Surgical Counts

Counts are performed for two main reasons: To ensure that the patient is not injured as a result of a retained foreign body To account for those items used during a case

Items to be counted: Sponges Sharps Instruments Miscellaneous items that are small enough to be retained

Sponges are defined as: Laparotomy sponges Raytecs (4x4’s and 4x8’s) Cottonoids and neuro-patties Dissectors such as kittners, peanuts, etc. Deaver covers and clamp covers Umbilical tape Tonsil and cylindrical sponges Radiopaque surgical towels

Sharps are defined as: Suture needles Scalpel blades Hypodermic needles Electrosurgical needles and blades Safety pins and dura hooks Razor blades and weck blades

Instrument Counts ALL INSTRUMENTS used on the procedure are to be included in counts, including all pieces of the instruments (screws, wingnuts, suction tips, etc.)

Adding instruments during the case: When a new set of instrument is introduced, even for only one or two items to be removed and used, the set is to be counted in its entirety before the instruments are removed. The introduced set will then be included as part of all counts during the procedure.

Miscellaneous counted items: Vessel loops Suture boots Rubber shods Cautery scraper pad (scratch pad) Trocar sealing caps Bulldog clamps Irrigating tips Any item small enough to be retained

Who performs counts? The circulating nurse and the scrub nurse count together and out loud, quietly, while visualizing each item.

When to perform sharps and sponge counts: Before an incision is made Before closure of a cavity within a cavity As wound closure begins At skin closure or end of procedure At the time of permanent relief of either the scrub person or the circulating nurse

No initial count… Counts not completed prior to skin incision will be counted as incorrect. An inventory count will be completed at the end of the case.

Additional counts are required when: Multiple teams will be working in the same site (e.g. pelvic exoneration). Sponge counts will be completed at the conclusion of each procedure. Multiple sites, multiple teams (e.g. mastectomy/tram flap). Multiple site case where more than one individual procedure is completed, therefore counts are completed separately.

How are sponges counted? When counting initially and when adding sponges during a case: - break the tape - separate sponges, visualizing each sponge

Countable Items that are Packaged Incorrectly If an incorrect number of sponges or sharps is in a package, the scrub nurse hands it off to the circulator, who bags it and labels it as incorrect. A new package is then given to the scrub nurse. The incorrectly-packaged item(s) are NOT added to the count sheet!

Intraoperative Precautions NEVER cut sponges or towels! Counted items are not removed from the room until final counts are complete and correct No trash is removed until final counts are complete and correct

Off-field sponges -OR- When counting “off-field” sponges, lay them on an impervious sheet in the number that they were originally packaged to facilitate visualization by scrub and circulator -OR- Use the sponge bag counting device

Incorrect Counts Whenever a count comes out incorrect for a non-emergent case: - inform the surgeons, call the attending if he/she has left the room - recount all items; open all bags of sponges and recount - search the trash, linen, and floor - request additional help if necessary

When counts remain unresolved: An x-ray must be done before the patient leaves the room. The x-ray must: Include the entire operative site Be read by the attending surgeon before patient leaves the OR Circulating RN calls ED Reading Room at phone number # 343-7185 or pages # 835-1239 for Stat Read by an Attending Radiologist.

Documentation of Incorrect Count VPIMS Patient tracker “Counts” screen Count Worksheet Occurrence Report (VERITAS) Results of x-ray Reader of x-ray

Intentionally Retained Sponges For cases with excessive bleeding (e.g. trauma) in which the surgeon determines that for the benefit of the patient sponges must be left in the patient, the count is considered incorrect. The surgical attending confirms the number and location of intentionally-retained sponges when possible with the scrub person and circulating nurse The circulator documents in the intraoperative record the number of intentionally retained sponges per the surgical attending An x-ray is not required for this initial procedure An x-ray is required for patients returning to the OR for final removal of intentionally-retained sponges

If an x-ray is needed, plan accordingly to avoid delays! Time Out Each patient will be assessed by the surgical team for risk factors that lead to a potential of retained foreign body If an x-ray is needed, plan accordingly to avoid delays!

Identified Risk Factors An operation was performed on an emergency basis (e.g. Level I Trauma) An operation involved a major unexpected change in procedure (e.g. endovascular converted to open) More than one surgical team is involved or one team performing different procedures simultaneously Permanent change of nursing staff during the procedure (e.g. change of shift relief)

Requires an X-Ray If one or more risk factors for retained foreign body are identified and the surgical wound is able to be closed, an intraoperative x-ray must be taken and read by the attending surgeon, with final reading by a radiologist Attending will document the findings of the x-ray in his/her operative note

Trauma, Packed Wounds ALL LEVEL I TRAUMA CASES where the surgical wound or abdomen is closed primarily will require a mandatory x-ray The attending trauma surgeon will be responsible for the initial reading with a final reading by an attending radiologist

Damage Control When the patient undergoes a “damage control” procedure and the surgical wound is deliberately packed and left open, the count will be considered incorrect This is to be documented in VPIMS and in the surgeon’s operative report An x-ray is NOT required during the initial portion of the damage control procedure

Requesting an X-Ray Radiology technologist will be notified in advance by the OR Charge Nurse or designee of all boarded Level I cases Radiology technologist is paged when portable image is required If more than one body cavity is entered, images of both are necessary X-ray order(s) specifies the possible foreign body type

Requesting an X-ray 5. Digital image(s) are developed and sent to PACS Surgeons review image on OR PACS workstations Circulating nurse calls ED reading room at phone number 343-7185 or pages 835-1239 for stat read by an attending radiologist Final report is signed before patient discharge