American Legion Says VA Center Acted Quickly to Address Instrument Processing Issue

The Department of Veterans Affairs acted swiftly and correctly to temporarily suspend surgeries earlier this month at the John Cochran VA Medical Center in St. Louis after stains and water spots were noticed on some medical trays and one surgical instrument, American Legion National Commander Jimmie Foster asserts.

"The spots were reported to hospital officials by an employee acting diligently on more stringent self-monitoring policies now in place throughout the VA healthcare system," Foster adds. "We believe VA is taking very seriously its need to provide the cleanest, safest possible care for our nation's veterans. Self-reporting of any possible threat to that safety even a questionable water spot is an important part of VA's commitment to transparency."

The American Legion's System Worth Saving (SWS) Task Force inspected the St. Louis facility Jan. 12-13 and received a report from the hospital's Reusable Medical Equipment Committee, which was formed after some 1,800 veterans in the St. Louis area were called in last year to be tested for possible hepatitis B, hepatitis C and HIV exposure from improperly sterilized equipment at the VA dental clinic.

The clinic was closed following the revelation, the chief of dental service was removed from VA employment, and a new state-of-the-art facility with tighter oversight requirements was opened to replace it.

Two weeks after the meeting between the SWS Task Force and the St. Louis VA officials, however, the hospital suspended surgeries after an employee reported the water spots to supervisors. The hospital responded quickly, investigating all equipment in the facility, while making arrangements elsewhere for patients in immediate need of surgery, according to a follow-up report from the healthcare system.

The Legion's SWS Task Force has closely scrutinized VA performance on medical equipment sterilization procedures since a 2009 VA Inspector General's Office report revealed the potential for contamination due to the cleaning procedures of reusable endoscopy and colonoscopy instruments.

The report noted that, in 2004, 2,000 veterans in California were notified by VA that an endoscope reprocessing machine had malfunctioned; in 2005, 200 veterans in Pennsylvania were notified when VA colonoscopes were found to have been inadequately disinfected.

The VA Inspector General's investigation which focused on facilities in Tennessee, Florida and Georgia where problems had been reported in the media led to system-wide directives to reduce the risk of exposure caused by VA medical equipment. Included among them were improved supervision, closer compliance with manufacturers' recommendations for cleaning reusable equipment, better training, self-monitoring and inspections.

"VA responded to these problems by looking in the mirror and holding the whole system to a higher standard than ever before," Foster says. "And that's a good thing. Our nation's veterans deserve the best possible standard of care and safety. The American Legion is dedicated to helping VA fulfill that commitment."

The American Legion's SWS Task Force was established eight years ago, when more than 300,000 veterans were waiting 30 days or longer for primary-care appointments with their VA doctors.

The task force, which includes American Legion volunteers and staff, inspects approximately 50 VA healthcare facilities a year, interviewing hospital officials on such issues as access, adequate staffing, quality of care, facility space and cleanliness. The inspections are assembled into an annual report that is submitted to Congress, the White House and VA Central Office.