Aurora VA stopping surgeries is rare; sterilization problems aren’t

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.