1. Surgical Counts

2. 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

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

4. 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

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

6. 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.)

7. 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.

8. 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

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

10. 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

11. 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.

12. 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.

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

14. 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!

15. 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

16. 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

17. 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

18. 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 # or pages # for Stat Read by an Attending Radiologist.

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

20. 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

21. 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!

22. 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)

23. 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

24. 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

25. 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

26. 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

27. 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 or pages for stat read by an attending radiologist
Final report is signed before patient discharge