This July, a state inspector walked through the halls of UCHealth University of Colorado Hospital and documented a germaphobe’s grisly nightmare.
In the hospital’s sterile processing department — or SPD, the place where surgical instruments go to get cleaned and put back into service — the inspector saw 17 stainless steel carts, each one with between 11 and 30 trays of dirty surgical instruments waiting to be cleaned. Upstairs near the operating rooms, there were more: nine additional carts in a holding room where instruments are taken immediately after surgery and two carts sitting out in the hallway.
In all, there were hundreds of backed-up trays of surgical tools waiting to get scrubbed and sanitized.
“Observations further revealed the surgical instrument sets were open to air and heavily soiled with dried blood and tissue,” the inspector wrote.
The details, contained in newly released inspection reports, provide more information about what caused an extraordinary week-long pause in surgeries at the state’s flagship hospital this summer.
They show that state regulators were so concerned about the hospital’s backlog in cleaning instruments that they declared the situation an “immediate jeopardy,” a serious finding that concludes patients are facing imminent harm if the issue isn’t resolved quickly. And the reports raise questions about UCHealth’s explanations at the time that the issue was the result of just a short-term staffing crunch.
When The Colorado Sun in August asked UCHealth spokesperson Kelli Christensen about what had happened, she wrote in an email explaining the situation: “About two weeks ago, the sterile processing department (SPD) at UCHealth University of Colorado Hospital was working at a reduced capacity. As a result of the reduced capacity, some elective surgery cases were postponed or moved to other hospitals or ambulatory surgery centers.”
Asked specifically about a state investigation, which is conducted by staff from the Colorado Department of Public Health and Environment, Christensen responded, “We partnered with CDPHE on this situation.”
The Colorado Department of Public Health building is seen on Wednesday, August 11, 2021, in Glendale. (Olivia Sun, The Colorado Sun)The inspection documents show that regulators visited the hospital after receiving a complaint about possible state and federal violations. (State staff conduct federal inspections in Colorado.) The state ordered UCHealth to make fixes.
“We issued a deficiency at an immediate jeopardy level, which required the facility to develop an immediate and a long-term plan to correct any violations,” CDPHE spokesperson Alexandrea Kallin wrote in an email to The Sun on Wednesday.
What caused the backlogs
The reports tie the backlogs in the SPD to the opening of new operating rooms in the spring. According to the reports, UCHealth documents show that the SPD required 65.2 full-time equivalent employees to be fully staffed prior to the new operating rooms opening. After the new rooms opened, that need increased to 85.2 FTE.
“The facility was unable to provide evidence SPD staffing levels had been increased to meet the post-expansion requirement,” an inspector wrote in one report.
In another report, an inspector wrote that a hospital vice president said hospital leadership was aware of the staffing shortage but had not considered adjusting the surgical schedule to ease the department’s overwhelming workload.
UCHealth University of Colorado Hospital in Aurora. (Olivia Sun, The Colorado Sun via Report for America)This meant that surgical instruments often went more than 24 hours without being cleaned following a surgery, and a technician told inspectors that at times the cleaning delay could last up to six days. In reviewing reports from SPD team meetings from April to July, inspectors documented dozens of days in which more than 100 contaminated surgical instrument sets went unprocessed.
On several days, there were more than 400 instrument sets that went unprocessed, and one day saw 500 sets go unprocessed, according to the inspection reports.
Christensen said the hospital can use close to 1,000 trays a day and thousands of individual surgical instruments.
Blood, tissue and “biofilm”
This was a problem because when blood or tissue dry on an instrument, it becomes much harder to remove and can create something called biofilm — a hardened accumulation of bacteria and other organic gunk.
“Delayed reprocessing of contaminated surgical instruments caused biofilm formation and resulted in less effective disinfection and sterilization,” an inspector wrote in one report.
To address this, a department director told inspectors that staff were instructed to spray uncleaned tools every 72 hours with a pre-cleaning solution to keep material from drying. But inspectors noted that was contrary to the manufacturer’s instructions for use.
In a subsequent interview, the director told inspectors that the number of staff members hired directly by the hospital to work in the SPD had declined over the past year and hospital leadership had “prohibited” adding workers from outside staffing agencies. The director said the processing backlogs had been communicated to hospital leadership through the SPD’s daily reports.
Christensen, the UCHealth spokesperson, wrote in an email this week to The Sun that, “Over the summer, we faced some challenges filling open SPD positions, which resulted in the staffing shortage.”
CDPHE did not identify any instances in which patients were harmed by the sterilization issues. Christensen said UCHealth has not identified any infections linked to the problem.
But one report does note a procedure that was delayed because staff had to evaluate, clean and assemble the specialized syringe that was required. Even after that, the procedure couldn’t be completed as intended when one needle on the instrument tray was found to be bent and another clogged.
“UCHealth’s quality team continuously monitors safety and performance metrics, benchmarking against national standards,” Christensen wrote in her email this week. “(University of Colorado Hospital) is a nationally recognized top tier hospital for quality and safety.”
Fixing the problem
The pause on nonemergency surgeries lasted from July 16 until CDPHE lifted the immediate jeopardy finding July 25, according to the inspection reports.
CDPHE ultimately hit the hospital with multiple violations and required the hospital to fix them. The hospital responded by adding more staff in the SPD and implementing better monitoring of staffing levels and delays in cleaning instruments. That additional monitoring is ongoing.
Christensen said staffing has grown in the department to 140 FTEs — “exceeding national benchmarks for staffing” — and pay for those positions “currently leads the market.”
Walkways in the University of Colorado Hospital on the Anschutz Medical Campus in Aurora, photographed on Oct. 18, 2019. (John Ingold, The Colorado Sun)When state inspectors visited again in September, they found the problems had been fixed.
“The facility is in compliance with all regulations surveyed,” an inspector wrote.
Because of that, Kallin, the CDPHE spokesperson, said the hospital will not face additional sanction. She said the agency’s focus is on ensuring health facilities are in compliance with regulations and provide safe care. CDPHE does have the ability to issue fines or even revoke a facility’s license. But when UCHealth successfully implemented its correction plan, Kallin said CDPHE determined no further action was required.
Christensen said that shows patients can have confidence in the hospital’s 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 now taken place.”
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