Improperly Cleaned Surgical Instruments Puts CA Hospital Into 'Immediate Jeopardy'

A California hospital was assigned "immediate jeopardy" after state health officials discovered improper surgical instrument cleaning processes, according to a 10News report.

In its State Operations Manual, the Centers for Medicare & Medicaid Services (CMS) defines immediate jeopardy as: "A situation in which the provider's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident."

The problem was found at UC San Diego Health, Hillcrest campus in March during a routine compliance check conducted by the California Department of Public Health (CDPH). Officials stated that "surgical instruments were not cleaned and processed according to nationally recognized infection control standards," according to the report.

Deficiencies discovered reportedly included the following:

  • trays with surgical equipment that had brown staining;
  • sterilizing machines with large amounts of dark rust color and exteriors covered with dirt; and
  • instruments in a post-operative room with red stains.

In a statement provided to 10News, the hospital said, "Opportunities for improvement were identified within an early phase of instrument cleaning that occurs before the actual sterilization. Immediate actions were taken. … UC San Diego Health conducted a review of surgical data before, during and after the survey. This review found no infections related to cleaning and sterilization processes. There has been no evidence of patient impact or harm."

After reprocessing all surgical instruments, an approach approved by CDPH, immediate jeopardy was lifted.

10News reported its research has determined that the hospital was placed into immediate jeopardy at least seven other times in recent years, with at least one case resulting in a fine.

Reprocessing Remains Significant Infection Prevention Challenge Nationwide

Despite the ongoing efforts of infection prevention professionals to promote "best practices," suboptimal practices within the reprocessing of medical devices and instruments continue to plague facilities — inpatient and ambulatory surgery centers (ASCs) — across the nation. Phenelle Segal, President of Infection Control Consulting Services and her team of infection prevention experts, spend a significant amount of time consulting in the perioperative environment. The ICCS team places a major emphasis on sterile processing, including onsite observations in hospitals and ASCs as well as development of policies and procedures to ensure that facilities comply with federal, state and accreditation organization requirements.

"We focus on the inpatient and outpatient surgery environment and have expanded our services to include onboarding infection prevention designees as we continue to find gaps in knowledge, understanding of practices, available resources, monitoring and accountability," says Phenelle. "Our team has identified that these factors and others contributed greatly to the pitfalls as described in this immediate jeopardy situation."

Phenelle and her team of experts observe a variety of facility practices, with varying levels of compliance, and believe that ongoing failure is a multifactorial issue. Tight surgery schedules, quick turnover of cases, staff turnover and lack of monitoring and conducting competencies contribute to noncompliance.

She notes that reprocessing of medical devices is a practice that cannot be compromised for any reason. It is up to a team of key players, such as OR and central processing and infection prevention personnel, to oversee processes and conduct compliance monitoring with competencies. Administrators of outpatient centers and the C-suite in hospitals should provide the appropriate support and resources at all times.  

Learn more about how ICCS assists facilities nationwide with central processing department compliance.