It took almost six months to fix sterilization equipment issues at Stanton Territorial Hospital, but there’s no guarantee the problems won’t happen again.
In late July 2020, all three of the devices used at the hospital in Yellowknife to sterilize surgical instruments began malfunctioning.
The trays that hold the instruments kept coming out of the machines with moisture, meaning they couldn’t be stored for future use as dampness can attract bacteria. While the hospital worked to address that problem, the towels that wrap around the trays then started coming out of the machines with rust-coloured stains.
In January this year, health minister Julie Green said those two issues had been “basically resolved.” While some staining was still occurring, she said, testing had determined the instruments were coming out sterile and safe to use.
In response to questions from Frame Lake MLA Kevin O’Reilly earlier this month, Green said the health authority had spent around $50,000 on equipment testing and consultant expertise to identify and address the issues. She added the cost could have been much higher if the device manufacturer hadn’t provided support at no cost.
The minister couldn’t promise, however, that the issues had been permanently resolved.
“The staff at Stanton would like to put this issue behind them but, unfortunately, this is historically a recurring problem that is most often occurring in April and May and aligns with the spring melt and the difference in the water chemistry,” Green said.
“It has turned out to be a very unpredictable problem. It will appear and disappear, making it very difficult to investigate the root causes.”
Internal emails obtained by Cabin Radio through an access to information request suggest health officials still don’t definitively know what ultimately solved the problems. All of the “typical solutions” did not result in a fix. It’s not clear which efforts to address the issues were effective or what role environmental factors may have played.
Earlier this month, Green told the legislature the moisture issue – a problem that created “wet packs” coming out of the machines – was the result of humidity. By the fall of last year, that humidity had naturally decreased and was no longer a concern.
David Maguire, a spokesperson for the NWT’s health authority, told Cabin Radio officials believe higher-than-normal humidity and rainfall in Yellowknife last summer were contributing factors. Mobile dehumidifiers were used, he said, and the hospital’s heating and cooling systems were adjusted.
The staining, meanwhile, was due to copper and iron in the water.
Maguire said the root cause of that staining has not yet been determined, but the sterilization equipment itself had been ruled out. Testing continues to determine the cause.
What the health authority did
In emails, the NWT health authority characterized the issues with the sterilizers as “complex” as many systems were connected: the sterilization units themselves, the steam-generating units, the building systems, and the water source.
Environmental factors like high water levels, increased chlorine in the system due to high rainfall, or an increase in humidity could also have an impact.
As soon as the sterilizers started malfunctioning, the territorial government, Dexterra (the contractor that manages the hospital), and the Boreal Health Partnership (which is responsible for maintaining the hospital) began work to pinpoint and fix the problems.
Despite a range of efforts, by September 11 “minimal progress had been made,” according to an email from Green to MLAs.
Steps taken included:
- visits from the device manufacturer and water quality specialists;
- a tank of deionized water being introduced to try to eliminate water mineralization, with no impact;
- dehumidifiers being installed in the devices, and heating and cooling systems reprogrammed to reduce moisture;
- testing different towels and trays in the sterilizers, along with varying the contents of each load;
- filters being added to the intake water supply; and
- asking the City of Yellowknife about any changes to water treatment.
“What’s being described basically sounds like a big experiment,” O’Reilly told the legislature on October 27. “What’s at stake here is not the functionality of a technical system but the health and even suffering of our residents.
“I don’t think it’s an oversimplification to say that I have heard of no comparable situation at other hospitals in Canada. We can’t get this right, and does it mean that we will never have reliable sterilization at Stanton?”
Common issues across Canada
However, experts say other hospitals do experience the same problem.
Ajay Jain is the chief business development officer for Steripro Canada, an Ontario-based specialist sterilization company that helps hospitals across the country.
Jain said staining and wet packs are two of the most common problems hospitals can face, and they often go hand in hand.
“It’s great that the hospital was able to actually identify that they have this issue,” he said of Stanton Territorial Hospital. “There are a lot of hospitals I visit that don’t even know they have this issue until we go in and do an audit.
“It can become an expensive problem to fix.”
Jain described sterilizers as being like complex, fancy dishwashers. He said any deviation in the temperature or chemical composition of the water can lead to wet packs.
Staining issues are often traced to the water supply, Jain said. The water already has minerals in it and additional chemicals are added in the sterilizer. Along with the detergent used to clean towels and the temperature of the water needed to kill viruses and bacteria, that can combine to cause staining over time.
“It becomes this vicious cycle where you have a transfer of elements taking place between different instruments and towels,” he said. “What will happen is you reach a tipping point and then all of a sudden you have staining.”
Some hospitals use a copper-silver ionizer in the water line to prevent Legionnaires’ disease, which can also contribute to mineral staining, he said. Another cause could be sterilizing high-quality and lower-quality surgical instruments in the same load.
“There are so many reasons that could be causing this,” Jain said. “You basically use a process of elimination to determine what the root cause is.”
Based on his experience, Jain said old hospital infrastructure is often the biggest contributing factor – though in Stanton’s case, the building has only been operational for a little under two years.
Another leading cause is the inability to properly maintain the machines or test the water. Those tasks can be challenging, Jain said, as it’s a specialized field and local staff may not have the right skills.
What happens if the issues return?
The malfunctioning sterilizers resulted in 124 surgeries being delayed or cancelled, leaving some people waiting in extreme pain. An unknown number of people simply weren’t put on the waiting list for surgery at all, as it was unclear if or when surgeries would take place.
Not until January 11 did all surgeries resume – the last to return being joint surgeries, which were disproportionately affected as larger surgical equipment was harder to sterilize.
By January 14, the health authority said just 15 of the delayed surgeries had yet to be completed, eight of which involved joint replacements. The authority now says the last of those surgeries is expected to be completed in April, as some patients asked for later surgery dates.
While officials were working on a solution to the wet packs and staining, they also looked into alternative ways to get patients into the operating room quicker. That included sending instruments for sterilization and patients for surgery to hospitals elsewhere in the territory or Alberta. They also looked into using pre-sterilized, single-use surgical instruments.
Five of the 124 cancelled surgeries were completed in Inuvik. Health officials said the Hay River Health Centre didn’t have the capacity to deal with surgeries as it doesn’t have a full operating room. Staff in the town are only trained to assist with low-risk endoscopy procedures and dental surgeries.
No patients were sent to Alberta as the province’s health system was overwhelmed due to a spike in Covid-19 cases that resulted in the cancellation of surgeries for even Alberta residents.
As for sending instruments elsewhere for sterilization, Hay River, Inuvik, and Fort Smith each have one steam sterilization device. However, the NWT’s health authority said those devices are smaller and cannot handle the same capacity as those in Yellowknife.
Maguire, the health authority spokesperson, said sending surgical instruments outside the NWT for sterilization was ruled out due to the risks of Covid-19 and restrictions under public health orders.
As a precautionary measure, Green said the health authority has purchased new trays that require fewer towels. That will help the wet pack problem should it return.
Maguire said the authority was working with Dexterra on localized dehumidifier systems to reduce the possibility of wet packs in the future.