Healthcare Hygiene magazine December 2019 | Page 36

sterile processing
By Hank Balch
The Tip of the Iceberg: It’s Not Just Goshen
On
Nov. 18, 2019, hospital administrators at Goshen
Health in Goshen, Ind. notified nearly 1,200
surgical patients that they may have exposed to hepatitis
B, hepatitis C and HIV due to improperly processed surgical
instruments. 1 The story itself is one that we’ve heard again
and again in recent years, from places like Seattle Children’s
Hospital, Detroit Medical Center, and Porter Adventist Hospital
in Denver.
While the locations for these quality breakdowns change,
the overarching script does not. Some process was not
followed, some step in Sterile Processing was not taken, and
now thousands of patients are given the news that instead
of healing them, their hospital visit may have infected them
with a deadly virus. Not the kind of news any patient ever
deserves. Unfortunately, most patients have no idea how
systemic these challenges really are.
As frightening as this news is, inside the sterile processing
(SP) industry we are not surprised when we see a headline like
this hit the evening news. Many of us are surprised that we
don’t see more of them. Discussions around non-compliance
for point-of-use cleaning, challenges around manual cleaning
protocols, breakdowns in automatic cleaning equipment, and
staff competency concerns are constantly discussed during
our national annual meetings and local seminars. Research is
regularly being presented via whit papers, industry magazines,
and posters that highlight serious shortcomings related to
current cleaning, disinfection, and storage practices in the field.
For SP consultants who visit multiple facilities a month
across the country, there is no question that the kinds of
quality headlines we see from hospitals like Goshen are far
more common than the public is aware. We know we are just
beginning to scratch the surface of the real depth and breadth
of these infection control risks. While the mainstream media
reports on the occasional tip of the iceberg, there is a massive
problem lurking just underneath that has the attention of many
SP professionals, microbiologists and regulatory agencies.
When specific process-breakdowns like this are identified
in hospitals, there is an immediate rush to calm public
fears, get accurate information out to the media, and try to
explain how something like this could happen in SP. In fact,
the CDC has an entire resource page dedicated to walking
facilities through this notification process in a transparent,
yet controlled manner.
One of the central phrases from the CDC resources
instructs hospitals to tell patients, “We believe the risk to be
extremely low.” If you closely review the communications
from the hospitals listed at the beginning of this article, and
other examples of surgical sterilization problems, you will see
this refrain used again and again. While the comparatively
low risk of exposure is true enough in a statistical sense,
when we hear interviews from the patients who receive these
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notifications there is concern, fear and anger. One patient
from the Goshen case said, “I was mad, I was really, really
mad because when you tell somebody that they could be at
risk for something like that, it not only involves you, it involves
your family, your significant other. I mean I have grand kids
and kids. I have a life.” 2
This patient feedback is a far better indicator for what the
public finds value in knowing about how their surgical care
is delivered to them. Patients who have been notified of an
infection control breach do not care about cold, dry statistics
from some government agency. They want to know why
this happened in their town, during their surgery, and if the
results of their test is going to change the rest of their life.
So how do we bridge this disconnect between tremendous
ongoing quality struggles in SPDs around the country,
and public awareness of the situation before it leads to a
wide-scale patient notification scenario? One of the best
opportunities before us is to bring our internal industry
conversations out into the public arena. This will mean a
pivot from talking to ourselves about ourselves, to talking
and educating a public who has very little understanding of
the current state of medical device reprocessing.
A great example of this type of public facing approach
can be seen in the work of Aakash Agarwal, PhD, who has
conducted recent media interviews and publications around
contamination concerns with surgical implants. Through
these platforms, and other social media outlets, Agarwal is
engaging with this topic in the public sphere, where potential
patients can encounter and respond to the content from
an educational perspective. This is just one of a hundred
different topics that touch the Sterile Processing industry
which could be more actively and transparently discussed,
with the goal of stirring up awareness of and support for
additional resources to find real solutions for the challenges
that currently plague us.
The longer we respond to situations like Goshen Hospital
as if they were the rare exception, instead of a symptom of a
deeper problem, the larger the risks grow to see more patients
receive notifications of potential exposure. Instead, we should
pull back our industry curtains, and let the light of public
transparency melt the quality iceberg in our path. 
Hank Balch is an internationally recognized thought
leader in the sterile processing industry, as well as podcast
host, and founder of Beyond Clean.
References:
1. https://wsbt.com/news/local/close-to-1200-patients-at-goshen-
hospital-may-have-been-exposed-to-infectious-disease
2. https://wsbt.com/news/local/it-scared-the-heck-out-of-me-goshen-
hospital-patient-says-shes-worried-for-her-future
december 2019 • www.healthcarehygienemagazine.com