Colorado hospitals cited for contaminated equipment, including 3 instances of ‘immediate jeopardy’

A handful of Colorado hospitals over the past three years have been cited by the state health department for contaminated equipment, The Denver Gazette has learned.

Contaminated equipment was what led officials at the Rocky Mountain VA Medical Center in Aurora to reschedule hundreds of dental and surgical procedures earlier this year. VA officials told The Denver Gazette on Wednesday that the source of the contamination has been identified as flecks of plastic.

Contaminates on reusable equipment can introduce bacteria, viruses or fungi into the surgical site and lead to infections.

Colorado Department of Public Health and Environment citations since 2021 show just four hospitals — Children’s Hospital of Colorado in Aurora, St. Luke's Medical Center in Denver and Animas Surgical Hospital and Mercy Hospital in Durango — have had issues with contaminated equipment or with the sterilization process.

In at least three instances, officials with the state health department deemed the issue serious enough to find what’s called “immediate jeopardy” against Animas, Children’s and St. Luke’s.

"Immediate jeopardy" is any situation in which noncompliance puts the health and safety of patients at risk of serious injury, harm, impairment or death.

Hospital officials with St. Luke’s, Animas and Mercy did not respond to multiple emails seeking comment.

Sarah Bonar, a Children’s Hospital spokesperson, referred to the hospital’s plan of correction submitted to the state, which said, in part, that it took immediate action to strengthen the “processes around the infection control practices for high-level disinfection of endoscopes and reprocessing of sterile instruments.”

“Given the reliance on equipment and technology in today’s health care settings, issues with equipment do sometimes arise,” Cara Welch, a spokesperson for the Colorado Hospital Association, has said.

“As a result, hospitals typically plan for this as part of their emergency preparedness program," she said. "Those plans typically provide guidance on how to manage a variety of equipment issues and are focused on ensuring quality, safety and patient care are prioritized.”

‘Promising results’

Healthcare-associated infections are preventable.

Roughly 3% of patients in U.S. hospitals have had a healthcare-related infection, according to a 2015 survey.

It’s unclear how many Colorado patients have had a healthcare-associated infection, which can require additional treatment, and cause suffering and death. State health officials did not respond to an inquiry by The Denver Gazette in time for publication.

Surgical equipment can be disposable or reusable.

Reusable equipment includes items such as scalpels and dental tools, which impact surgeries and routine dental appointments.

Janelle Beswick, a VA Eastern Colorado Health Care System spokesperson, said testing last month indicated that previously unidentified “black flecks” on two surgical trays found on reusable surgical equipment in April were plastic.

Standard operating procedure requires an equipment inspection prior to all procedures. It was during this inspection that the residue was discovered.

The issue, Beswick has said, appears to have been with the hospital’s steam sterilization system used to clean reusable medical equipment.

Officials had found residue on roughly 5% of the VA hospital’s surgical trays.

Beswick said the hospital began using reusable medical equipment on July 15, after a vendor “fully refurbished our sterilizer washers and replaced internal parts that were worn.”

“As of July 22, 100% of RME surgical sets passed rigorous inspection, and we continue our phased reopening of surgical services,” Beswick said in an email to The Denver Gazette. “If these promising results continue, we will further expand procedures and return to full surgical operation on Aug. 12.”

Not all surgeries at the VA, though, involve reusable medical equipment that is cleaned in house through a sterilization process.

Surgeries that can be done using disposable equipment have continued.

As a federal entity, the state health department does not provide regulatory oversight of the VA hospital.

Corrective steps at the VA hospital had included, among other things, replacing filters throughout the system, cleaning the equipment chambers and a scope assessment of the lines in the hospital’s steam system.

In total, 52 dental appointments and 181 surgeries in April were either re-scheduled or referred to community hospitals or other VA facilities.

“This is not a protocol failure; it is an example of safety processes working as intended,” Beswick said previously.