Contamination at White Rock hospital impacted 27 surgeries

More than two dozen surgeries booked at Peace Arch Hospital had to be delayed or shifted off-site recently, following an equipment failure that resulted in contaminated surgical equipment, officials confirm.

In a statement, Cindy Laukkanen – executive director for surgery and anesthesia networks, medical device reprocessing and surgery information systems – said the steps were taken “to ensure patient safety” in the wake of “an unexpected technical issue” in the unit where medical instruments are cleaned and sterilized.

“In total, 27 surgeries were postponed,” Laukkanen said.

And while the final related postponement occurred June 6, one local doctor said the issue highlights a need for change in how the health authority responds to such matters.

There was “a very sluggish response to fixing this problem,” Dr. Arno Smit told Peace Arch News. 

“It’s not unheard of that things come up from time to time. This was different. It was a systemic problem that kept repeating itself over and over consistently, particularly with the big pieces of equipment.”

Smit – who has operated at the hospital since 1999 – said the contamination was first spotted in early May. He recalled a general surgeon telling him about seven scopes that had to be sent back due to “residue” on them.

“On that particular day, cases were delayed or couldn’t be done,” Smit said.

While front-line personnel recognized “very quickly that there was a serious problem,” Smit said the response from department heads was “very lacklustre.”

“More denial of, there could be a problem,” he said.

Laukkanen, however, said the team “took immediate action to investigate and worked with our facilities maintenance department, equipment vendors and municipal partners to ensure water, steam, HVAC and all sterilization equipment are running to specifications.”

“Patient safety is our highest priority, and our rigorous infection prevention and control standards enabled us to take immediate action to address this technical issue.”

The hospital’s medical-device processing unit underwent extensive upgrades in 2021, with the renovated suite fully operational since January 2022. 

Located in the hospital’s basement, it is where every device used in hospital procedures and surgeries – ranging from eye operations and C-sections to endoscopies and emergency-room treatments – is sent for sterilization or high-level disinfection.

In showcasing the unit to PAN two years ago, officials highlighted improvements to efficiency due to embedded artificial intelligence; dedicated elevators for transporting clean and soiled equipment between the reprocessing unit and the operating rooms; and improved layout to ensure the clean and dirty sides of the reprocessing process are kept separate.

New equipment, including metivators to ensure a one-way flow of equipment during the cleaning process, essentially eliminated the possibility of human error or cross-contamination between clean and dirty devices, PAN was told.

“What we do is not seen as as-important,” however, if the unit ceases to function, “that hospital is at risk for delivering care to the patient,” the unit’s manager told PAN.

In Laukkanen’s June 17 statement, she said all surgical instruments go through five steps of cleaning and sterilization, with the final inspection done in the operating room prior to use. Anything that does not meet the federal standard is returned for reprocessing and replaced.

“We are not aware of any instruments impacted by this technical issue being used in surgery,” Laukkanen noted.

Procedure rescheduling or relocation was the only identified impact to patients, she added, noting patients were notified of changes “as soon as we were aware” they were necessary, and prior to arrival at the hospital where possible.

Smit said one of his patients who was sent home after her surgery had to be rescheduled “completely lost confidence in the hospital” due to the lack of communication.

“The patient had waited for over a year for her joint replacement,” he said. “She sat there all day, no explanation, basically, other than the nurse saying we don’t have equipment.

“Nobody bothered to reach out to them, explain … that the equipment wasn’t safe to use.”

None of three patients impacted by the issue within a two-week period were contacted by Fraser Health, he added.

Smit said Fraser Health was asked for written assurance that the problem had been resolved so that that reassurance could then be given to patients. To his knowledge, none was provided. 

South Surrey senior Nancy Alliston was among patients impacted by the contamination problem. Scheduled for a May 21 hip replacement, the 83-year-old said she made extensive arrangements to prepare for the procedure and aftermath, including booking help with meals and ensuring she had someone who could stay with her husband – who was recovering from a broken hip – while she was in hospital.

At the hospital, after nurses prepped her IV and the anesthetist asked the standard pre-op questions, Alliston said she was left in limbo.

“I just laid there for the whole morning,” she said. “I kept asking them, ‘Am I going to go to surgery?'”

The answer she received was, “I don’t know.”

“You could tell that everybody was extremely anxious about a situation,” she said.

Eventually, Alliston was told her surgery had to be cancelled because the equipment needed for it wasn’t clean.

She described the ordeal as “not a nice experience at all.”

Noting she felt bad “belly-aching” about what happened, Alliston – whose surgery is now set for July 19 – said she agreed to share her story in the hopes it would help motivate the powers that be to do more to ensure she and others don’t have to relive it. 

“If I don’t belly-ache, they’re not going to get at the problem fast enough,” she said, describing a lack of capacity within the system to serve the population. “The more we can get it out into the public, then hospitals and Fraser Health, they’re going to have to deal with it. BC government, they’re also going to have to deal with it.”

Alliston said she won’t take word of a second cancellation lightly.

“I can’t play with it emotionally like that (again),” she said. “If I get cancelled again, I’m going to tell them no. It’s too hard.”

A Fraser Health spokesperson confirmed to PAN Friday (July 5) that the issue “has now been resolved.”