In the Phoenix VA report, which you can download in its entirety here, the VA’s Office of Inspector General discussed 45 cases of veterans reflecting “unacceptable and troubling lapses in follow-up, coordination, quality, and continuity of care.” The report links 20 veteran deaths to poor care. We present cases 16-30 below:
A man in his mid-30s had a history of anxiety and suicidal ideation. He called PVAHCS for an appointment and was placed on the EWL. Five weeks later, he was called by the facility and told he had a Primary Care appointment in another 4 weeks.
The patient had been hospitalized at an East Coast VAMC for 1 week during the prior year for suicidal ideation and anxiety. At discharge, he declined further treatment, saying that he was moving to Phoenix. The East Coast VAMC Suicide Prevention Coordinator (SPC) wrote a note in the EHR indicating that PVAHCS SPC was alerted by a voice mail about this patient, but there was no documentation from the PVAHCS SPC that acknowledged receipt of that message.
The patient was seen in a PVAHCS Primary Care Clinic as scheduled, and a referral was made to the Mental Health Clinic. Three weeks later, the patient was contacted by the Mental Health Clinic to arrange an intake appointment.
For this patient with a history of hospitalization for suicidal ideation and anxiety, continued outpatient mental health treatment was important. The delay in scheduling an initial Primary Care appointment led to a delayed referral to Mental Health.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his 50s had a history of chronic tobacco use, chronic obstructive pulmonary disease (COPD), diabetes, and anxiety. In mid-December 2013, he presented to the PVAHCS ED with symptoms suggestive of an upper respiratory infection and COPD. The patient was treated and discharged with medications. Through a Schedule an Appointment consult, Primary Care follow-up was requested within 1 month.
About 1 month later, the patient returned to the ED because he ran out of his medications. He had not been scheduled to be seen in Primary Care. In early February, he returned to the ED with symptoms suggestive of another COPD flare. About 1 month later, he returned to the ED requesting medication refills. In early May, he was seen for his first scheduled appointment in Primary Care.
This case reveals a missed opportunity to treat a patient with a chronic disease in an outpatient setting and demonstrates why some patients use the ED for “primary care.” At least one of the patient’s COPD exacerbations may have been averted if the patient had been seen in Primary Care sooner.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his late 80s lives in the Midwest for half the year and in Arizona the other half. He receives both private care and VA care, and is registered with and followed by Primary Care at a Midwest VAMC.
In late December 2013, the patient presented to the PVAHCS ED with symptoms suggestive of a urinary tract infection, and blood tests revealed evidence of kidney disease. He was prescribed an antibiotic, and adjustments were made to his anti-hypertension regimen.
In early January 2014, the patient walked in to Primary Care for repeat labs and a blood pressure check, as instructed by the ED physician. His blood pressure was found to be 165/82 mm Hg. He had a new patient appointment pending for about 3 weeks later at PVAHCS. When he arrived for that appointment, he was not triaged, but rather, a licensed practical nurse (LPN) informed him that he cannot have two Primary Care teams (that is, in Phoenix and the Midwest). The patient left after choosing the Midwest VAMC as his home base.
While VHA policy discourages the practice of assigning more than one Primary Care team, it is not prohibited in all circumstances. VHA policy allows for the assignment of two Primary Care teams when veterans split their time between different residences located in different geographic areas.1 The patient could have had a Primary Care team assigned at PVAHCS, while maintaining his care in the Midwest.
This was an elderly patient with a change in his blood pressure medication regimen and significantly reduced renal function. The patient, after being on his new regimen for 1 week, had persistent hypertension and might have benefited from a medication adjustment. The patient presented for a scheduled appointment but left after being given misinformation regarding VHA management of veterans who split their residence between two different locations.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his late 50s who had a history of methamphetamine abuse presented to PVAHCS in early May 2013 complaining of new blurry vision and was found to have a blood pressure of 224/124 mm Hg. He was evaluated that day by Ophthalmology and referred to Primary Care. The ophthalmologist who saw the patient in the following week attributed his visual changes to hypertension.
Four months after his initial ED visit, the patient went to the ED requesting a refill of medications he had been prescribed a few days earlier at a non-VA hospital. He reported that he had been diagnosed with a stroke there. The ED physician who saw him submitted another consult request for Primary Care follow-up.
In early October, the patient contacted the facility requesting a new Primary Care appointment “as soon as possible.” The first successfully scheduled Primary Care appointment was made for 1 month later. In early December, the patient completed an appointment in Primary Care. About a month later, the patient was admitted to a non-VA hospital for a new stroke, which resulted in significant loss of vision in both eyes.
The patient was an amphetamine abuser and had dangerously elevated blood pressure during his initial visit. His wait for Primary Care was excessive, and while waiting, he suffered a stroke. A timelier Primary Care visit could have improved his blood pressure control and allowed for treatment of his substance abuse which could have reduced his risk for stroke.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his mid-50s was seen in the PVAHCS ED in late January 2014, 2 weeks after his release from incarceration. He stated that his blood pressure was 180/120 mm Hg while incarcerated and that he had not been taking his medications after being released. In the ED, his blood pressure was 162/128 mm Hg, and his urine tested positive for amphetamines and cocaine. He was prescribed two medications for his blood pressure and instructed to follow up with a PCP, even if outside the VA system, or at an ED if his blood pressure readings remained markedly elevated.
With blood pressure readings so high in a patient with significant heart disease, any delay in follow-up and primary care is concerning. The EHR did not reflect a sufficiently aggressive approach.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his early 60s had a history of diabetes, COPD, obstructive sleep apnea, and obesity. He had been seen regularly at a PVAHCS Primary Care Clinic from 2007 through 2011. He had no further encounters until early March 2014 when he presented as a “walk-in” complaining of swelling and shortness of breath. He said that he had recently lost his private insurance and no longer had any medication. A nurse noted that his oxygen saturation was reduced (89 percent; normal is greater than 95 percent). After consulting with the physician on staff, the nurse advised the patient that she was going to call Emergency Medical Services so that patient could be transported to the nearest ED. The patient refused but did agree to drive himself to the PVAHCS ED.
After an evaluation at the PVAHCS ED, the patient was admitted to the medicine ward. He was restarted on his medications, pulmonary function and other tests were scheduled, and a Schedule an Appointment consult was placed for Primary Care. Six weeks later pulmonary function tests were performed, revealing significant COPD. Nineteen weeks after hospitalization, the patient had not been scheduled with a PCP.
Despite discharge instructions indicating a need for Primary Care follow-up within 2 weeks, this patient with significant pulmonary disease had not been scheduled for Primary Care.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his late 60s was seen at the PVAHCS ED for right knee pain. In the course of his evaluation, the patient was also found to have a markedly elevated blood pressure (241/137 mm Hg). The ED provider treated his hypertension and requested that the patient be seen by Primary Care within a week. Seven months later, the patient had not been scheduled for a Primary Care appointment nor had he made other visits to PVAHCS.
This patient’s blood pressure elevation warranted treatment in the immediate weeks after his ED visit, but no treatment was documented for the next 7 months.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his early 40s had a history of major depressive disorder, diabetes, hyperlipidemia, and hypertension. His initial contact with PVAHCS was in October 2013, when he was hospitalized for a major depressive disorder. At that time laboratory values indicated very poor diabetes control and marked cholesterol elevation (total cholesterol, 470 mg/dl; LDL cholesterol, 307 mg/dl). His medical regimen at discharge included drugs for diabetes and hypercholesterolemia, including insulin, glyburide, metformin, and atorvastatin.
The discharge summary specified, “please schedule for a new patient Primary Care appointment.” The patient was not scheduled in Primary Care for 6 months. When he was seen, his diabetes control was even worse and he had blurred vision.
This patient, with very poorly controlled diabetes and extreme hyperlipidemia, had substantially delayed care.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
This patient is a man in his early 40s who registered for care at PVAHCS in September 2012, and his first primary care appointment was 8 months later. At that appointment, he revealed a history of hypertension, hyperlipidemia, severe alcohol abuse, anxiety, and depression. He was later diagnosed with steatohepatitis. The patient subsequently underwent successful treatment for alcohol abuse.
This patient with significant mental and physical health issues waited 8 months for initiation of treatment.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his 60s presented to the PVAHCS ED in late January 2014 with chest pain and shortness of breath. He reported that he had recently been treated at a non-VA hospital for coronary artery disease and had a stent placed. In the ED, an electrocardiogram showed no abnormalities, and blood tests were negative for acute myocardial infarction. He was considered to have “atypical chest pain,” and a Schedule an Appointment consult was placed. An appointment for Primary Care was made for 2 months later. When he presented for that appointment, he was sent to the ED, where he was admitted with a cough and shortness of breath. He was subsequently evaluated by a pulmonologist and his symptoms were attributed to gastroesophageal reflux.
This patient with known significant coronary artery disease had a delay in initial primary care that might have exposed him to unnecessary risk.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
This man in his early 40s has a history of polysubstance abuse, panic disorder, and homelessness.
In early December 2013, he was seen in the ED for a rash, and an ED physician placed a consult for a PCP assignment. Throughout January 2014, the patient repeatedly sought care in the ED, frequently requesting narcotics, and multiple references were made as to the need for “follow-up with PCP.” In late January, an ED physician again entered a consult requesting PCP services.
This high-risk patient with polysubstance abuse was utilizing the ED for basic health care needs. As of June 3, 2014, the patient had not been seen in Primary Care.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his late 50s had a history of bipolar disorder, alcohol dependence, and four suicide attempts. He moved to Phoenix from Texas where he had been followed by both Mental Health and Primary Care. His last visit with his mental health provider in Texas was in late July 2013, with plans for a follow-up in 4 months, which the patient did not attend.
In early December, the patient registered with PVAHCS and applied for an outpatient medical appointment. He was placed on the EWL 3 days later. In early April 2014, the patient contacted PVAHCS about the status of his appointment and reported he was having “ongoing issues.” A medical services assistant informed the patient that he could come into any clinic as a “walk-in.”
On two occasions in mid-April, PVAHCS staff unsuccessfully attempted to call the patient to set up a new appointment and left voice messages. In late April, the patient called to schedule an appointment; he was informed that someone would contact him. In early May, the facility made another unsuccessful attempt to contact the patient and also sent a letter to the patient with the facility’s contact information.
Three days later, the patient committed suicide by gunshot. His brother told the suicide prevention social worker that the patient had been depressed for a long time.
This patient was at increased risk of suicide. A timely Primary Care appointment was not available at the time of initial contact, and the patient was placed on the facility’s EWL. Better availability of an appointment for this patient might have changed the outcome.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
This man in his early 60s had a history of schizophrenia. He was released from prison after being incarcerated for 16 years following a conviction for manslaughter. One year later, he registered for care at PVAHCS at a “Stand Down” (a homeless veteran outreach event), and he was given an appointment for primary care for 4 months later. He was seen in Primary Care 2 weeks before his scheduled appointment, and hallucinations and suicidal ideation were discussed. He was referred to Mental Health.
Although it is unclear what PVAHCS knew about his history at the time of registration, this patient was a potential threat to himself and others. He had schizophrenia and a history of violence and was without medication and having auditory hallucinations and suicidal ideation. A timely appointment at the time of registration should have been provided.
In addition to the 28 cases discussed earlier that had clinically significant delays, OIG identified deficiencies unrelated to delays in the care of 17 patients, including 14 who were deceased.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his early 60s had a history of severe cardiomyopathy (disease of the heart muscle), hypertension, poorly controlled diabetes, hepatitis B, hepatitis C, and tobacco use. An echocardiogram performed in late summer 2013 showed the patient’s cardiac function was severely depressed, indicating severe heart failure and increased risk for abnormal heart rhythms and sudden death.
The patient was followed in PVAHCS’s Primary Care and Cardiology Clinics. Two days following the echocardiogram, a cardiologist entered a consult to the Tucson, AZ, VAMC’s Cardiology-Electrophysiology Service for consideration of an implantable cardioverter defibrillator (ICD) with or without cardiac resynchronization. The patient had an ICD placed approximately 5 years previously, but it was removed because of complications caused by either infection or metal allergy.
Two weeks after the consult to the Tucson VAMC was entered, a Cardiology nurse practitioner at the Tucson VAMC called the patient. During that conversation, the patient stated that he wanted allergy testing before any new device was placed.
Five weeks later, an allergy patch test revealed no reaction to metals. The PVAHCS cardiologist sent a note attached to the consult to the Tucson VAMC’s Cardiology-Electrophysiology Service stating that the patient “can now be scheduled for CRT-D [cardiac resynchronization therapy with defibrillator].” The cardiologist recommended that the procedure be done in the next 4 to 5 weeks.
One month later, the patient was seen by a PVAHCS cardiologist. The cardiologist added another note to the Tucson VAMC Cardiology-Electrophysiology consult stating that the patient needed to be seen for device implantation.
In early 2014, the patient had a routine follow-up appointment at PVAHCS in Primary Care. One week later PVAHCS was informed of his death.
Medical records from a local non-VA hospital indicated that 3 days prior to his death, the patient’s family witnessed him collapse in his kitchen. Upon arrival, Emergency Medical Services notes indicated that the patient was pulseless and in ventricular fibrillation.
According to PVAHCS records, the patient was on an EWL for an Endocrinology Service consult that had been placed in late spring of 2013 for management of the patient’s poorly controlled diabetes. The patient reportedly agreed to an appointment 1 month later, but he did not go to that appointment.
The ICD should have been placed within a few months of the most current plan. This patient’s severe cardiac disease placed him at risk for sudden death at any time. ICD placement might have forestalled that death.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014
A man in his mid-50s had a history of hypertension and chronic pain due to degenerative joint disease involving his neck. He was followed by Primary Care, and his pain management plan consisted of physical therapy and limited use of hydrocodone. He was awaiting a Neurosurgery evaluation of his neck to determine if a surgical intervention could help with his pain.
In mid-2013, the patient called his PCP requesting stronger pain medication, as his usual medication was not helping his “torso pain.” Two days later, the provider documented that the patient could pick up an alternative pain medication at the outpatient pharmacy. There is no documentation in the EHR that the provider evaluated the patient by phone or in person.
Two days after starting the new medication, the patient presented to the ED complaining of severe abdominal pain. He was noted to have “10/10” (worst possible) abdominal pain, a temperature of 95 degrees Fahrenheit, and a pulse of 111 beats per minute. He was evaluated by an ED physician within 20 minutes. A CT scan of his abdomen, completed 2 hours later, showed a perforated bowel (a hole in the wall of the bowel that can quickly lead to life-threatening infection and/or sepsis). A surgical consult was requested 4 hours after the CT scan, and another hour passed before a surgery resident evaluated the patient. The patient was taken to the operating room for an exploratory laparotomy (a surgery that opens the abdominal cavity) within 2 hours of the surgeon’s evaluation. The patient remained on pressors (intravenous medications used to elevate blood pressure in the setting of shock) and ventilator support postoperatively. Two days later, the family removed life support and the patient died.
This patient being treated for chronic neck pain described a new location of pain, and this description should have prompted a telephone or face-to-face assessment. At his final presentation to the ED, hypothermia and tachycardia warranted prompt and intensive interventions. Earlier diagnosis and treatment might have altered the outcome in this case.
– Department of Veterans Affairs, Office of Inspector General Report, “Review of Alleged Patient Deaths, Patient Wait Times, and Scheduling Practices at the Phoenix VA Health Care System,” August 26, 2014