×

Inspector General cites Van Zandt VA Medical Center

Government office finds problems with anesthesiologist

A government organization that exercises scrutiny over the Department of Veterans Affairs has found fault with an anesthesiologist who worked at the Van Zandt VA Medical Center for eight years, ending last summer.

In a report released July 5, the VA Office of Inspector General also found fault with management’s supervision of the doctor.

Dr. Michael Knitter — his name was revealed indirectly by the OIG and Van Zandt — used more anesthesia and sedative medications for outpatient procedures than recommended by the Food and Drug Administration, potentially increasing patients’ risk of respiratory and cardiac failure, according to the OIG, which investigated after receiving a complaint. Knitter was the only anesthesiologist on the center’s staff at the time.

The Mirror was unable to reach Knitter for comment.

Knitter also once placed a patient under general anesthesia, even though the hospital wasn’t qualified for its use, according to the OIG.

No evidence was found that patients were harmed by the higher-than-recommended drug dosing, according to the report.

The OIG also found that hospital managers didn’t provide “oversight of the anesthesiologist (in keeping with) Veterans Health Administration and Facility credentialing and privileging and ongoing supervision policies,” the report stated.

Knitter was discharged from Van Zandt last summer for “non-patient care issues,” halfway through the OIG investigation and not because of the anesthesiologist’s “inconsistent medication administration,” the OIG report stated.

Knitter filed a complaint in 2016 in federal District Court, alleging that VA policies allowed registered nurses to countermand his orders, putting patients at risk.

A judge dismissed the complaint in March.

Both regional VA Director Michael Adelman and Van Zandt Director Sigrid Andrew concurred with the findings of the OIG report, according to an appendix to the report.

“We always appreciate reports done by regulatory bodies,” Andrew said.

“It gives us added insight,” Van Zandt spokes­man Shaun Shenk said.

Specifics

According to the OIG, Knitter administered more than the recommended doses of two drugs to 17 of 20 patients whose records were examined.

He gave higher-than recommended doses of Midazolam to five of those patients, the report states.

He gave higher-than-recommended doses of propofol — both initial startup doses and subsequent maintenance doses — to 15 of the patients, according to the OIG.

He stayed within the guidelines for Fentanyl — although all 20 patients received the maximum dose, according to the OIG.

At one point, Knitter gave an outpatient general anesthesia in violation of a Van Zandt policy that states that all patients requiring general anesthesia be transferred to the VA Pittsburgh Health­care System or a qualified non-VA facility, the report states.

The policy is meant to ensure patient safety because under general anesthesia, patients can experience respiratory and cardiac failure and “medical equipment and experienced staff must be available” to treat them, according to the report. Van Zandt, a Level 3 facility, lacks a surgical unit, an intensive care unit and a post-anesthesia unit, the report states.

Management

Van Zandt leaders fell short by granting Knitter privileges that included permission to manage patients under general anesthesia during surgeries and “certain other medical procedures,” and permission to supervise critically ill patients in special care units, the report states.

Because Van Zandt is a Level 3 facility and doesn’t care for critically ill patients, “facility leaders should not have granted those privileges,” the report states.

Van Zandt management also fell short in its supervision of Knitter by not including a check on his use of controlled drugs and sedatives — which can cause unconsciousness and put patients at serious health risk — as part of the hospital’s “ongoing Professional Practice Evaluations,” according to the report. Van Zandt’s evaluation of Knitter “lacked this type of data review and did not meet the intent of Veterans Health Adminis­tra­tion policy to monitor data that was provider-specific, as well as reliable,” the report states.

Had the hospital’s evaluations of Knitter included a review of his handling of controlled drugs and sedatives, the risk to patients might have been uncovered earlier, according to the report. Such findings could have led to “suspension or reduction of clinical privileges” and should have generated a report to the National Practitioner Data Bank, the report states.

Patient advocate

The OIG also cited a Van Zandt patient advocate’s failure to document patient complaints in the VA’s web-based Patient Advocate Tracking System and failure to document descriptions of issues involved, actions taken and complaint resolutions.

“VHA requires that VA facilities have a Patient Advocacy Program to ensure that patient complaints are resolved in a proactive and timely manner,” the report states. “VHA also requires full utilization of PATS to track patient complaints. Entering all complaints in PATS provides facility and national leaders with a comprehensive understanding of patient issues and concerns.”

PATS also help quality managers “focus quality improvement efforts,” the report states.

Instead of using PATS, the patient advocate documented patient complaints on a desktop spreadsheet, according to the report.

Of 822 patient complaints listed from November 2015 through July 2016, 781 did not include a description of issues involved, according to the report. Among those same complaint listings, 173 also didn’t include a description of an action taken or complaint resolution, the report states.

Recommendations

The report recommended that the hospital conduct an evaluation to ensure the anesthesia program complies with hospital policies, that hospital service chiefs grant doctor privileges specific to the facility and that it conduct doctor-specific evaluations.

The report also recommended that Van Zandt consider whether the anesthesiologist should be reported to the NPDB and State Licensing Board for the policy violations detailed in the report; and that the patient advocate enter all patient complaints into the PATS system, with descriptions of issues and resolutions.

According to Van Zandt director Andrew, writing in the appendix, the hospital’s chief of staff and quality management staff have reviewed the anesthesia program and have aligned it with the hospital’s capabilities.

Between now and August, the chief of staff will evaluate privileges to make sure they’re facility-specific, while checking out evaluation practices to makes sure they’re provider specific, Andrew wrote.

Hospital leaders planned to consult with the VA’s Office of Special Counsel to determine whether they should report the anesthesiologist to the NPDB and the State Licensing Board, Andrew wrote.

The hospital has been using PATS as prescribed by the VA since October, Andrew wrote. The hospital has gone beyond that, developing “clearer guidelines on language and descriptions (and) a one week expectation for closing reports.” The hospital is also “in the process of developing training for all staff so communication can be done almost exclusively in PATS,” Andrew wrote.

All feedback from patients will be entered in PATS “to allow for a better understanding of patient experience,” she wrote.

Mirror Staff Writer William Kibler is at 949-7038.

Starting at $2.99/week.

Subscribe Today