Why were the surgical instruments at the Kansas City VA coming out of sterilization with rusty-looking stains, gray film and residue?

NOTE from Larry Scott, VA Watchdog dot Org ... Be sure to read this story all the way to the end.  The VA says one thing, but one of the nurses says it might be something different.  All information on VA's contaminated equipment is here.

-------------------------

VA Medical Center delays some surgeries over sterilization concerns

By ALAN BAVLEY
The Kansas City Star

Call this “The Case of the Rusty Retractor.” Or maybe “The Mystery of the Funky Forceps.”

The conundrum: Why were the usually gleaming surgical instruments at the Kansas City VA Medical Center coming out of steam sterilization with rusty-looking stains, gray film and residue?

The dirty appearance caused the hospital to delay some surgeries last month without giving patients an explanation, hospital employees said.

The operating room was shut down for at least a day as hospital personnel scrambled to find the source of the problem.

Instruments were sent to the VA Medical Center in Leavenworth to be sterilized. And the hospital paid employees overtime to scrub hundreds of instruments by hand.

Hospital officials said last week that they had traced the cause to an equipment failure. No patients were jeopardized by unsanitary instruments, they said, and the faulty equipment has been fixed.

“We really did bend over backwards to make this extra effort so we wouldn’t put people at risk,” said hospital chief of staff James Sanders. “The last thing we want is for our veterans to think we used unsterile instruments.”

Linda McEwen, a nurse and president of the hospital’s professional workers union, said administrators should have been more open.

“I think if you have a problem you should be honest with patients,” McEwen said. “You should tell them, ‘I’m not going to cut on you because I’m not sure of the instruments.’ ”

Sterilization practices in the VA system have come under intense scrutiny lately. VA hospitals in Murfreesboro, Tenn.; Augusta, Ga.; and Miami failed to properly clean or set up equipment for colonoscopies and ear, nose and throat procedures. Some patients tested positive for HIV or hepatitis, and more than 11,000 have been told to have their blood checked for infections.

Experts interviewed by The Kansas City Star said the stains and film like those found on the instruments at the Kansas City VA don’t necessarily mean the instruments are unsanitary. But they do raise a red flag about the sterilization process.

“A very thin film may not affect sterility of instruments, but what is thin? I wouldn’t want to speculate,” said Marcia Patrick, a board member of the Association for Professionals in Infection Control and Epidemiology.

Film on instruments may be innocent mineral deposits. Or, as in the case of the Duke University Health System hospitals in Raleigh and Durham, N.C., it may be something alarming.

In 2004, about 3,800 patients at the two hospitals may have been operated on with instruments that had mistakenly been washed in used elevator hydraulic fluid. Some patients sued, claiming injury.

Rust on instruments also can spell trouble if corrosion has pitted the metal enough to hold debris, Patrick said.

“There could be things lurking in it,” she said.

Staff at the Kansas City VA became concerned early in May when they found increasing numbers of dingy instruments in the sealed packs provided to operating rooms.

“The concern with anything that doesn’t look right is that it may not be sterile,” Sanders said. “It doesn’t engender confidence in the OR staff.”

Sanders said tests found that the instruments were still sterile. But the hospital still had to sort through the multistep sterilization process to find out what was causing the problem.

Instruments routinely go through a “pre-wash” and a second, more thorough wash before being sealed in packages and steamed.

“We had manufacturers’ representatives in. We had pipe fitters in. We put valves in the sterilizers. We looked at supply lines. We did detective work,” Sanders said.

Meanwhile, the surgery schedule was scaled back as packs of sterilized instruments were detoured to “scrub parties” of workers on overtime.

Sanders said the problem finally was traced to a device that removes minerals from the wash water. It was fixed within a day, he said.

Minerals in water can react with detergents to leave deposits on metal instruments. And some equipment used to sterilize instruments has design flaws that can leave stains.

But McEwen, the VA nurse, is concerned that her hospital hasn’t devoted enough staff to sterilizing instruments. She said she has inspected some of the sterilized instruments and found worrisome stains.

“You couldn’t tell if it was rust or blood,” she said.

-------------------------

TOPICS: veterans, veterans' benefits, VA, Department of Veterans' Affairs, contaminated equipment, sterilization, Kansas City