Dublin VAMC
WASHINGTON, DC — Lawmakers are looking to intervene following the latest documented failure by a VA hospital to properly sterilize reusable medical equipment.
Congressmembers are introducing legislation that would require VA to make improvements to its sterile processing service (SPS). Some advocates agree that the move is necessary, while department officials argue that VA already has the authority to make improvements on its own.
“The Veteran Infection Prevention Act … responds directly to a pattern of serious and well-documented failures within VA’s sterile processing protocols, failures that have led to catastrophic consequences for veteran patients and need to be fixed,” declared Rep. Jen Kiggans (R-VA), during a legislative hearing of the House VA Oversight Committee. “Findings at the Dublin VAMC found that lapses and breakdowns in sterile processing protocols created unacceptable risks to patient safety.”
In spring 2024, VA Office of Inspector General (OIG) investigators were conducting a routine inspection of the Carl Vinson VAMC in Dublin, GA, when they learned of an incident involving a rectal tray—a set of 90 surgical instruments used in a variety of GI procedures. According to staff, the tray, which was used for a biopsy, included tools that were pitted, stained and tarnished.
Opening an investigation, OIG discovered additional rectal trays containing “nonconforming equipment” and learned of a disagreement between sterilization staff and operating room staff over who had the responsibility for recognizing and removing them. The OIG report also found that a conference room located at the opposite end of a large sterile processing services (SPS) storage area was used by staff for lunch breaks—something facility staff had long recognized as a contamination hazard.
“There’s a big open room with sterile instruments and people are just walking through right next to it with their lunch on the way to the break room. This has to be addressed as soon as possible,” the hospital’s infection control leader told the facility chief of safety in an April 2021 email. “Clean instruments can’t be considered to remain clean if we don’t store them in a protected area where general traffic does not just walk through.”
The Dublin VAMC is not the only facility where sterile processing failures have been identified, however. The issue is one that has come up a number of times in recent years, both in OIG reports and congressional hearings.
“This is not an isolated issue, but a systemic one,” Kiggans said. “It demonstrates the urgent need for reform and reinvestment in the VA workforce, particularly those roles that work behind the scenes. Those that, if they aren’t done properly, can have serious consequences for patient care.”
If passed, Kiggan’s bill would require that all SPS staff beyond entry-level be trained and certified as a sterile processing technician by an accredited institution within 2 years of their appointment. Currently, VA’s SPS training is done internally.
“VA supports the goal of strong sterile processing practices but notes that legislation is unnecessary because VA already has the authority to set qualifications and certification expectations,” explained Isle Wiechers, MD, MPP, MHS, acting deputy undersecretary for health for patient care services. “We have an internal VHA certification process that is free for all staff to take that requires 400 hours of hands-on experience to be eligible to take this certification exam and requires annual continuing education for maintenance of that certification.”
“A lot of our sterile processing staff must show and prove their competency in the reprocessing of reusable medical devices under direct observation,” Wiechers added “For our highest risk devices, they have to demonstrate their competency in that every year.”
Joseph Avila, the administrator of the University of Virginia Health System’s sterile processing department, argued that VA’s current certification process does not take the place of more professional training.
“While the VA has made recent progress requiring certain staff such as their facility SPS chiefs to obtain certification, the rest of the sterile processing technicians are required only to complete an online training management tool,” Avila noted. “These modules lack rigor, competency-based assessment, and third-party oversight.”
According to Avila, an average hospital with 15 operating rooms can handle 13,000 surgical cases annually, each using an average of 450 instruments, resulting in five million instruments processed in a single year.
“Sterile processing is not widely understood by the average patient, but it is the foundation of surgical safety and directly influences outcomes,” he said. “Contaminated equipment exposes veterans to dangerous pathogens, costly follow-up care, and week-long delays at a facility when contamination occurs.”
The legislation was passed out of the subcommittee in April for consideration by the full House VA Committee.