Home E-Weekly April 10, 2018

Colorado Hospital Suspends Surgeries After Instrument Cleaning Breach

Published: April 10, 2018

Sterilizing Instruments CAUSE FOR CONCERN Porter Adventist Hospital says instruments were not properly pre-cleaned before sterilization.

A hospital in Denver, Colo., has suspended all surgeries after revealing inadequately cleaned instruments put orthopedic and spine surgery patients at risk of suffering post-op infections and contracting HIV or hepatitis B and C.

Porter Adventist Hospital says in a statement that the infection control breach involves the improper manual pre-cleaning of instruments before the tools underwent machine washing cycles and steam sterilization. Its ORs will remain shuttered until the Colorado Department of Public Health & Environment (CDPHE) determines it's safe for surgeries to resume.

The CDPHE was notified of the instrument cleaning issue on Feb. 21, 2018, and the next day conducted an on-site inspection of the hospital's infection control practices. Following the inspection, the CDPHE advised the hospital to notify patients who underwent surgeries between July 21, 2016, and Feb. 20, 2018, of their possible exposure to bloodborne pathogens.

CDPHE investigators conducted another on-site inspection on April 5, the day Porter Adventist suspended surgeries due to "a potential change in water quality relative to surgical equipment." The CDPHE suggested Porter Adventist extend the warning about improperly cleaned instruments to patients who had procedures done from Feb. 21 to April 5.

The risk of infection is considered "very low," according to the CDPHE, which says it is unaware of any infections associated with the cleaning breach. Mark Salley, a CDPHE spokesman, says the department can't comment further on active investigations.

Porter Adventist says patient safety remains its top priority and has sent letters to all patients who underwent surgery during the period in question to warn them of their potential risk of infection and offer the opportunity to be tested for bloodborne pathogens. Hospital spokeswoman Chrissy Nicholson did not respond to a request for comment.

Daniel Cook

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