Medical center curtails surgeries

Instruments at Brooke Army hospital were improperly sterilized.

Brooke Army Medical Center, the flagship of the Army’s health system and famous for the burn ward that has treated hundreds of war victims, has closed more than half its operating rooms and reduced elective surgeries after last month finding improper sterilization of instruments in 73 cases, including 16 incidents in which fragments of organic material such as bone, skin or blood were left on surgical tools.

The San Antonio facility’s commanders said they shuttered 16 of the 28 operating rooms because of a shortage of 600 sets of properly sterilized instruments.

They could not say when the hospital would improve the sterilization department to the point that it could reopen the operating rooms.

The temporary closure does not affect the Level 1 trauma center, which has priority for the sterilized equipment. One of 15 such centersin the country, it handles 48,000 emergency cases a year from 22 Texas counties.

The hospital, which has treated thousands of troops from the wars in Iraq and Afghanistan, did not directly say whether dirty instruments led to infections, noting that Army rules prevent such disclosure.

One commander, Dr. Douglas Soderdahl, a colonel, said that “there’s no concerning spikes or things going in the wrong direction” regarding the center’s medical care.

Brooke officials, who disclosed the problem in an April 21 briefing with several hundred doctors and other medical personnel, wouldn’t confirm the number of cases butacknowledged the sterilization problem and closure

of operating rooms. A physician familiar with the meeting provided the numbers to the San Antonio Express-News and said the hospital also recorded 24 cases of improperly processed surgical sets in December and 14 in September.

“It was a point of contention during the meeting. Several surgeons stood up and said, hey, this is an issue. We’re having poorly sterilized equipment, it’s a recurring issue and ... it happens, if not on a daily basis, multiple times a week,” said the doctor, who asked to remain unidentified for fear of retribution.

“It doesn’t mean 16 patients had those instruments used on them. Those instruments may have come up to the operating room and while they were being opened and getting ready to be used on a patient were identified,” the doctor added. “But the way many people look at it, it’s evidence of an underlying problem, and if we’re catching 16 of those, then how many are out there; how many are we not catching?”

Soderdahl, the deputy commander for surgical services, cautioned against drawing conclusions from the numbers provided to the newspaper, saying, “Charts can tell different stories and can be interpreted in different ways.”

The hospital publicly announced its action in a short news release Friday after the Express-News interviewed Soderdahl and others earlier in the week.

The potential danger of organic material left on sterilized instruments, called “bioburden,” was a point of contention for Soderdahl and a San Antonio expert.

Soderdahl described bioburden as “unintended remained material” after sterilization. Asked whether it could survive sterilization, he said infectious disease colleagues have told him that “it’s unlikely for a living organism to make it through the process.”

Weston “Hank” Balch, director of sterile processing operations at San Antonio’s University Health System and president of the South Texas Association for Sterile Processing, said bioburden is a potential threat.

He said a substance called “biofilm” can form on an instrument containing leftover organic material after it has been sterilized.

The substance may cause illnesses if the tool is used on a patient, he said, adding that Brooke isn’t alone in confronting the problem.

“I think you would be hard-pressed to find a facility in the U.S. that has not had that issue. Enough people die every single day because of medical errors to fill a 747,” he said.

The hospital’s commander, Brig. Gen. Jeffrey Johnson, who also is a doctor, said the hospital documented a backlog of more than 600 sets used in surgeries.

Medical teams will use one or more instrument sets, depending on the nature and complexity of an operation.

The hospital did not say how many elective surgical procedures would be canceled, but Johnson said efforts are underway to boost staffing at its Sterile Processing and Distribution facility, where 60 military and civilians work.

“We really found where the demand and the supply became unequal, and that’s why we had to slow things down,” he said. But he said Brooke would not limit its ability to treat trauma cases.

Touted as the Army’s premiere medical facility, Brooke replaced a Depression-era facility in 1994.

It’s the Army’s sole Level 1 trauma center and operates the Defense Department’s only burn treatment facility.

The hospital underwent a $724 million expansion a decade ago and now includes 425 military and civilian inpatient beds, and it can expand to 613. The project also added a rooftop helipad that allows trauma patients to be moved directly to the emergency rooms.

The 1.5 million-squarefoot facility boasts six outpatient clinics that draw 4,000 patients a day.

The hospital employs 8,500 military and civilian workers and has alliances with Army researchers and others throughout San Antonio, as well as Bexar County’s University Hospital.

Johnson said the backlog in sterilized sets is rooted in an order to boost the number of elective surgeries, which was part of “a deliberate strategic initiative to increase the amount of care that we do here” and improve proficiency.

“So we increased the number of surgeries that we were doing in order to provide more readiness,” he said. “That increase in number of surgeries then created strains on the support team systems that go with that.”

Over the past six to nine months, Johnson explained, hospital commanders began to see “a variety of different strains on our surgical line” that went beyond Sterile Processing and Distribution.

“So some of those strains are equipment, some of it space, some of it people, some of it time, and they’ve all been trying do their own adjustments . ... But in the long run, some of those adjustments actually made us less efficient,” he said.