Porter Adventist Hospital warns of sterilization breach; CDPHE says no infections found so far

DENVER – The Colorado Department of Public Health and Environment (CDPHE) is warning people of a breach in the sterilization process of medical instruments used for certain surgeries at Porter Adventist Hospital over the past two years, though it says no patients have so far been found to have been infected.

The hospital says it is notifying people who had orthopedic or spinal surgeries between July 21, 2016 and Feb. 20 of this year about the breach, which the hospital says could have put some patients at risk of hepatitis B or 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,” Dr. Larry Wolk, the Colorado Department of Public Health and Environment’s executive director and chief medical officer, said in a statement.

Wolk said the risk of infection was unknown as it related to this specific situation, but said the risk of a patient contracting HIV or either of the aforementioned hepatitis viruses was “very low.”

Wolk says the hospital notified the CDPHE of the breach on Feb. 21, and that the department did an inspection of the hospital’s infection control practices the next day.

An investigation into the hospital’s disease control program is ongoing, Wolk said, but he added that in the department’s most-recent visit on March 28, officials said the hospital’s current practices meet standards.

The hospital stopped using its equipment and reprocessed it on Feb. 20, the CDPHE says, and Wolk said there appears to be no current risk to any patients who have had surgery since.

Wolk said the hospital mailed letters to patients who had surgery during the affected timeframe on Wednesday, and said anyone with further questions could contact the hospital at 303-778-1955.

Chrissy Nicholson, a spokesperson for the hospital, sent Denver7 the following statement:

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.

Editor's Note: This story corrects the job title of Dr. Larry Wolk.

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