CDPHE Report Exposes Flaws Behind UCHealth Anschutz Procedure Pause
Unsafe Conditions in Sterile Processing Department
A state investigation revealed that the sterile processing department at UCHealth University of Colorado Hospital was operating under unsafe and unsanitary conditions during the summer. The findings indicated that hundreds of contaminated surgical instruments were left unprocessed for days, and staff failed to adhere to sterilization protocols. This situation raised serious concerns about patient safety and the overall quality of care provided by the hospital.
The Colorado Department of Public Health and Environment (CDPHE) initiated an investigation on July 14 after receiving public complaints regarding the Aurora hospital’s sterile processing department. This department is responsible for cleaning and sterilizing surgical tools, making it a critical component of the hospital’s operations. Inspectors discovered several issues, including contaminated tools, inadequate staff training, and poor oversight that had been ongoing for months.
Under the supervision of CDPHE, UCHealth implemented daily cleaning audits, restricted surgery scheduling to prevent overload, and retrained staff throughout August. By early September, inspectors concluded that the hospital had achieved “sustained compliance.” However, the problems identified during the summer highlighted significant lapses in the hospital’s procedures and management practices.
During the inspections over the summer, CDPHE investigators observed 17 three-tiered carts containing 30 or more trays of surgical instruments left uncovered and “grossly soiled with dried blood and tissue.” Technicians explained that improperly cleaned instruments could not be sterilized and posed a risk of causing surgical site infections. In four separate observations, inspectors found that staff failed to follow manufacturers’ cleaning instructions — known as IFUs — in every instance.
One technician was noted for brushing only the front side of hinged instruments without moving the joints, while another performed only visual inspections and skipped required rinsing steps. Investigators also observed a technician failing to pull an instrument for reprocessing/repairing/replacement that was tarnished with visible rust.
Risks and Consequences of Contamination
An incident in early July demonstrated the risks associated with these problems. A patient admitted for a laryngoscopy on July 9 experienced a procedure delay of several hours after surgical staff discovered that their syringe assembly contained defective parts. One needle was bent, another missing, and a third clogged beyond use, forcing the surgery to be abandoned.
Hospital records indicated that the contamination problem had been escalating for months. In May, the sterile processing department reported 20 days when more than 112 contaminated instrument sets were left unprocessed, peaking at over 500 sets on May 17. In June, unprocessed sets exceeded 120 on 18 days, surpassing 400 on June 5 and 6.
Technicians informed inspectors that contaminated tools could sit unprocessed for up to six days. Staffing shortages contributed to the backlog — the number of direct-hire SPD workers had declined over the past year, and the hospital prohibited adding agency staff. Despite the growing backlog, daily “huddle reports” outlining contamination levels were shared with hospital executives, including the vice president of perioperative and procedural services.
Leadership, including the chief nursing officer and infection prevention directors, reviewed the issues on July 16 and 17. The following day, July 18, the hospital halted all nonemergency surgeries to reprocess contaminated instruments, retrain staff, and overhaul sterilization practices.
UCHealth spokesperson Dan Weaver told 9NEWS at the time of the investigation, “some elective cases will be postponed to ensure we have the instruments needed to provide all urgent and emergent surgeries and procedures.”
Patient Kora Benck had her gender-affirming surgery postponed. She had been waiting nine months for gender-affirming surgery, originally scheduled for July 25. She wasn’t treated until Sept. 25.
“I was definitely upset when it got delayed, but now that we’re on the other side of it, I feel really great,” Benck said.
State inspectors also found that staff competency assessments were not documented as required. Managers had not verified employees’ training within the mandated three-year interval. Some staff appeared to misunderstand sterilization protocols altogether. One director claimed that spraying contaminated tools with cleaning solution “reset the 72-hour window” for sterilization — a statement the manufacturer’s instructions did not support.
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