Staffing shortages in University of Colorado Hospital’s sterilization department were so acute this summer that state inspectors reported finding trays of surgical tools caked in blood and tissue that had been left sitting in rooms and a hallway for more than 24 hours.
UCHealth, which owns the 700-bed hospital in Aurora, postponed non-emergency surgeries for a week in July following those shortages. At the time, the Colorado Department of Public Health and Environment confirmed it was investigating a complaint involving the hospital, but didn’t say what it was about.
Newly released reports from that investigation show that when a state inspector visited the hospital on July 14, they discovered 17 stainless steel carts strewn across the sterilization department in such a way that it was difficult to walk through the area.
Each cart held between 11 and 30 contaminated surgical instrument sets, according to investigation reports released by the state health department.
“Surgical instruments were grossly soiled with dried blood and tissue,” the inspector wrote about a kidney transplant tray on one of the steel carts.
Officials at the state health agency were so concerned about what they found during their investigation that they declared “an immediate jeopardy,” which is issued when a problem has caused — or is likely to cause — serious harm, injury or death to a resident or patient.
The health department required UCHealth to develop a plan to correct the violations, and the hospital is now in compliance, so the agency won’t take further action, Department of Public Health and Environment spokeswoman Alexandrea Kallin said in an email Thursday.
“We postponed some elective procedures to ensure patient safety and worked closely with CDPHE to implement changes to return (the sterilization department) to full capacity,” UCHealth spokeswoman Kelli Christensen said in a statement. “It is important to clarify that used surgical instruments awaiting the decontamination process are often stored in various non-patient-facing areas. At no point during this situation were patients at risk.”
The state’s investigation — the results of which were first reported by the Colorado Sun — found University of Colorado Hospital failed to put in place measures to mitigate staffing shortages before opening four new operating rooms in June, which led to an increase in the number of surgical instruments needing to be cleaned.
The sterilization department required 85.2 employees after the rooms opened, 20 more than previously required, according to the reports.
“Upon request, the facility was unable to provide evidence (that sterilization department) staffing levels had been increased to meet the post-expansion requirement,” the inspector wrote.
An administrator told state officials that hospital leaders knew of the staffing shortages before opening the additional operating rooms, but the facility struggled to hire and keep employees because the salaries UCHealth pays are below market rate, according to the reports.
Another employee told the state inspector that staffing levels had dropped in the sterilization department over the past year, but the hospital prohibited hiring replacements, according to the reports.
Employees told state officials that because of the shortages, surgical instruments were not cleaned in a timely manner and often remained unprocessed overnight — and sometimes for up to six days because staff couldn’t keep up with the volume, according to the reports.
One employee told the inspector that employees were trained to spray surgical equipment every 72 hours to prevent “bioburden” from hardening and making it difficult to properly sterilize the equipment, according to the reports.
The inspector found that between April and July, anywhere between 100 to more than 500 surgical instrument sets remained unprocessed, depending on the day.
The state reports said the hospital postponed non-emergency surgeries so staff could clean surgical instruments and implement a system to manage case volumes.
“Throughout this situation, patient safety remained our top priority,” UCHealth’s Christensen said. “We have not identified any health-care-associated infections linked to the (sterilization department) staffing issue.”
The hospital’s sterilization department now has 140 full-time employees, she said.
UCHealth’s decision to postpone surgeries whiles staff addressed the sterilization problem stands out from other hospitals that have found themselves in similar situations.
Colorado cited at least 16 hospitals for sterilization problems between 2019 and 2024 — most of which occurred because employees made mistakes that could have contaminated instruments — and saw hospitals continue to provide surgeries even as the facilities retrained employees on sterilization techniques.
Last year, the Rocky Mountain Regional VA Medical Center in Aurora also paused surgeries after discovering a mysterious residue on medical equipment.
Poorly sterilized surgical equipment can lead to infections, including death, such as those linked to a breach at Denver’s Porter Adventist Hospital in 2018.
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