Colorado Investigating Infection Control Breach at Denver Hospital

The Colorado Department of Public Health and Environment issued a statement April 4 about the breach at Porter Adventist Hospital. The department is working with the hospital, which is notifying people who had orthopedic or spine surgery there between July 21, 2016, and Feb. 20, 2018, that some orthopedic or spine surgery patients may be at risk for surgical site infections or for hepatitis B, hepatitis C, or HIV. No patient infections have been confirmed.

Dr. Larry Wolk, executive director and chief medical officer of the Colorado Department of Public Health & Environment, issued a statement April 4 about an infection control breach being investigated at Denver's Porter Adventist Hospital. The department is working with the hospital, which is notifying people who had orthopedic or spine surgery there between July 21, 2016, and Feb. 20, 2018, about an infection control breach that may have put some orthopedic or spine surgery patients at risk for surgical site infections or for hepatitis B, hepatitis C, or HIV. "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," his statement says.

It says the department is not aware of any patient infections related to the breach at this time.

On its homepage, the hospital has posted this statement about the situation:

"At Porter Adventist Hospital, patient safety remains our top priority. Patients who underwent orthopedic or spine surgery at Porter Adventist Hospital between July 21, 2016 to February 20, 2018 are being notified of a gap in the pre-cleaning process of surgical instruments, prior to manual washing, machine washing, and sterilization. Please note that only those orthopedic and spine surgery patients during this period are impacted by this notice and will receive a letter by mail.

"The Colorado Department of Public Health and Environment stated on their website that, 'The department is not aware of any patient infections related to the breach at this time.' In an abundance of caution, patients are being provided information about surgical site infection and are being given the option to be tested for bloodborne pathogens. All hospital instruments go through heat sterilization following a multistep pre-cleaning process, which is designed to inactivate viruses including Hepatitis C, Hepatitis B, and HIV. We understand that this information may cause concern, and are working closely with our patient care team, doctors and staff to ensure any patients involved have the information and resources they need.

"We want to assure patients that our team immediately acted to remedy the situation. Recent survey results released by The Joint Commission, which accredits hospitals in the United States, revealed no errors in our process or protocols. Patients that had an orthopedic or spine surgery during this time frame may call our patient hotline: 303-778-5694 if they have additional questions."

Wolk's statement says "the risk of surgical site infection related to this event (above the usual risk related to surgery) is unknown. The risk of getting HIV, hepatitis B or hepatitis C because of this issue is considered very low." It explains that the health department was notified of the breach Feb. 21 and conducted an on-site survey of infection control practices the following day; a disease control investigation is ongoing. When the department last visited the hospital March 28, it confirmed that current infection-control practices there meet standards, it says.

Wolk also wrote that the stopped using and reprocessed all surgical equipment in question Feb. 20. "While there is always a risk of infection during surgery, it appears there is no increased risk to current patients having surgery at Porter Adventist Hospital because of the infection control breach. On April 4, Porter Adventist Hospital mailed letters to patients who may have been put at risk. People who had orthopedic or spine surgery at Porter between July 21, 2016 and Feb. 20, 2018 can contact Porter Adventist Hospital," he explained.

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