State inspectors have revealed that UCHealth’s University of Colorado Hospital’s week-long shutdown of nonemergency surgeries came after they found dozens of contaminated surgical instruments caked with dried blood and tissue around the facility.
In July, inspectors uncovered a massive backlog of uncleaned tools, prompting the hospital to halt all nonemergency surgeries from July 16 to July 25 while safety violations were addressed.
The inspection, triggered by a formal complaint, found 17 stainless steel carts in the hospital’s sterile processing department (SPD) bearing between 11 and 30 trays of dirty surgical instruments each.
Additional carts were discovered in a holding room near the operating suites and in a hallway, with hundreds of trays left “open to air and heavily soiled with dried blood and tissue,” inspectors wrote, according to The Colorado Sun.
The state regulator classified the situation as an “immediate jeopardy” finding, indicating that patients faced imminent harm unless corrective measures were implemented quickly.
UCHealth spokesperson Kelli Christensen told The Sun that the hospital’s SPD had been operating at reduced capacity, leading to postponed or relocated elective surgeries.
The hospital worked closely with the Colorado Department of Public Health and Environment to address the violations, a spokesperson added.
“We issued a deficiency at an immediate jeopardy level, which required the facility to develop an immediate and long-term plan to correct any violations,” CDPHE spokesperson Alexandrea Kallin told The Sun this week.
The backlog emerged amid the opening of new operating rooms, which dramatically increased the SPD’s workload.
Before expansion, the hospital estimated needing 65.2 full-time equivalent staff. After expansion, the need rose to 85.2 full-time equivalent staff. Inspectors found no evidence that staffing had increased to meet this demand.
At times, instruments went unsterilized for more than 24 hours, but technicians told investigators that the delays could stretch up to six days.
From April to July, inspectors documented dozens of days during which over 100 sets of contaminated instruments went unprocessed, including one day with 500 sets left unprocessed, according to reports.
Inside the SPD, staff were instructed to spray uncleaned instruments every 72 hours with a pre-cleaning solution, which inspectors said violated manufacturer instructions.
The hospital can use up 1,000 trays a day and thousands of individual surgical instruments, Christensen toldThe Sun.
This is a problem as dried blood and tissue increase the risk of biofilm, a hardened bacterial buildup that is difficult to remove. This could result in “less effective disinfection and sterilization,” one inspector wrote.
The SPD director reported staffing shortages over the past year, with backlogs reported daily to leadership.
Christensen confirmed to The Sun this week that the hospital faced challenges filling open SPD positions, resulting in the temporary shortage.
During the July shutdown, UCHealth expanded SPD staffing to 140 FTEs, exceeding national benchmarks, and increased pay for these positions, Christensen told the outlet.
The hospital also implemented stricter monitoring of staffing levels and instrument cleaning delays. By September, state inspectors confirmed the hospital was in compliance with all surveyed regulations and imposed no further sanctions.
Inspection reports did not identify any instances of patient harm directly linked to the sterilization failures. UCHealth said it found no infections connected to the backlog, though at least one surgery was delayed while staff cleaned or replaced specialized instruments.
Christensen framed the incident as a temporary staffing crisis resolved through a close partnership with the CDPHE.
She said the hospital’s commitment to making the necessary changes demonstrates that patients can trust the hospital to provide safe, reliable care.
“Their findings affirmed that our processes are safe, effective and aligned with the highest standards of patient care,” Christensen wrote to The Sun. “All patients whose procedures were postponed have been rescheduled and the majority of those surgeries have now taken place.”
The Independent has reached out to UCHealth and the CDPHE for further comment.
