Problems with sterilizing medical instruments, like the Aurora VA hospital recently acknowledged, are relatively common in Colorado, but the decision to halt procedures isn’t so ordinary.
The Rocky Mountain Regional VA Medical Center has stopped all surgical procedures involving reusable instruments while staff tries to figure out why an unidentified residue has been appearing on sterilized equipment. Procedures with disposable instruments have continued, while the VA is sending patients who need emergency surgery to other hospitals.
VA officials said no patients underwent procedures with contaminated instruments.
State and federal inspection records show at least 16 Colorado hospitals have been cited for improper sterilization since 2019. (See the full list below.)
Specific problems included:
- Not soaking instruments long enough to remove debris
- Using the wrong disinfectant for a particular type of instrument
- Trying to sterilize and reuse items intended for only one use
- Using sped-up “flash” sterilization on a routine basis, rather than as a last resort
The sterilization rules have to be rigorous because surgical instruments often have small, difficult-to-clean parts that could transport bacteria between patients, said Dr. Nasia Safdar, a professor of infectious disease at the University of Wisconsin School of Medicine and Public Health.
Some post-surgical infections respond well to antibiotics, but others lead to severe illness, disability or death.
“The bar is high and the stakes are high,” she said. “If the instrument was only going to be used on the same patient, the concern is less, but that is not how surgical instruments are used.”
Only two of those 16 facilities, Saint Joseph Hospital in Denver and Animas Surgical Hospital in Durango, had reports of visible contamination on their instruments. Both citations were from 2021, and the state accepted the hospitals’ correction plans.
Even instruments that aren’t obviously dirty can cause infections, however, if a hospital hasn’t correctly followed the directions to kill bacteria and viruses. Having blood or other biological material on an instrument isn’t a good sign, but what matters most is whether the germs survived the cleaning process, Safdar said.
“I liken it to finding a hair in your food — not great, but not a health risk necessarily. But E. coli in your food, even though you can’t see it, is always a health risk,” she said.
Colorado almost never imposes penalties for infection-control lapses. In most cases, the state only investigates after someone has filed a complaint about care at the hospital, because the private organization Joint Commission conducts routine licensing inspections, which aren’t public records.
The VA has its own internal inspector, and its hospitals’ results don’t show up in state data.
The information available on the state website also doesn’t include Porter Adventist Hospital’s spate of infections, because it only goes back to 2019.
An investigation in 2018 identified 76 times when supposedly sterilized instruments arrived in Porter operating rooms with blood, bone or other debris still on them. Dozens of patients sued the Denver hospital, alleging that the failure to sterilize instruments before their surgeries led to severe infections.
In most instances identified in inspections, hospitals continued providing surgeries after agreeing to retrain employees on sterilization techniques and periodically observe them as they processed instruments.
Only two of the 16 cited hospitals — Rangely District Hospital in western Colorado and Sedgwick County Health Center in Julesberg — temporarily stopped performing some procedures that required reusable instruments. A spokeswoman for Rangely said no one developed a surgical site infection, but the hospital switched to disposable instruments in its emergency room while updating processes.
San Luis Valley Health’s Conejos County Hospital consolidated sterilization at its sister facility in Alamosa after being cited for trying to sterilize one-time-use instruments, while Haxtun Health in northeast Colorado temporarily switched to only using disposable equipment.
One major difference from the VA’s situation is that inspectors typically knew what had gone wrong with sterilization at the cited hospitals, either from watching employees work or reviewing records.
But officials at the Aurora VA hospital said they’ve checked all the common reasons why instruments might be contaminated after sterilization, but haven’t found an explanation.
The residue looks like black flecks, but the hospital hasn’t yet identified what it is, said Janelle Beswick, regional spokeswoman for the U.S. Department of Veterans Affairs. An outside lab is testing the material, and the hospital’s sterilization department is replacing equipment trays and carts to determine whether those are causing the problem, she said.
“We have also consulted with regional and national experts to ensure that every potential step towards resolution of the issue is taken,” she said.
Colorado hospitals cited for sterilization violations since 2019
Animas Surgical Hospital, Durango, September 2021: 20 cases of biological material remaining on instruments after sterilization in one year; using sped-up “flash” sterilization on a regular basis rather than last resort; not soaking instruments long enough
Foothills Hospital, Boulder, October 2020: Using flash sterilization regularly
Haxtun Health, Haxtun, August 2023: Technician didn’t wear correct protective equipment when cleaning instruments, used wrong detergent
Heart of the Rockies Regional Medical Center, Salida, July 2021: Didn’t soak instruments long enough
Kit Carson County Memorial Hospital, Burlington, August 2019: Technician didn’t wear protective equipment correctly and mismeasured sterilizing solution
Mercy Hospital, Durango, July 2021: Technicians followed wrong sterilization directions for particular instruments
Middle Park Medical Center, Kremmling, June 2023: Using flash sterilization routinely; soaking instruments for wrong length of time and not frequently disinfecting sink
Pioneers Medical Center, Meeker, July 2021: Technician didn’t follow sterilization directions
Rangely District Hospital, Rangely, February 2023: Soaking instruments for wrong length of time
Rio Grande Hospital, Del Norte, January 2024: Improperly cleaning a scope
Saint Joseph Hospital, Denver, December 2021: Four instances of visible contamination in a year
San Luis Valley Health Regional Medical Center, Alamosa, October 2022: Improperly cleaning a scope
San Luis Valley Health Conejos County Hospital, La Jara, July 2023: Reprocessing single-use instruments
Sedgwick County Memorial Hospital, Julesberg, September 2023: Not properly sterilizing vaginal probes
University of Colorado Hospital, Aurora, August 2019: Using flash sterilization routinely
Wray Community District Hospital, Wray, July 2023: Using flash sterilization routinely
Source: State and federal inspection reports maintained by the Colorado Department of Public Health and Environment
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