Updated: 3:04 p.m.
Rocky Mountain Regional VA Medical Center in Aurora will resume all surgeries on Monday after figuring out and repairing problems with its on-site steam sterilization equipment.
In May, officials discovered a black plastic residue on several surgical equipment trays. Officials traced it to a reusable medical device washer used in the sterile processing of reusable medical equipment.
Hospital leaders ordered a halt to surgeries, forcing patients to wait or go elsewhere. During that pause, 608 procedures were postponed or referred to other hospitals in the community, according to a press release from the VA.
Hospital care teams are now working with veterans to make sure their procedures are rescheduled.
“The reason we've had this two or three month gap was to ensure that safety is in place,” said Michelle Mountfort, associate director of patient care services, essentially the chief nursing officer, for VA’s Eastern Colorado health care system. The patient’s safety “is our number one priority. We want to do their procedures, we want to give them high quality care, and we will only do it in a safe environment. The care that they got was safe and the care that we'll provide going forward is safe.”
“Relieved” was how she described her feelings about getting the trouble fixed. “Because we just need to ensure that it never happens again.”
She said the equipment cleans thousands of pieces of surgical equipment a day.
“It'll have forceps and scalpels and needles and needle drivers and retractors, and you name it. Some cases, there are literally trays and trays and trays of instruments that they need,” said Mountfort.
The reopening and return to full operations comes after a “four-week phased soft start to ensure that all sterilized surgical equipment was safe for use,” according to the VA.
Early last month, VA staff worked with a manufacturer-trained service vendor to refurbish the hospital’s sterilizer and washers.
They then ran test loads of equipment to ensure the issue was resolved.
“Our surgical staff are excited to be in the operating room providing excellent care to Veterans,” said Dr. Victor Quijano, the medical center’s Chief of Surgery. “Many Veterans trust their VA doctors so much that they chose to wait to receive their procedures with us. We are happy to be helping these patients.”
When the surgical team first discovered the residue, they did what’s called “stopping the line,” Mountfort said, which means “this case will not proceed until we correct whatever the issue is.”
Doing that took weeks.
In May, the facility also established an Incident Management Team, which met daily.
“Working with regional and national experts, staff systematically worked through replacing parts and equipment in the system,” according to the release.
“I was so proud of the staff who stopped the line when they saw the black flecks, which meant that we didn’t have any patients harmed by this issue,” said Amir Farooqi, Interim Director of VA ECHCS, in the release. “It reinforces that no matter what, patient safety comes first. I’m also extremely proud of the hard work by staff to improve our systems and processes to ensure we don’t see this issue again.”
The equipment fix will come as welcome news at the VA Medical Center, which is under renewed scrutiny after a pair of investigations documented a “culture of fear” and an earlier “extended pause” in cardiac surgeries.
The reports from the U.S. Department of Veterans Affairs Office of Inspector General blamed the problems on since-departed top leaders there who investigators said undermined patient safety.
In a press statement in response to the reports, the VA said inspectors “did not substantiate” any harm to patients.
“However, VA recognizes that a negative employee culture can have a negative impact on patient experience,” the release said, noting interim leadership at VA Eastern Colorado Health Care System “is focused on creating a psychologically safe and healthy environment for staff.”
“VA is committed to maintaining excellent patient care and prioritizing a culture of safety. Allegations of unsafe patient care or misconduct are taken seriously,” said Sunaina Kumar-Giebel, network director of the Rocky Mountain Network of the VA. “These investigations will help ensure veterans, employees, and stakeholders have full confidence in the quality and integrity of the leaders and care delivery provided.”
