The Importance of Surgical Counts
Among the many critical procedures carried out in the OR, the practice of surgical counts holds a significant place. This process, which involves accounting for all surgical instruments, sponges, and other items before, during, and after surgery, is essential for patient safety.
Understanding the Risks
The failure to accurately count surgical items can lead to severe complications, including retained foreign objects (RFOs). RFOs are items inadvertently left inside a patient's body during surgery, leading to infections, obstructions, pain, and the need for additional surgeries. According to a study published in the New England Journal of Medicine, RFOs occur in approximately 1 in 5,500 surgeries, with sponges and towels being the most commonly retained items.
Best Practices in Surgical Counts
To mitigate the risk of RFOs, adherence to stringent surgical count protocols is crucial. The Association of periOperative Registered Nurses (AORN) recommends the following best practices:
Pre-Operative Planning: Ensure all team members are aware of the types of items that will be used during the surgery and their quantities.
Standardized Count Procedure: Implement a consistent method for counting, which should include an initial count before the surgery, a count before closure of a cavity, a count before wound closure, and a final count at the end of the procedure.
Double-Checking: Each count should be performed by two individuals, typically a nurse and a surgical technologist, to ensure accuracy.
Use of Count Sheets: Utilize standardized count sheets to document each item used during the procedure.
Immediate Reconciliation: In case of a discrepancy, conduct an immediate recount and if necessary, use imaging techniques to locate missing items.
Items That Need to Be Counted
Sponges: These are the most common items used in surgeries for absorbing blood and other fluids. They can easily be left inside a patient due to their size and the fact that they can blend in with the surrounding tissue.
Needles and Sharps: Due to their small size and critical use in surgeries, needles and other sharp instruments like scalpel blades must be meticulously counted to avoid being left inside a patient.
Surgical Instruments: This category includes forceps, clamps, retractors, and other tools. The variety and quantity of these instruments can vary greatly depending on the type of surgery.
Other Miscellaneous Items: This can include guide wires, trocars, tubing, and any other items specific to certain types of surgical procedures.
Timing of Counts
Initial Count: Before the surgery begins, an initial count of all items is conducted. This serves as a baseline for all subsequent counts.
Count Before Closure of a Cavity: Before closing any cavity within the body, a second count is necessary to ensure that all items are accounted for.
Count Before Wound Closure: Before suturing the surgical wound, another count is performed. This is critical as it's the last opportunity to ensure no items have been left inside the patient.
Final Count: At the conclusion of the surgery, a final count is conducted. This serves as a confirmation that all items are accounted for.
Types of Procedures and Their Specific Considerations
General Surgery: Procedures like appendectomies, cholecystectomies, and bowel resections require a range of instruments and sponges. The focus is on ensuring no items are left in the abdominal cavity.
Orthopedic Surgery: These surgeries often involve a lot of small instruments and implants like screws or plates. Special attention is needed to track these items due to their size and the complexity of the procedures.
Cardiothoracic Surgery: Involving critical areas like the heart and lungs, these surgeries require precise counts, particularly of sponges and needles, due to the intricate nature of the work.
Neurosurgery: Given the sensitive area of operation, even the smallest item left behind can have serious consequences. Specialized instruments and sponges used in these procedures must be carefully counted.
Obstetric and Gynecologic Surgery: Procedures like cesarean sections and hysterectomies require careful counting of sponges and instruments, as the pelvis can easily hide these items.
ENT (Ear, Nose, and Throat) Surgery: These procedures often use very small instruments and sponges, making accurate counts critical to avoid retained surgical items.
Potential Complications and Their Prevention
Complications from inaccurate counts can be dire. They include the need for additional surgeries, prolonged hospital stays, infections, and even life-threatening conditions. To prevent these complications, surgical teams should:
Implement Technology: Use of bar-coded sponges and radio-frequency identification (RFID) tags can help in tracking items more accurately.
Continuous Education: Regular training sessions for OR staff to reinforce the importance of accurate counting and to keep them updated on new protocols or technologies.
Foster a Culture of Safety: Encourage a team-based approach where every member feels responsible and empowered to speak up if they notice a discrepancy.
Education and Training Strategies
Education and ongoing training are vital in maintaining effective surgical count practices. This includes:
Simulation-Based Training: Using real-life scenarios to practice count procedures and manage count discrepancies.
Regular Audits and Feedback: Conducting audits of surgical count procedures and providing feedback to the team can help identify areas for improvement.
Interdisciplinary Collaboration: Involving surgeons, nurses, and other OR staff in training sessions to foster a collaborative approach to patient safety.
Conclusion
The practice of surgical counts is a critical component of patient safety in the operating room. By understanding the risks, adhering to best practices, utilizing the right tools, and committing to continuous education, surgical teams can significantly reduce the incidence of retained surgical items and ensure the highest standards of patient care.
In conclusion, surgical counts are not just a routine procedure; they are a vital safety check that protects patients at their most vulnerable. As healthcare professionals, our commitment to meticulous surgical counts reflects our dedication to patient safety and quality care. Through diligence, teamwork, and ongoing education, we can continue to uphold the trust that patients place in us when they enter the operating room.
AEC Consulting LLC specializes as a surgical nursing expert, including pre-, intra- and post-operative patient care. Alexis Chaudron is the owner of AEC Consulting LLC, an independent nurse legal consulting practice through which she provides legal nurse consultant expertise honed through 15+ years of healthcare experience. She is currently clinically practicing as a circulating nurse and provides charge nurse coverage. Alexis is an operating room nurse expert, with a specialty in orthopedic and spine surgeries. Additionally, Ms. Chaudron was trained and worked in Neurosurgical, General, ENT, Plastics, DaVinci, GYN, Cystoscopy, and Pediatric surgical cases.
Alexis provides surgery nurse expert witness services for medical legal cases. She has analyzed medical charts, depositions, declarations and other related documents to ascertain if the nursing standard of care has been met. As an operating room nurse expert, she utilizes nursing textbooks, guidelines and peer reviewed articles and journals to bolster her surgical nursing expertise. Alexis has provided depositions, expert testimony, affidavits and reports as needed depending on case requirements. She has worked for both plaintiffs and defense in medical malpractice and wrongful termination cases.
The initial call is confidential and complimentary. Alexis can discuss your legal issues and how she can best assist your organization.
