When John Harrison checked into a Texas hospital in 2009 for rotator cuff surgery, he thought that after a six-week recovery period, he’d be as good as new. But two weeks after the operation, the 63 year-old was experiencing severe discomfort and swelling in his shoulder and knew something was terribly wrong.
During an emergency visit to the hospital, doctors told him that he had been infected during surgery with a deadly bacteria called P. aeruginosa. And Harrison wasn’t the only one -- six other patients who had undergone surgery at the same hospital had contracted potentially lethal infections as well.
The hospital, along with the Centers for Disease Control and Prevention, launched an investigation and closed operating rooms for two weeks. Surgery was cancelled while they searched for clues and they found some, in something called an arthroscopic shaver. Somehow potentially deadly bacteria had survived the sterilization process and infected Harrison’s shoulder.
And the problem isn’t isolated. Other investigations in hospitals across the country have revealed the use of other dirty surgical instruments, such as endoscopes used for colonoscopies, have led to infection outbreaks.
Investigative reporter Joe Eaton of the Center for Public Integrity, a Washington, D.C., nonprofit that focuses on ethics and public service, tackled the issue head on. As a result of the CPI investigation, NBC News Chief Medical Editor Dr. Nancy Snyderman took a closer look at the wide range of instruments used during surgical procedures and the care with which they are handled. Who is in charge of cleaning the instruments? How are they sterilized? And how is the process regulated?
Q&A with Joe Eaton: Dirty surgical tools are gross, dangerous and more common
What NBC found suggests that the handling of the increasingly high-tech instruments can be a weak link in hospitals’ patient safety net.
Trust in the System
Every time surgeons enter the operating room, they and a team of skilled technicians, follow a very specific protocol. They check everything from electrical outlets to oxygen tanks, and double check the basics too, like confirming patient identity. Still, mistakes are made and infections occur -- sometimes because of factors out of the surgeon’s control.
The team in the operating room consists of trained specialists who undergo years of schooling for their respective professions. They have degrees. They are licensed. But the technicians responsible for sterilizing the tools used in procedures are actually not technicians at all.
In the Basement
The departments responsible for cleaning and reassembling surgical instruments -- usually known as “sterile processing” -- are frequently found in hospital basements and sometimes staffed by underpaid hourly laborers. These workers can be a forgotten and neglected part of the team involved in a surgical procedure. As the CPI report indicates, the sterilization workers say they feel more like they’re doing an unrecognized service, with pressure from nurses and surgical staff to make the process as fast as possible. The faster the instruments make it into the operating rooms, the more patients are moving through the surgical suites. But what may seem like a push for efficiency can backfire, with disastrous consequences.
New Jersey is the only state that requires hospital sterilization workers to undergo training.
Sharon Greene-Golden, head of “sterile processing” at Bon Secours Mary Immaculate Hospital in Virginia, points out that this is a job that must be done by skilled and certified technicians. She thinks of her team as the unseen patient advocates and says, “It is a job that cannot be given to robots because the robot doesn’t have the critical thinking to say this is still dirty.” At Bon Secours, Greene-Golden has made her sterile processing department state of the art, a model for what should be happening across the country.
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