Porter Advocate Infection Breech: Cleaning Process Was Flawed

DENVER, CO -- Executives at Porter Adventist Hospital apologized Thursday for the 'significant health breach' that could have exposed 5,800 orthopedic and spine surgery patients to infectious diseases such as HIV and Hepatitis.

The hospital’s Chief Medical Officer, Dr. Patty Howell, and Centura Health’s Senior Vice President, Morre Dean said the problem was caused by human error, but did not say how many patients were affected.

The administrators said orthopedic and spine surgery tools were not appropriately pre-cleaned and still may have contained "bioburden" -- potentially infectious human tissue -- when they were cleaned with mechanical cleaners and sterilizers.

“Those instruments tend to be highly complex. There’s a lot of nooks and crannies, sharp areas, mechanisms, that exist in those," Howell told FOX31 news station Thursday. "Staff was doing cleaning, but they felt there should be more cleaning.”

A doctor found a piece of bone fragment on a surgical instrument in April, 2017, the Denver Post reported. The doctor did not use the device and received a whole new tray of cleaned instruments. The hospital did not recognize a flaw in their cleaning protocol until a February visit from the national accrediting agency the Joint Commission warned the hospital about problems in the cleaning process.

The Colorado Department of Public Health and the Environment said patients had post-surgical infections after procedures between July 21, 2016 and April 5, 2018.

"It is unknown if these infections are linked to the breach, and we may not be able to determine linkage," a letter from CDHE said Wednesday.

On April 5, Porter voluntarily closed its operating rooms for two reasons. The primary concern was with the cleaning process for surgical tools following orthopedic and spine surgeries. The other potential concern was related to residue on surgical tools after sterilization. Porter reported this was potentially due to a water quality issue. As a result, water testing was conducted, and water quality at Porter was found to be well within the typical range found in drinking water.

Porter reopened for some scheduled surgeries Thursday.

A patient hotline was set up for inquiries at: 303-778-5694.

The public can call the Colorado Health Emergency Line for Public Information (COHELP) at 303-389-1687 or 1-877-462-2911 for general questions about surgical site infections, HIV, hepatitis C and hepatitis B. COHELP hours are 9 a.m. to 7 p.m. Monday through Friday and 9 a.m. to 5 p.m. Saturday and Sunday. The public also can email COHELP at mailto:COHELP@rmpdc.org.

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