The impact of the recent dirty surgery headline out of New Jersey is understandably shocking. But it reveals much more about our industry than we may like to admit...
Reoccurring Themes of Failure
In the "Curtailment of Services" letter sent from the New Jersey Department of Health to HealthPlus Surgery Center, all services were ordered to cease immediately, and the following deficiencies were highlighted as a representative sampling of the reasons why:
* "No competencies completed for 3 staff regarding infection control."
* "Sterile instruments observed with debris in hinges, rusty and discolored."
* "Instructions For Use (IFU's) were not available for all instruments."
* "Biologicals are being used incorrectly and validation testing is not being done correctly."
Sterile Processing professionals on the frontline will immediately recognize these findings -- and remember that we have seen very similar deficiencies before. In fact, as the old preacher in Ecclesiastes reminds us, there is nothing new under the sun. And when it comes to the challenges facing infection control of surgical instruments, this could not be more true. Headlines from Porter Adventist Hospital in Colorado, Detroit Medical Center in Michigan, and Brooke Army Medical Center in Texas all sing the same sad song of broken processes and patients put at risk. But do we know the real risks? Or at least the whole truth?
The Half Truths of Low Risks
Unsurprisingly, every surgical instrument quality breakdown that hits the news comes with a standard script that is then parroted by a mainstream media who is largely unaware of what actually went wrong with the sterilization process, and how difficult it will be to "fix" the problem. One of the biggest examples of this twisting of the truth is actually perpetrated and encouraged by the Centers for Disease Control (CDC) themselves. In their toolkit for dealing with patient notifications, they encourage facilities to
"Stay on message: repeat to reinforce – e.g.,start off by saying the risk is low, repeat (using different words) as often as possible..." [from the Guiding Principles of Risk Communication section]
While I understand the technical statistics behind this argument, supported by articles such as this one from William Rutala in the American Journal of Infection Control, the manner in which hospitals use this far too often takes the form of public relations gymnastics, which end up being little more than a hypothetical odds game. Again and again you see the same language in their press releases which say "the risks are extremely low," etc, etc. When in reality, patients are not asking for risk ratios in general, and they are definitely not asking for a lesson in comparable statistics (such as the likelihood of them dying in a car crash as compared to having surgery in your hospital). What they want is the truth -- and rallying around the cry of "low risk!" is not giving it to them.
The Dirty, Rusty, Unacceptable Truth
So, what is the truth? What do patients and the public at large deserve to know about what is really happening in our Sterile Processing departments? The fact is, the deficiencies identified in the New Jersey outbreak are far, far too common in countless hospitals across the country. Ultimately, this is not a headline about some particular surgery center in some town on the East Coast. This is a story about a hospital or surgery center that is likely sitting in your backyard.
Importantly, Sterile Processing professionals themselves are often aware of the subpar quality of their instruments and reprocessing programs long before an "event" occurs which would prompt a state inspection or make a national headline. Department leaders and frontline technicians must not only be empowered to raise the alarm and escalate these issues up the chain of command -- but surgical service leaders and C-suite administrators MUST be committed to listening to these concerns and providing appropriate administrative and budgetary support to these teams before patient lives are put at risk.
One final question to sum this article up:
Is there any patient in the country who would willingly accept to undergo surgery in a facility with rusty surgical instrumentation?
Whatever the reasons and whatever the risks, large percentages of our hospitals in the US today are operating with surgical devices with visible rust and corrosion present. Until the public realizes this truth and raises appropriate amounts of hell, we will continue to see more of these headlines and get 3,778 more reasons why patients were unnecessarily put at risk.
And this is nothing short of unacceptable.
What say you?
W. Hank Balch Ⓒ January 2019
Hank Balch is the co-founder and Principal of Beyond Clean, a next generation Sterile Processing consulting firm with focus on operational improvement, accreditation survey preparedness, interim-leadership placement, and brand consulting for CS/SPD vendors. He is also the Co-Founder & Host of the Beyond Clean Podcast, a weekly international podcast discussing industry topics with the biggest names in Sterile Processing. You can find over 100 other Sterile Processing articles and commentary here, along with published articles in Becker's Hospital Review, Infection Control Today, AAMI News, AAMI BI&T Journal, Outpatient Surgery Magazine, and contributions to Healthcare Purchasing News. Hank's CS/SPD team in Louisville, KY was named the "2016 CS/SPD Department of the Year" by HPN, he's served as the President of the South Texas Association of Sterile Processing Services and President of the Kentuckiana IAHCSMM Chapter, and was nominated for the 2017 President-Elect & 2018 President-Elect of the International Association of Healthcare Central Service Materiel Management.