State inspectors have revealed that the weeklong closure of non-emergency surgeries at UCHealth University of Colorado Hospital came after they found dozens of contaminated surgical instruments covered in blood and dried tissue around the facility.
In July, inspectors discovered a huge backlog of uncleaned tools, prompting the hospital to suspend all non-emergency surgeries from July 16 to 25 while safety violations were addressed.
The inspection, sparked by a formal complaint, found 17 stainless steel carts in the hospital’s sterile processing department (SPD) with between 11 and 30 trays of soiled surgical instruments each.
Additional carts were discovered in a waiting room near the operating rooms and in a hallway, with hundreds of trays left “open to the air and heavily soiled with blood and dried tissue,” inspectors wrote, according to The Colorado Sun.
The state regulator classified the situation as an “immediate jeopardy” finding, indicating patients faced imminent harm unless corrective measures were quickly implemented.
said UCHealth spokesperson Kelli Christensen. the sun that the hospital’s SPD had been operating at reduced capacity, resulting in elective surgeries being postponed or relocated.
The hospital worked closely with the Colorado Department of Public Health and Environment to address the violations, a spokesperson added.
“We issued a deficiency at an immediate danger level, which required the facility to develop an immediate and long-term plan to correct any violations,” CDPHE spokesperson Alexandrea Kallin said. the independent in a statement.
The delay arose amid the opening of new operating rooms, which dramatically increased the SPD’s workload.
Before the expansion, the hospital estimated it needed 65.2 full-time equivalent employees. After the expansion, the need increased to 85.2 full-time equivalent employees. Inspectors found no evidence that staffing had increased to meet this demand.
Instruments sometimes remained unsterilized for more than 24 hours, but technicians told researchers delays could extend up to six days.
From April to July, inspectors documented dozens of days during which more than 100 sets of contaminated instruments were left unprocessed, including one day when 500 sets were left unprocessed, according to reports.
Within the SPD, staff were instructed to spray uncleaned instruments every 72 hours with a pre-cleaning solution, which inspectors said violated the manufacturer’s instructions.
The hospital can use up to 1,000 trays a day and thousands of individual surgical instruments, Christensen said.The sun.
This is a problem since blood and dry tissues increase the risk of biofilm formation, a hardened bacterial buildup that is difficult to remove. This could result in “less effective disinfection and sterilization,” one inspector wrote.
The SPD director reported staffing shortages over the past year, and delays were reported daily to management.
Christensen confirmed to the sun This week the hospital faced challenges filling vacant SPD positions, resulting in a temporary shortage.
During the July shutdown, UCHealth expanded SPD staffing to 140 FTE, exceeding national benchmarks, and increased salaries for these positions, Christensen told the outlet.
No UCHealth University of Colorado Hospital patients were harmed in connection with delayed sterilization (UCHealth University of Colorado Hospital)
The hospital also implemented stricter monitoring of staffing levels and instrument cleaning delays. In September, state inspectors confirmed that the hospital was in compliance with all regulations under investigation and imposed no further penalties.
“The University of Colorado Hospital Authority demonstrated that they successfully implemented their plan of correction and did not require any additional action from the department at this time. We found the facility to be in compliance,” Kallin said. the independent.
Inspection reports did not identify any cases of patient harm directly related to sterilization failures. UCHealth said it found no infections linked to the delay, although at least one surgery was delayed while staff cleaned or replaced specialized instruments.
Christensen framed the incident as a temporary staffing crisis resolved through close collaboration with CDPHE.
He said the hospital’s commitment to making the necessary changes demonstrates that patients can trust the hospital to provide safe and reliable care.
“Their findings affirmed that our processes are safe, effective, and aligned with the highest standards of patient care,” Christensen wrote to the sun. “All patients whose procedures were postponed have been rescheduled and the majority of those surgeries have already been performed.”
the independent has reached out to UCHealth for further comment.