Unsafe culture permeates Aurora VA hospital’s ICU, staffers allege

On Feb. 20, 2023, a 77-year-old man was admitted to the intensive care unit at Aurora’s Rocky Mountain Regional VA Medical Middle for continual kidney illness.

Two weeks later, nurses and docs grew involved after studying the person’s vital different, unbeknownst to ICU workers, had been giving him a tincture beneath his tongue whereas he slept.

The care group didn’t know what was on this treatment. But ICU management instructed nurses to maintain giving it to the affected person, telling clinicians that the hospital’s chief of workers, Shilpa Rungta, permitted the tincture, inner emails present.

“I don’t discredit that we actually have NO thought what’s in it, and have been taking (the caregiver’s) phrase for it, but when one thing occurs to (the affected person) and it’s deemed that it was attributable to this ‘affected person’s personal remedy’ it doesn’t fall on us,” Melissa Nickerson, the ICU nurse supervisor, wrote within the e-mail to intensive care workers, which was reviewed by The Denver Put up.

A number of VA clinicians refused to present the unknown remedy, they informed The Put up, fearing they could be prone to shedding their license or getting sued. A number of mentioned they submitted complaints to the U.S. Division of Veterans Affairs’ Workplace of Inspector Common, which conducts impartial oversight of the sprawling federal company.

“The message from management: ‘Shut up and do what you’re informed,’” mentioned one VA worker, who spoke to The Put up on the situation of anonymity for concern of retribution. “‘Don’t go together with your intestine. Don’t comply with protocol.’”

This case represents only one instance of what whistleblowers say are persistent affected person questions of safety within the VA’s ICU, which is tasked with treating the sickest veterans admitted to the Aurora hospital.

Interviews with a half-dozen essential care suppliers, together with inner VA emails, present the ICU used COVID-era staffing workarounds lengthy after the general public well being disaster eased. This implies nurses had been requested to look after extra sufferers than is usually thought of acceptable, and untrained nurses had been tasked with serving to critically ailing veterans.

VA management even introduced in exterior suppliers three years in the past to evaluate the ICU’s well being and supply suggestions to enhance practices. Staff say, although, {that a} committee convened to deal with the problems met as soon as and by no means once more.

When clinicians do increase issues to administration, they are saying they’re met with admonition and retaliation. “Folks don’t know that in the event that they went throughout the road they’d get higher care,” the VA worker mentioned.

The allegations within the ICU come because the Aurora VA has been roiled by controversy in current months.

In October, VA management eliminated the Jap Colorado VA’s director and his chief of workers over issues about “operational oversight, organizational well being and office tradition.” Greater than a dozen VA staff described to The Put up a tradition of concern and a hostile work setting among the many 4,000-person workforce. A federal investigation into the oversight issues is ongoing.

The Put up reported in November that the pinnacle of the hospital community’s prosthetics division was canceling veterans’ orders to remove a backlog, prompting congressional oversight from U.S. Rep. Jason Crow. The pinnacle of the VA’s nationally famend suicide prevention middle, in the meantime, was reassigned following The Put up’s story outlining a poisonous office tradition rife with “emotional, psychological and psychological abuse.”

Aurora VA officers declined a number of interview requests for this story. Officers had supplied an interview to The Put up in January, however withdrew the supply after studying the subjects the reporter needed to debate.

In an e-mail, an company spokesperson mentioned they might not touch upon the ICU points as a result of an ongoing investigation. The VA declined to reply any particular questions.

After The Put up revealed this story on-line, the director of the VA’s Rocky Mountain area, Sunaina Kumar-Giebel, informed The Put up in a press release that the company is “actively trying into these allegations and security issues, and we’re conducting additional investigations to right any present processes that aren’t upholding the best requirements of care.”

She added that the VA seeks to revive a working setting through which workers really feel they’ll really feel heard and lift issues.

“No regard for affected person security”

Through the peak of the pandemic, the Aurora VA — like different hospitals throughout Colorado and all through the nation — acquired an onslaught of sufferers that strained its capability.

The hospital, in response, instituted emergency practices associated to staffing and nurse-to-patient ratios that went past regular procedures.

However the Aurora VA allowed a few of these practices to stay in place properly after the disaster eased, a number of ICU staff informed The Put up.

Up till December, staffing shortages at instances pushed the ICU to assign every nurse three sufferers when customary nursing protocol dictates they need to solely have two, a number of staff informed The Put up. Nurses caring for stepdown sufferers — these transferring out of intensive care — are speculated to have a most of three sufferers, however as an alternative they had been tasked with caring for as many as 4 at a time, the staffers mentioned.

“There’s no regard for affected person security,” mentioned one essential care supplier, who spoke on the situation of anonymity for concern of retaliation.

Nurses, starting in 2020 and persevering with to the current, have flooded their union representatives with objection letters. The notices — referred to as “task regardless of objection” letters — enable nurses to tell the union once they’re given assignments that they really feel could possibly be unsafe for sufferers or workers.

The letters, a few of which had been reviewed by The Put up, mentioned insufficient staffing ranges meant nurses couldn’t deal with conditions through which a affected person or customer went lacking. One 2023 letter acknowledged insufficient workers impacted look after acute sufferers and people with behavioral points.

A February 2024 staffing chart, reviewed by The Put up, nonetheless confirmed personnel ranges considerably beneath goal targets for almost each shift. On Feb. 23, for instance, there ought to have been 16 nurse-hours spent on the common ICU affected person, however the VA may solely allocate 11 nurse-hours, the information exhibits.

The hospital’s govt management group “is upset with nurses for complaining about staffing,” one supplier wrote in a September 2022 e-mail to union brass. “I see the burnout in all the nurses. It is vitally disheartening to look at.”

Sharda Fornnarino, an Aurora VA nurse and president of the Nationwide Nurses United union, mentioned the hospital is brief nurses in all however one unit throughout the ability, together with psychiatry, the emergency room and the spinal twine damage unit. The Rocky Mountain Regional Medical Middle, in an August survey, reported extreme shortages in 34 nursing occupations.

Nurse-to-patient ratios are increased in different models along with the ICU, Fornnarino mentioned. The spinal twine damage unit, for instance, ought to have one nurse for each 4 sufferers, she mentioned. Generally nurses in that unit are given as many as six sufferers, she mentioned.

“It issues me we’re not going to present the correct care that’s wanted,” Fornnarino mentioned.

A number of states — although not Colorado — have legal guidelines regarding nurse-to-patient ratios. California mandates hospitals stick to 2 sufferers for each nurse in intensive care models. Massachusetts regulation prohibits multiple affected person per nurse generally within the ICU. They’re forbidden to take a 3rd affected person.

“There’s a slew of proof that if it goes past two sufferers within the ICU it will possibly turn out to be precarious,” mentioned Pamela B. de Cordova, an affiliate professor at Rutgers College’s Faculty of Nursing.

The dangers, she mentioned, could be critical: With out full consideration from workers, sufferers may fall; central traces could possibly be contaminated; sick people may develop ventilator-associated pneumonia.

A 2010 research in Well being Companies Analysis discovered decrease nurse-to-patient ratios had been related to considerably decrease mortality. When nurse workloads had been according to California-mandated ratios, nurses’ burnout and job dissatisfaction had been decrease, and staff reported persistently higher high quality of care.

With fewer nurses accessible, VA leaders instituted a system referred to as “group nursing,” a number of ICU staff informed The Put up. Beneath this mannequin, a nurse assigned three ICU sufferers can be assisted by a licensed nursing assistant or nurse from one other division.

The issue, ICU suppliers say, is that ground nurses usually are not skilled to work within the intensive care unit. They’re not skilled to deal with ventilators, for instance, or constantly monitor cardiac rhythms.

“Their stance is ‘a nurse is a nurse is a nurse,’” mentioned the essential care worker who spoke concerning the nurse-to-patient ratios. “They take you from one specialty to a different that you simply’re not correctly skilled on. You’re not skilled to look after these sufferers.”

Lee Parmley served because the Jap Colorado VA’s chief of workers when COVID hit in 2020, and was a part of the management group that instituted the team-nursing mannequin because the hospital was inundated by the surge in sufferers.

He mentioned he was shocked to be taught the hospital was nonetheless utilizing this framework — properly after the general public well being disaster had abated. Workforce nursing, Parmley mentioned, shouldn’t be used to maintain the hospital at a minimal staffing degree. And ICU nurses shouldn’t handle greater than two sufferers, he mentioned.

“I don’t see any motive why they might nonetheless be in that fallback place,” Parmley mentioned.

Denver Well being, by comparability, makes use of one nurse for each two ICU sufferers — a ratio that remained constant even throughout COVID, a spokesperson mentioned. The hospital doesn’t ship nurses from different departments to the intensive care unit.

The Colorado Hospital Affiliation, in its literature, says most ICUs are staffed with one nurse to each one or two sufferers — although it acknowledged that circumstances can range at federal and specialty services such because the VA.

To maintain nurse ratios at accepted ranges, the VA has been downgrading ICU sufferers to decrease acuity beds earlier than they’re prepared, a number of suppliers informed The Put up. In six to eight cases since January, a affected person has been downgraded prematurely, solely to finish up again within the ICU, the essential care employee, who’s been a part of these conversations, mentioned.

“They determine they’re going to downgrade as a result of we don’t have sufficient workers,” this particular person mentioned. “If they honestly are ICU sufferers, they should be getting that care.”

ICU administration, in a gathering this month, suggested workers to be “artistic on affected person assignments,” in response to assembly minutes reviewed by The Put up.

Janelle Beswick, a VA spokesperson, mentioned in a press release that the Aurora VA faces lots of the similar challenges with staffing as different hospitals. The VA continues to “aggressively recruit prime expertise,” she mentioned, utilizing aggressive pay constructions.

Nursing shortages are hardly distinctive to the Aurora VA. Ninety-two % of VAs nationwide reported extreme shortages for nurses, in response to the 2023 Workplace of Inspector Common report.

Colorado, even exterior the VA system, faces a scarcity of nurses statewide. A 2021 research from Mercer discovered the state ranked within the prime 5 when it comes to want, with an estimated scarcity of 10,000 registered nurses by 2026.

Within the wake of the pandemic, about 100,000 registered nurses left the workforce nationally as a result of stress, burnout and retirement, in response to a research final 12 months by the Nationwide Council of State Boards of Nursing.

Maryann Alexander, the group’s chief officer of nursing regulation, mentioned the mass exodus “will turn out to be a higher disaster and threaten affected person populations if options usually are not enacted instantly.”

The thriller tincture

For frontline staff, the instruction to manage the unknown tincture final 12 months raised critical issues over administration’s adherence to medical requirements.

Nickerson, the ICU’s nurse supervisor, informed suppliers within the March 11 e-mail that the hospital was following coverage. (She didn’t reply to messages looking for remark.)

VA statute states drugs acquired from sources exterior the VA are prohibited except approved by the chief of workers. Drugs, together with natural treatments introduced in by sufferers, “is not going to be used for inpatient administration” aside from analysis functions, or if the inpatient pharmacy is unable to provide them and so they “are essential to a affected person’s care” — akin to oral chemotherapy.

A number of nurses informed The Put up they refused to present the thriller treatment, citing these insurance policies and state nursing pointers surrounding the administration of unknown drugs.

One of many docs was so involved that, the day after Nickerson’s e-mail, they ordered a blood take a look at for heavy metals — an uncommon take a look at for ICU sufferers, one clinician informed The Put up.

The affected person died March 15. The take a look at confirmed low ranges of arsenic within the man’s system, although properly inside the “regular vary,” in response to his post-mortem report. The Adams County coroner dominated the style of demise to be pure, attributable to sepsis.

The post-mortem report famous the affected person had been taking a homeopathic remedy, delivered by his household, from Feb. 20 to March 7 “with out the hospital’s data.”

However specialists raised alarm that the VA would have allowed this unknown substance to be given in any respect — not to mention by the hospital’s personal suppliers as soon as it was found.

“That’s not what I’d contemplate customary apply,” mentioned Parmley, the VA’s former chief of workers. “I will surely not have carried out that.”

He mentioned he was completely happy to listen to that suppliers had been uncomfortable giving this treatment. “They need to have been,” he mentioned.

Rungta, the then-chief of workers who permitted the unknown remedy, didn’t reply to messages from The Put up looking for remark. She was reassigned from the place in October amid the VA’s investigation into oversight and office tradition issues.

One other incident in October raised extra pink flags about ICU practices.

A affected person had a code blue — or medical emergency — on the hospital ground, in response to a VA workers member who spoke to The Put up concerning the ICU ratios. The person wanted to go to the ICU instantly, however there have been no open beds.

Workers beforehand had pleaded with management to depart one mattress open for these conditions however had been denied, a number of staff informed The Put up. Many hospitals go away a mattress open for these kind of instances — referred to as a “crash mattress” — although it’s not uniform in each establishment.

With no open beds, suppliers had been pressured to drag a affected person out of one of many rooms with no thorough cleansing, a apply referred to as a “soiled mattress swap,” the staffer who witnessed the incident mentioned.

A full cleansing between sufferers usually takes 45 minutes, the worker mentioned. The swap took quarter-hour.

Parmley, the previous VA chief of workers, mentioned this “actually appears like a substandard apply.”

“That shouldn’t be obligatory, ever,” he mentioned.

Workers raised issues about “soiled mattress swaps” in early 2023 to VA management, together with former director Michael Kilmer, who thanked the staff for bringing it to his consideration, in response to emails reviewed by The Put up. Sharee Taylor, the Aurora VA’s affiliate director, instructed staff to let her know in the event that they see the apply once more “as this isn’t acceptable for affected person care.”

Kilmer and Taylor didn’t reply to messages looking for remark.

However clinicians say the potential for “soiled mattress swaps” stays in place, although workers couldn’t recall one other occasion through which it occurred. The concept it may occur once more, although, makes clinicians extraordinarily nervous, they mentioned.

The Las Vegas report

VA management sought exterior assist with the Aurora hospital’s ICU as early as 2021.

That 12 months, VA administration introduced in a bunch of executives from the Las Vegas VA system to audit and supply suggestions to the Aurora group. After shadowing and observing hospital workers, the Nevada group compiled a report, figuring out shortcomings and areas for enchancment, in response to a replica of the report reviewed by The Put up.

The doc famous a wide range of issues, together with managers not reviewing security occasions or classes discovered with workers. Frequent management adjustments, in the meantime, had led to a “fractured and inconsistent administration model,” leaving nurses confused about which directives to comply with.

One other discovering mentioned that the construction of medical protection within the ICU creates a “difficult and unsafe apply setting.” The ICU hiring new graduates, the report states, “is inherently harmful.” The doc famous that nurses complained about being short-staffed however that the “knowledge doesn’t help this.” (In interviews with The Put up, nurses pushed again on how management defines “short-staffed.”)

Aurora VA management, after the report’s conclusion, convened a committee to collect enter from the frontline staff who can be implementing the report’s suggestions.

The group met on April 29, 2021, breaking down the report and telling the committee members they’d loads of work lower out for them. Management delegated sure duties and agreed to fulfill once more to debate.

However there was by no means one other assembly, in response to one committee member.