PATIENTS AT RISK OVER SURGICAL INSTRUMENTS

Breach involving surgical instruments may affect patients, but chance “very low”

Surgery patients at Porter Adventist Hospital may be at risk of contracting hepatitis B, hepatitis C or HIV after surgical instruments were not properly cleaned. »2A

An infection-control breach involving surgical instruments at Porter Adventist Hospital may have put some surgery patients at risk for contracting hepatitis B, hepatitis C or HIV, hospital and state health officials said Wednesday.

The breach may have affected patients who had orthopedic or spine surgery between July 21, 2016, and Feb. 20. The risk of getting HIV, hepatitis B or hepatitis C is “very low,” said Larry Wolk, the executive director and chief medical officer for the Colorado Department of Public Health and Environment.

The hospital did not immediately respond when asked how many patients could have been impacted. Wolk directed the inquiry back to Porter.

“The process for cleaning surgical instruments following orthopedic and spine surgeries was found to be inadequate, which may have compromised the sterilization of the instruments,” read a statement from Wolk. The department doesn’t know of any patient infections related to the breach, he said. The hospital mailed letters to patients who may have been at risk.

The health department, which was told of the breach Feb. 21, conducted an on-site survey of infection-control practices at Porter the next day. A disease-control investigation is ongoing.

Patients notified by the hospital are receiving a list of frequently asked questions.

The letter explains that the sterilization issue revolved around the first step in a multistep process. The first step is a pre-cleaning process that happens before instruments go through “an intense heat sterilization,” the letter said.

“Although extremely low, there is a risk of surgical site infection or bloodborne pathogen transmission,” the letter read. “In the rare event that a patient tests positive for a bloodborne pathogen, there are many treatment options available. Your health care provider will discuss these with you in the unlikely event you receive a positive test result.”

The letter explains that a surgical site infection tends to present itself within 30 days of surgery, but in a very limited number of cases, symptoms might occur up to a year later if the surgery involved placement of a prosthetic limb.

Symptoms of an infection include pus, pain, tenderness or redness at the site of the surgical wound, the letter said. Patients being tested will be seen by independent laboratory LabCorp, which will need to draw several vials of blood. Results will be procured in 14 to 30 days.

Patients can call a hotline, 303-778-5694, for more information.

As of March 28, the infection-control practices at Porter met standards. The hospital has since stopped using all surgical equipment in question from that time period.

“Patient safety is our top priority at Porter Adventist Hospital,” read a statement from Porter spokeswoman Chrissy Nicholson. “We are proactively working with the Colorado Department of Public Health & Environment about a gap in the pre-cleaning process, prior to sterilization. While we take any gap in our pre-cleaning process seriously, at this time we are not aware of it having caused any infections. We are reaching out to patients who underwent orthopedic and spine surgery during the time in question. We remain committed to transparency; additional details will be forthcoming.”

In 2016, nine University of Colorado Hospital patients developed infections. Three of the patients later died. They had undergone operations with a duodenoscope, a hard-to-clean surgical device inserted into a patient’s throat.

Another 2016 state Health Department investigation found that workers at Memorial Hospital in Colorado Springs failed for years to properly disinfect vaginal ultrasound probes and other pieces of medical and surgical equipment.

Memorial Hospital officials said they found no evidence of infections caused by the hospital’s failure to properly disinfect medical tools.