The Rocky Mountain Regional VA Medical Center in Aurora is halting surgeries until it can determine the source of a mysterious residue found on the hospital’s medical equipment.
The VA had rescheduled or referred to community hospitals more than 230 procedures — 181 surgeries and 52 dental appointments — as of Friday, said Janelle Beswick, a regional spokesperson for the U.S. Department of Veterans Affairs.
Staff noticed the unknown substance on some of the Aurora hospital’s reusable equipment during recent pre-surgery inspections, VA press secretary Terrence Hayes said in a statement. None of those surgeries went forward and no patients received inadequate care, he said.
“We commend our staff for identifying this issue and ensuring our veterans are safe,” Hayes said.
In light of the contamination, the hospital is rescheduling all surgeries that involve reusable medical equipment. Surgeries using disposable equipment will continue, Hayes said. Emergency surgeries, meanwhile, are being referred to community hospitals.
Hospital leadership, in an employee town hall meeting on Wednesday reviewed by The Denver Post, acknowledged they have no idea where the residue came from.
“This has not proved to be simple in IDing what the cause is,” said Michelle R. Mountfort, associate director of patient care services. “We can’t resolve until the actual problem is” identified.
Experts have checked for common contamination causes, she said. None have produced results.
Staff sent samples of the residue for testing to determine its makeup.
Experts say the best practice in situations involving potential contamination of surgical equipment is to delay elective procedures while the hospital conducts a root-cause analysis. Surgeries that cannot wait should be farmed out to other hospitals.
Ultimately, making sure contaminated equipment stays away from patients is critical, said Dr. Nasia Safdar, a professor of infectious disease at the University of Wisconsin School of Medicine and Public Health.
Using compromised equipment can have “pretty dire consequences,” she said, noting that patients, in some cases, could develop serious surgical-site infections.
Colorado hospitals have previously dealt with other contamination issues.
In 2019, more than 60 patients who suffered post-surgical infections sued Denver’s Porter Adventist Hospital over a breach in sterilization procedures.
A state investigation of the hospital determined contaminated surgical instruments and trays — tainted by blood, bone chunks, cement, hair and even a dead insect — were brought into operating rooms 76 times in 2017 and 2018.
The residue issue comes as Aurora VA has been in the midst of a leadership crisis in recent months.
Agency brass in October removed the Eastern Colorado VA’s director, Michael Kilmer, and his chief of staff over culture and oversight concerns.
The following month, The Post reported that the head of the hospital network’s prosthetics department had been directing staff to delete orders from veterans in order to clear a sizeable backlog. VA leadership last month confirmed 1,000 orders had been canceled without veterans being contacted.
The federal agency in December also reassigned the director of its suicide prevention center amid allegations of bullying, racism and emotional abuse.
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