Brooke Army Medical Center closes unsterile operating rooms

| May 2, 2017

Mark sends us a link to an article about Brooke Army Medical Center closing 16 of their 28 operating rooms because “human matter” was discovered on their instruments after improper sterilization.

The hospital, which has treated thousands of troops from wars in Iraq and Afghanistan, did not directly say whether dirty instruments led to infections, noting that Army rules prevent such disclosure. One commander, Dr. Douglas Soderdahl, a colonel, said that “there’s no concerning spikes or things going in the wrong direction” regarding BAMC’s medical care.

BAMC, which disclosed the problem in an April 21 briefing with several hundred doctors and other medical personnel, wouldn’t confirm the number of cases but acknowledged the sterilization problem and closure of operating rooms. A physician familiar with the meeting provided the numbers to the San Antonio Express-News and said the hospital also recorded 24 cases of improperly processed surgical sets in December and 14 in September.

[…]

“I think you would be hard-pressed to find a facility in the U.S. that has not had that issue. Enough people die every single day because of medical errors to fill a 747,” [Weston “Hank” Balch, director of sterile processing operations at San Antonio’s University Health System] said.

“Everyone does it” is a perfectly acceptable excuse.

Category: Army News

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  1. In The Mailbox: 5.02.17 : The Other McCain | May 3, 2017
  1. Ex-PH2 says:

    “Everyone does it” – of course it’s perfectly acceptable. Enough blame for everyone.

    Is there any place to go to for real medical care that is safe these days? I know a couple of horse doctors and a pet vet….

  2. IDC SARC says:

    There’s no such thing as a sterile operating room.

    The problem cited does not appear to be operating room related, it appears that central sterile processing has the problem.

    Likely the sonic cleaner isn’t working properly or people are putting the instruments into the processor with the jaws closed…no cleaning will clean an instrument that is processed with the jaws closed.

    If you work in an OR you’re going to eventually open a set and find some tissue in it. Normally you just take it out of the room and get another set.

    In this case too many sets were contaminated which is why the rooms were closed, not that the operating room did anything wrong.

    CSRs are often staffed with people you won’t find working in the OR. However, somebody with proper qualification is usually overseeing the process and while this happens occasionally it should never be as widespread as it appears to be in this case.

    • AZtoVA says:

      Thanks for the inside baseball!

    • 11B-Mailclerk says:

      Maybe the current surplus of detail-obsessed E-9s can be re-purposed, from reflective PT belt inspections, lawn checks, social media patrols, and coffeepot content consumption, to more fruitful inspections of surgical setups?

      Would seem to be a win-win for both losing and gaining organizations.

  3. MrBill says:

    I’d encourage everyone to read the linked article. Sig Christenson is the Express-News’ lead military reporter, and he does an excellent job.

    The bottom line that I took from this article is that increased surgeries at BAMC had outstripped the capacity of the sterilization department, which has lost several personnel. So, they are cutting back on elective surgeries until they can increase their sterilization capacity. The situation shouldn’t have gotten out of hand in the first place, but this was the proper response one they figured out they had a problem.

    • 2/17 Air Cav says:

      Yeah, I read it and I agree that piece is quite balanced. Did you see that business that an M.D. who raised hell fears retribution if his name is released? Talk about a sick work environment. And if SEVEN personnel are lost, um, isn’t replacing them rather key? I bet they’re on that post haste at this moment. Crisis management seems to be the predominant VA management style. “Everybody sshhhh before we lose our phony baloney jobs!

  4. Graybeard says:

    I concur IDC SARC.
    The quest to keep a hospital and it’s environs sanitary is never ending, never 100%, and made more difficult by the realities that there is not enough money to pay the best and brightest to clean up the feces, blood, and other contaminants that are part and parcel of the workings of a hospital.
    That there were an abnormal number of problems at this hospital is, to me, indicative of a training and/or oversight issue with the staff in charge of clean-up.

    But there is no getting away from the reality that in any hospital these types of issues will occur. For those of us who can remember the state of the medical arts in the 1950s and 1960s, the current state of medicine is nothing short of awe-inspiring. That we can find things to gripe about will always be true. That we ought to be thankful for the men and women who are doing such an outstanding job taking care of our bodies should always be remembered.

    • 2/17 Air Cav says:

      “The quest to keep a hospital and it’s environs sanitary is never ending, never 100%…” This was about surgical instruments, not patient rooms, corridors, and eating utensils. Did they close the cafeteria? The restrooms? The waiting areas? The examinations rooms? The recovery units? No. They closed Operating Rooms because there were insufficient sterilized surgical instruments to continue the great risk to patients.

      • Graybeard says:

        2/17 – My intended point was that no where in a hospital can you get to 100% sanitary conditions at all times. There are problems in all areas in all cases at some time or another. The case in point is just a specific instance of this generalized statement.

        As IDC SARC points out, the human matter on the instruments was not necessarily unsanitary. There are other issues to be considered as well.

        Given the current state of healthcare (thank you, DC Swamp-critters) trying to keep financially solvent and fulfill their primary purpose is a conundrum that many hospitals are trying to address, not just the VA.

        And given the over-reactions that occur on social media to revelations of problems, I can see why an admin would want to keep things low-key while they try to address the issues.

        • 2/17 Air Cav says:

          Well, I suppose that M.D. who wishes to remain anonymous, as well as those who agreed with him, just don’t understand this stuff. If this is the norm, why would he worry about it and retribution? Now may be a good time to go under the knife at that place. You can bet your sweet ass the instruments will be clean and sterile. Now, why is that? Why is it that confidence is suddenly high? Because the place made the news for this very issue and, suddenly, “I guess it’s okay” and “It looks good to me” won’t cut it.

  5. 2/17 Air Cav says:

    “The hospital, which has treated thousands of troops from wars in Iraq and Afghanistan, did not directly say whether dirty instruments led to infections, noting that Army rules prevent such disclosure.”

    How is that and why is that? Infections don’t have names and gross statistics don’t either. So who is being protected against a release of that, and presumably other, information?

    And this crap about demand not keeping up with supply regarding surgical instruments? This didn’t happen last Tuesday. It’s a process, no doubt helped along by the loss of seven Sterile Processing and Distribution personnel over the past year. The hospital, it appears, waited for a mini rebellion among doctors before making the OR closures. 16 of 28 at once?As always, this goes to piss-poor management.

    • IDC SARC says:

      “How is that and why is that? Infections don’t have names…”

      Who says anybody did get any infections from this material? If the pressures and temperature were adequate in the autoclaves the material is free of viruses, fungi, bacteria and spores.

      The major problem would stem from the autoimmune response in the patient’s body were fragments of organic material left inside a wound or body cavity.

      It’s unsavory, but it’s not that the kits were unsterilized per se.

      • IDC SARC says:

        “As always, this goes to piss-poor management.”

        Agreed. And knowing what I know, somebody signed off on those sets. That person or persons on each CPD/CSR shift is in line for a pee pee whacking.

      • 2/17 Air Cav says:

        “Who says anybody did get any infections from this material?” Cripes. That’s my point. The Army has a reg that prohibits releasing such information. My question is why that is. My guess is to protect the administrators and others. It can’t be that such info is protected by HIPPA or something. What personal, patient identifiable info would be shared by saying, “Since last July at this facility, there were 178 infections traced to the use of non-sterile surgical instruments?” No, I don’t know whether there many or very many infections. That’s the issue. That there some I have absolutely no doubt.

        • IDC SARC says:

          “I have absolutely no doubt.”

          Then, typing further is pointless. Carry on, oh doubtless one.

          • IDC SARC says:

            …and btw, it’s HIPAA

            • Graybeard says:

              HIPAA – one of my favorite examples of the law of unintended consequences.

              I wonder how many have died because HIPAA has prevented family members from being given the information they needed to be able to make timely healthcare decisions for their loved ones?

            • 2/17 Air Cav says:

              Man, I hope you’re never on a jury. You’ll be the one saying, “But I have a doubt!” It’s reasonable doubt that controls, not doubt. Your done but I’m not. There were so many instances of unclean and non-sterile surgical instruments, which frequently gives rise to post operative infection that most ORs were shut. Why? Because of a shortage of clean and sterile surgical instruments. Was this a pre-emptive action, timely taken? No. Is it likely that infectations resulted? You bet. It’s a predictable, common, and reasonable outcome where unclean and non-sterile surgical instruments are used. How many infections were there? You suggest none, and say that I have no way of knowing. That is a ludicrous position for you to take, but it’s yours and you can keep it.

              • 2/17 Air Cav says:

                Since you want to play spelling Nazi, my 3rd line, fourth word should have been spelled “You’re.” I also omitted a comma or two.

                • 2/17 Air Cav says:

                  Infectations are akin to infections, only they’re much worse. It’s in the HIPPA/HIPPO/Whatever law. You can look it up.

                • IDC SARC says:

                  Not playing spelling nazi…just figuring if you wanted to learn about HIPAA you may want to actually know what it is. Health Insurance Portability and Accountability Act

                  I also found that BAMC participates in the National Surgical Quality Improvement Program (NSQIP) and by federal law the Morbility and Mortality Weekly Reporting (MMWR). You may actually be able to find the numbers you’re looking for there. I don’t have the time to do the leg work.

              • IDC SARC says:

                okee dokee

              • 11B-Mailclerk says:

                Personally, I find his comments on the practical practice of medicine most enlightening.

                It is kinda his specialty.

        • IDC SARC says:

          “Man, I hope you’re never on a jury.”

          You and me both 🙂

          • Graybeard says:

            Most of us on TAH are the types that lawyers have nightmares about being on their jury.

            The one time I was in the “select group” after both lawyers struck folks off, the defense (murderer) took one long look at the folks in slots 1-12, took his “client” off to a back room, and convinced him to go with the judge alone – waive jury trial.
            The poor defense attorney knew we’d give him the full ride to the death house.

  6. A Proud Infidel®™ says:

    It seems that we NEVER hear stories like this about the Medical Facilities that treat members of Congress.

    • Hondo says:

      Dunno about that, API. Pretty sure that the original Walter Reed AMC treated a fair number of Members of Congress before it closed. I’m not positive, but I seem to remember hearing some pretty bad stories about goings on there from time to time.

      • David says:

        Funny, when I lived in that area the news was always of some politician being admitted to Bethesda. I’m sure some were treated at WRAMC but Bethesda got all the publicity.

        • Hondo says:

          Could well be that Bethesda Naval was primary. However, I’m pretty sure that Walter Reed treated at least some Members of Congress too.

          But I could easily be wrong.

      • sj says:

        My prostate cancer surgeon at Walter Reed (the old one) had a wall full of pictures of movers and shakers that he had done. During mine the Post lost power and the generators failed too. My surg finished using flash lights and no air cond in August. They closed and evacuated the hospital the next day. I ended up at Bethesda. Hospital remained closed for weeks.

  7. Sparks says:

    Doctor “Who’s the patient?”
    Nurse “Corrine Brown”
    Doctor “Are we ready to proceed?’
    Nurse “Well Doctor, yes but there’s shit on most of the instruments.”
    Doctor “I’m calling an audible. It’s a go, besides, the colors match. Scalpel.”

    😀 😀 😀 😀 😀

  8. Sapper3307 says:

    “The Band-Aid was holding the fingernail on”
    Weston “Hank” Balch.

  9. HMC Ret says:

    Seems not to have enough time to do the job right but enough time to do it over?

  10. iHMC Ret says:

    I worked CSSR as a Corpsman for a time. I was an E3/E4 with 3rd Med. We had minor surgery sets, used in Emergency Room. No OR stuff. Taught by a grungy old HM1, probably 25 years older than me. It was a temp position and lasted, I think, maybe a month. First day he tells me something along the lines of: Look, dumbass, you gotta CLEAN the instruments before sterilization. It’s been nearly 50 years, but I THINK I cleaned with some geewhiz stuff, rinsed, cleaned again, rinsed, soaked in some other geewhiz stuff to kill even more pathogens, dry, wrap, autoclave. Remember, it’s been nearly half a century.

    Some might think soaking followed by autoclaving is adequate. They would be wrong.

    60 Minutes did a hit piece about a dozen or so years ago that involved improperly handled instruments. They took apart some supposedly ready-for-the-OR packs. Inside some of the instruments was particulate matter and also what was obviously blood.

    • timactual says:

      Sterilizing the equipment is the easy part. Keeping the OR personnel clean is more difficult.

      I did some work at a large hospital once, and in the cafeteria I saw a lot of people in scrubs, including hairnets and foot covers. They would break for lunch and then return to the operating room with their now contaminated operating room attire. The hospital ended up stationing someone at the cafeteria entrance to prevent this practice.

      As a side note, it is amazing how many people actually work in a hospital. You start to understand why medical costs are so high when you notice the number of people, medical and non-medical, working there. Some of them literally sit around doing nothing for hours at a time until they are needed. Ever hear of a Phototherapist?

      • Graybeard says:

        From my contacts still in the medical community, more cost is generated by the Federal regulations on paperwork, compounded by the overly-intrusive power the Feds have given to insurance companies.

        Some specialists do have downtimes in the hospital, I know. When they get busy, they get very very busy. But it is the admin slots for the paperwork that eats up the money – along with the software required to make it all happen.

        Why I advocate for revoking those regs and neutering HHS.

        • IDC SARC says:

          “But it is the admin slots…”

          Muggles

        • timactual says:

          I wasn’t being critical. Like a fire dept., someone has to be ready to do the job 24/7/365. It is just interesting to realize the size of the “logistical tail” involved in supporting every occupied hospital bed. Including the office that keeps track of those beds. The IT dept. alone had almost a hundred people in it.

          I think that in reality the percentage of costs due to unnecessary paperwork is overblown. There are just so many people and expensive equipment involved in the process that it is going to be expensive. Period. No matter what Congress does or does not do.

          • IDC SARC says:

            I was just joking about administrators …we call them muggles 🙂

            Since I also have an MBA in Health Care Administration I can poke fun, but also realize that administrators are very necessary.

  11. Dennis - not chevy says:

    This should be an opportunity for the hospital management to check itself. I was well acquainted with the three military hospitals that had a possibility of contaminated items reaching the operating room.
    The first hospital had the troops clean and re-clean every thing, re-sterilize all packs and instruments, and stand in line for several ass-chewings. The brass didn’t not let the groans of butt-hurtedness interrupt their kaffeeklatschen.
    The brass of the second hospital gave no thought of whose fault it was. The brass arranged coverage from local hospitals while the problems were identified and solved.
    The third hospital pooh-poohed the idea that such large autoclaves could mal-function. The troops ignored the brass, cleaned and re-cleaned everything, got the equipment fixed, and no one got hurt.
    I’d trust hospitals two and three. Hospital one has since closed.

    • IDC SARC says:

      The instruments and such are supposed to be cleaned prior to autoclaving. Autoclaves don’t clean instruments.

      Autoclaves do malfunction, that’s why graphs on them record whether they meet standards of temperature and pressure (mostly digital now), every pack contains a sterilization indicator that has to uniformly change color to indicate the cycle worked (first thing the scrub nurse checks upon opening the set), and biological testing is done using a non pathogenic spore forming bacillus (B. stearothermophilus). Any CSR will also usually have redundancy in the number of claves, so if any are down they can still process supplies.

      Some autoclaves have a washer/sterilizer function, but you can’t use that with wrapped sets.

      Additionally, the records of all that have to be continuous and on hand for inspection or that’s a major offense if inspected.It’s a very detailed process.

      It’s mind boggling that anyone involved in the preparation of surgical supplies would not be vigilant in recognizing how easily the process can fall apart an how seriously it can impact patients and accreditation .

  12. 2/17 Air Cav says:

    http://www.jbsa.mil/News/News/Article/1169553/bamc-takes-steps-to-continue-high-quality-surgical-care/

    Just read the official, JBSA-approved, account. No mention whatsoever of unclean or non-sterile surgical instruments. Not. A. Word. They’re playing hide the ball. They’re heroes, actually, and they’re doing it all for the children–patients! They’re doing it all for the patients. The timing is a bit odd, what their decision coming days after all hell broke loose, but, who are gonna believe, the VA or your life experience?