INTRODUCTION:

Perioperative practice is complex and highly technicalas well as demanding and is different from other settings¹. Peri-operative complications or associated adverse effects are to be prevented and managed using effective management strategies^2-6. Certain nontechnical and technical competencies of the operation theatre nurses are essential for the enhancement of patient safety in the theatre⁷. One of the essential objective to ensure surgical safety is the prevention of accidental retention of surgical items in surgical wounds¹^,⁸.

Retained Surgical Items: Causes and Consequences

After the operation, any foreign bodies left inside the patient are known as Retained Surgical Items (RSI). These items can be anything from surgical sponges, dressing materials, and pieces of drainage tubes⁹ and the most common is surgical sponges¹⁰. The most common sites include abdomen (56%), followed by the pelvis (18%) and the thorax (11%) (Agarwal 2018). The incidence of retained foreign bodies during surgery is estimated to be 1 in 5500 operations¹⁰^,¹¹.

However, even when the final counting is recorded as correct, surgical items may be still retained unintentionally¹². This enhances the morbidity, cost of treatment and potential mortality to the patient with the addition of medicolegal issues. To prevent devastating consequences of retained surgical instrument, it is necessary for the operation theatre team to know the magnitude, causes and consequences of RSI so that they can develop and practice best policy guidelines to prevent surgical instrument retention and prevent its penalties¹¹.

As per data from perioperative medical records and perioperative nurses, various factors related to RSI include patient and nurse characteristics, intraoperative circumstances or staff involvement. The most common causes of inaccurate surgical count include: higher surgical risk, emergency operations, lower body mass index, complicated procedure, unplanned procedure, lengthy procedures and change in nursing staff during procedures, extended procedural length of time and morbidly obese patients. Increased number of perioperative personnel, increased number of specialty teams involved⁹^,¹².

RSIs are rare medical errors that have the potential to cause significant harm to the patient and carry profound professional and medicolegal consequences to physicians and hospitals. The consequence of RSI may be manifested immediately after the operation, months or even years after the operation. Any item used in a surgery can result as a retained surgical item, but sponges are the most common and the abdomen is the most common location¹⁰^,¹³. In case of retained surgical sponge (RSS), the sponge is surrounded by omentum and intestines, which attempt to encapsulate it. It can result in severe pain, abscess or transmural migration, obstruction or fistulation. Transmural migration occurs as a result of the RSS causes erosion of the bowel loops leading to pressure necrosis¹¹. Migration can take place in any adjacent organ. Abdominal x-ray, ultra-sonography, CT, MRI can all be used to detect RSI. Surgical removal is the only practical option for management of RSI in most cases. RSS should be considered as a differential diagnosis in case of any post-operative complications. Though surgical removal is successful, it can result in some morbidity¹⁰. Morbidity is increased greatly if a mass of cotton material from any source (gossypiboma) is left in any body cavity after a surgical procedure¹¹.

Though, there are advances in the prevention of RSI, it is still an adverse event that occurs in operation rooms, causing physical, emotional and financial damages for patients, it also increases the healthcare cost services¹⁴. “Costs associated with retained surgical items include loss of the reimbursement for the procedure, cost of management of related complications, additional hospitalization or readmission, litigation, and malpractice settlements¹³.

Various Strategiesfor Surgical Counting Compliance

To ensure the avoidance of retention of surgical items in the intra-operative period, in all surgeries the surgical count process is recommended including counting of surgical instruments, sponges, and sharps⁷. Surgical counting is a manual process of counting the materials used in the sterile field during surgeries, with the aim of preventing their inadvertent retention in patients. Counting the surgical materials used during the surgical procedure is the responsibility of the nurses, doctors and all surgical team members¹⁵. Evidence in the literature shows that perioperative nurses along with surgeons are having the main responsibility of surgical counting. The following principles and techniques can help the surgical team to prevent RSIs.

Ethical guidelines:

Safety of patients and health care provider is always grounded in ethical principles and accountability to provide benefit and prevent patients from harm¹⁶. It is the moral responsibility of each surgical team member to be ethical towards their responsibilities to avoid any negligence to do no harm for the patients. Ethical principles have an important role in improving the service provided by any professionals. So well framed ethical guidelines must be available for the surgical team and must be communicated to them. Each registered nurse has ethical and moral responsibility to respect and protect patient autonomy and perform all the possible measures to prevent RSI¹⁷.

Responsibility and Accountability:

Responsibility according to Wallinvirta (2011) is a universal term and relates to how nursing activities are made visualized during patient care¹⁸. The responsibility and accountability of surgical counting lies in the entire surgical team with primary responsibility on scrub nurse, circulatory nurse and surgeon or technician. Every institute must make the team member accountable for doing this task¹⁹. In most of the institutes of our country, the accountability of surgical counting lies with scrub nurse, circulatory nurse and surgeon. Using any of the counting technique practiced in particular setting, the circulatory nurse counts the sponges before closure by keeping the scrub nurse and surgeon witness¹⁷.

Protocol:

An initial counting must occur before the beginning of the surgical procedure, and interim counting may occur by protocol and at the surgical team’s criterion. The closing counting (of agreement) must occur before and after surgical synthesis, checking the number of items recorded in the form with the number of items in the sterile field. Therefore, it is strengthened that the process of counting surgical instruments must begin in the sterile processing department, with the use of standardized boxes, with the number of pieces that will effectively be used, and each instrument identified with an appropriate colored ribbon. Boxes of each surgical specialty must have specific colors; instruments must be listed in appropriate forms according to the order of their placing on the surgical table, and checked before the beginning of surgery by the surgical technologist and circulating technician²⁰.

Techniques of Sponge Counting:

Recommendations regarding the use of specific resources for the counting of sponges are found in the literature, such as the count sheet and use of a white board in the operating room for records during the surgery, an appropriate and signalized place for counting and placing used sponges and use of buckets and bags for the counting of this surgical item. All the sponges must be radio-opaque, standardized by number in each package, checked before the beginning of the surgery by the surgical nurse and circulating nurse, recorded in appropriate forms, as well as noted on the surgical room’s board, for visualization of the whole team²¹. Sponges to dry hands and those used by anesthesiologists must remain separate from sponges of the sterile field; however, neither can be taken from the operation room until the end of the surgery²²^,²³.

Practice Standards for Sponge counting:

Any procedure where there is a possibility that a foreign object could be retained in the perioperative setting the sponges should be counted. The scrub nurse and circulatory nurse are given this responsibility before the procedure starts. The count sheet must include every new additional sponge that is used in the surgery. If the scrub or circulating nurse changes during the surgery there should be recount of the sponges used throughout the procedure. To confirm correct manufacturer and to ensure they are not sticking together all the sponges should be separated. All the sponges used must be x-ray detectable other than the dressing sponges. Radio-opaque sponges should not be used for dressings. All the surgical sponges should be removed from the theatre at the surgery. In addition, items added to the sterile field cannot be loose, and the use of appropriate boxes or containers is indicated for their placing²²^,²³.

Communication and Collaboration:

Good communication in the operating theatre is essential for minimize the errors during the operation.OT nurses should excel in communication, team work and plan and collaborate care in consultation with the patient, surgical team and other healthcare providers²⁴. To ensuring the correct patient, correct site and correct procedure, surgical time out must be performed prior to the incision, including patient identity, surgical procedure, consent, allergies and any surgical or anesthetics issues²⁵. Surgeon must be informed about the count before closing the wound and at the end of the operation. Surgical count sheet should be recorded and signed by two nurses and kept in patients file.

Documentation:

For record of the surgical count process, forms must be used for written record, with appropriate forms for sponges, instruments, and sharps. The movement (in and out) of all items of the operatory field must be documented, without trusting memory, preventing the occurrence of errors of retention²⁶. The forms must be included in the patient’s files, and the record of the counting process must be carried out by the circulating nurse²⁵.

How can we Improve Surgical Counting?

The performance of professionals involved in patient care during the procedure is linked with the retention of surgical items¹⁰. Therefore, it is responsibility of both healthcare professionals and healthcare services to help with the implementation of measures necessary to ensure safety of surgical patients. Some of the evidence-based findings show the need for investments for the standardization of surgical count processes, use of technologies to help manual counting, as well as the hiring of staff, especially surgical technologists, for the development of this practice according to recommendations suggested in the literature. Reduction in retained surgical items is an important part of any operating room patient‐safety effort. Appropriate techniques and careful measures must be incorporated aiming at promoting a safe practice and reducing the number of this item on the surgical table.

Quality improvement program:

Aquality improvement initiative will reduce or eliminate incorrect counts and count discrepancies, which increase the risk of an item being unintentionally retained after surgery. The interventions in a quality improvement initiative may included educating the perioperative staff members, standardizing count practices, formally reviewing every reported count discrepancy with the nursing team and reviewing and revising the count policy for prevention of retained surgical items²⁷. Quality improvement initiatives must include education and training, audit and feedback interventions using local data on actual checklist usage, fostering local champions and leadership, and accountability for compliance.

In service Continuous Nursing Education:

Nurses, while responsible for the management of the surgical center, are in charge of the standardization of the surgical count process, accomplishment of qualification for the nursing team and other professionals involved in patient care during the intraoperative period, as well as monitoring of this practice according to standards adopted.

Availability of Resources:

Hospitals must provide support to ensure the surgical counting process is done correctly, providing the required number of staff and purchase of support devices.

Enhanced Teamwork and Communication:

To improve the quality of communication, it is necessary to enhance physicians’ communication skills and for them to use structured conversation to ensure that individuals are completely informed before undergoing their procedures²⁸. For greater patient safety, it is important to ensure there is good inter-professional teamwork. Therefore, to improve intra-operative teamwork, The World Health Organization (WHO) checklist was introduced.

Strengthening Manpower:

Surgical teams must follow a standard for the undertaking of the procedure, including simultaneous manual counting by the surgical nurse and circulating nurse. Adequate manpower in the surgical team who are responsible and accountable for each surgery I s a mandate for ensuring the surgical safety including the surgical counting.

Technologies:

Conversely, there is evidence indicating that multidisciplinary approaches and new technologies may help to reduce the frequency of retention of surgical items. The use of scanning technologies (sponges with bar codes and sponges with radio frequency identification labels) must be encouraged, being adopted as a complement for manual counting and seen as relevant investment to prevent the problem.

Monitoring and Evaluation:

Along with implementation of various practice guidelines, it is also necessary to monitor the adherence of the surgical team to the policies that are implemented. With a good leadership skill, the OT nurse administrator has great responsibility in monitoring the compliance of surgical team to ensure surgical count accuracy.

Standardization:

In addition, investments are needed for implementation/standardization of the surgical count process. The standardization of the counting process may contribute to the prevention of retained items and reduce costs. However, the current organizational culture in operating rooms shows a range of procedures and customization of practices, strengthening the need for standardization. A universal standardization of surgical counting practice will definitely reduce the incidence of RSI as it will help the healthcare workers including nurses and doctors migrate from one centre to other centres within the country or across the country.

Recommendations for surgical counting by Association of Peri-Operative Registered Nurses:

Nurse led guidelines are found to be effective in improving quality of healthcare and has proven effective²⁹. The following Recommended Practices for Prevention of Retained Surgical Items were developed by the Association of Peri-Operative Registered Nurses(AORN) Recommended Practices Committee (AORN2017) and have been approved by the AORN Board of Directors³⁰^,³¹.

1. All perioperative team members should be responsible for the prevention of RSIs. A consistent multidisciplinary approach for preventing RSIs should be used during all surgical and invasive procedures.

2. Radiopaque surgical soft goods (eg, sponges, towels, textiles) opened onto the sterile field should be accounted for during all procedures for which soft goods are used.

3. Sharps and other miscellaneous items that are opened onto the sterile field should be accounted for during all procedures for which sharps and miscellaneous item are used.

4. Instruments should be accounted for on all procedures in which the likelihood exists that an instrument could be retained.

5. Measures should be taken to identify and reduce the risks associated with unretrieved device fragments.

6. Standardized measures for investigation and reconciliation of count discrepancies should be taken during the closing count and before the end of surgery.

7. Perioperative staff members may consider the use of adjunct technologies to supplement manual count procedures.

8. Personnel should receive initial and ongoing education and demonstrate competency in the performance of standardized measures to prevent RSIs.

9. Measures taken for the prevention of RSIs should be documented in the patient's medical record.

10. Policies and procedures for the prevention of RSIs and unretrieved device fragments should be developed, reviewed periodically, revised as necessary, and readily available in the practice setting.

11. A quality assurance/performance improvement process should be in place to evaluate the incidence and risks of RSIs and to improve patient safety.

A general strategy for preventing RSIs is to account for all items opened or used in a procedure at the end of the procedure because the potential risk for retention cannot always be predicted. Health care organizations are responsible for drafting and communicating policies and procedures applicable to their practice setting based on the latest recommendations. It is imperative to value teamwork and hold all perioperative personnel accountable for the adoption, implementation, and review of their designated procedures and practices.

CONCLUSION:

By following evidence based standard recommendations, we can prevent prevalence of retained surgical items and related adverse effects. When considering patient safety, the surgical count process is a very important practice to undertake. Operation theatre nurse administrators also have the responsibility in educating the entire surgical team and monitor the surgical safety practices to ensure safety for not only for the patients, but also for the health care team and the hospital. Incorporation of appropriate evidence-based measures and quality improvement measures will improve surgical counting, hence must be adopted in operating room settings. Soft skills of the team members including ethics, accountability, communication and team work cannot be replaced by any measures to achieve best results. Hence, perioperative nurses must have awareness, attitude and proper skill in implementing various techniques and advanced measures to ensure accurate surgical counting.

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Received on 24.03.2020 Modified on 13.04.2020

Asian J. Nursing Education and Research. 2020; 10(3): 375-379.

DOI: 10.5958/2349-2996.2020.00080.4