Healthcare Inspections 

(816) 997-6971 

Acknowledgments Jennifer Kubiak, Project Manager 

Andrea Buck, M.D., J.D. 

Dorothy Duncan 

Reba B. Ransom 

Jim Seitz 

Marilyn Stones 

VA Office of Inspector General 18 
Out-of-Operating Room Airway Management in Veterans Health Administration Medical Centers 

Appendix D 

Report Distribution 

VA Distribution 

Office of the Secretary 

Veterans Health Administration 

Assistant Secretaries 

General Counsel 

Veterans Integrated Service Network Directors (1-23) 

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 

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

VA Office of Inspector General 19