May 08, 2023

Kaiser employees call for halt of surgeries at Zion hospital citing 'contaminants' in surgical trays

Employees at Kaiser Zion Medical Center in Grantville are calling for the suspension of all surgeries at the facility due to what they say is visible contamination of the trays that hold sterilized surgical instruments.

"There are black/gray/brown particles of an unknown substance dusting the interiors of our surgical trays, in addition to black greasy smears of a known, but not surgically-approved substance," said Elizabeth Haynes, a surgical technician at Zion who provided a copy of a petition signed by more than 70 employees asking for the suspension.

She said the contaminants have been inside the trays that hold the instruments, but not the instruments themselves.

"Sterilization guidelines are that anything non-sterile (or) non-sterilizable found inside a surgical tray renders that tray contaminated," Haynes said.

On Friday, June 2, she said, it was necessary to open 23 trays before one was found without materials inside. The contaminants, she said, continued to appear during her overnight shift Monday to Tuesday.

"We opened 18 trays last night in an attempt to perform one procedure," Haynes said.

In a written statement, Kaiser rejected employees’ calls for a surgical shutdown at Zion.

"Providing safe, quality, and timely care to our patients is our top priority and we will continue to schedule surgeries at Zion that can be safely performed," Kaiser said. "We have confirmed that all measures we are taking to clean, process and transport surgical equipment to our Zion Medical Center for use is safe and medically appropriate."

The health system did confirm that it has had to adjust its sterilization operations after detecting an "isolated issue" at Zion with equipment used to wash surgical instruments before they are sterilized. This issue, Kaiser's statement says, did cause "minute residual particles" from a hot water tank to appear.

"We are currently cleaning and flushing the lines of this equipment to remove all residual particulates," Kaiser said. "In the meantime, surgical instruments used at Zion Medical Center are being safely cleaned and processed at our nearby San Diego Medical Center and an outside agency."

It was not clear how particles could continue to appear in surgical trays if washing was no longer occurring at Zion.

In health care, instrument sanitation is a multi-step process. After use, instruments and the trays that hold them are first cleaned, generally with microbe-killing solutions. A final step involves using heat — usually inside a machine called an autoclave — to kill any remaining sources of infection.

Haynes said that management has told workers that sterilization renders the particles they have found "inert and non-microbial," meaning they present no danger of causing an infection during a surgical procedure.

She rejected that reasoning, given that instruments are entering surgical wounds and particles could easily come along for the ride.

"The fact that a contaminant is ‘safe’ (not a microbe) doesn't mean that contaminant is implantable," Haynes said.

Zion's hot water troubles started on May 17 when issues with the facility's hot water system were first detected. Some surgeries were moved to San Diego Medical Center in Kearny Mesa as maintenance was performed, with Kaiser saying that flushing and safety testing were performed and the system was returned to service on May 21.