Surgical Counting
Counting for all accountable items throughout the operative procedure(s) includes :-
1) Before the procedure to establish a baseline (#Initial Count)
2) Prior to closure of a cavity within a cavity (#Additional Count)
3) Before wound closure begins (#First Count)
4) At skin closure or at the end of the operative procedure(s) (# Final Count)
5) At the relief of the scrub person (# Relief Count)
Purpose of Surgical
Counting To ensure all items used during surgical
procedure are removed
Reduce the risk of injury (ACORN,
2006)
Gold standard to manage this risk
(Gibbs, 2003)
Responsibility of peri-operative RN in
charge of the case
Major items required to be
counted
Absorbent Items Sharps
Vascular ItemsDisposable Retraction
Instruments
Major countable Items
Sentinel Event
Unexpected Occurrence
• Death
• Physical Injury
• Psychological Injury
Loss of Limb
• Loss of function
• Risk thereof
• Immediate investigation required
Focus on RSI
• Retained surgical instrument
HOSPITAL AUTHORITY (HS)
Statutory Body under Hospital Authority
Ordinance
Manage Hong Kong’s Public Hospitals
Accountable to Hong Kong Special
administrative
Region Government
Contribute to fulfillment of Hong Kong SAR
Government’s policy
HA Sentinel Events (SEs)
4 5 4 6 7 60
2
4
6
8
10
12
14
16
18
20
2007/08 2008/09 2009/10 2010/11 2011/12 2012/13
RSIs in Other Departments
RSIs in Operating Theatre (32 cases) 40%
80 cases
37%
Site of RSIs
AbdomenExtreme
Tonsillar bed
Eye
Thoracic
Oesophagus
Other
11
http://www.ha.org.hk/riskalert
63%
Type of RSIsTiny dislodged
fragment or broken
part
Raytec gauze &Abdominal pad
Malleableretractors
68%
Contributing factor of RSIs
Quality
(Integrity)
Quantity(Counting)
40%
RSIs in
Open Surgery
Open Abdominal
Surgery
Open Other Surgery
67%
RSIs in Minimally Invasive Surgery
Laparoscopic
Surgery
Endoscopic Surgery
67%
Raytec gauze or
abdominal pad
Malleable retractors
100%
Tiny disloged
fragment or broken
part
Complications due to RSI
Perforation of bowel
Sepsis
Loss of Limb or function
Death
2008
Gyn. Lap. surgery
Plastic insulated sheath of a lap. forceps
Abdomen
HA Risk Alert, Issue 4 (2008)
A segment of plastic insulated sheath of a
laparoscopic instrument was retained inside
patient
16
Contributing Factors
Difficult specimen retrieval
• Peeling off a piece of instrument coating
Improper integrity of instruments
• No proper checking of instruments before the end of operation
Recommendations
Non Insulated metal
• Instrument can be used with non insulated metal outer tube for specimen retrieval
Ensure integrity of instrument
• Instruments should be checked for their integrity before the end of operation
An oval shaped metallic clamp button
from stapler was retained in patient’s
abdomen
20
2008
Lap. resection of rectum
Metallic clamp button from the stapler
Abdomen
HA Risk Alert, Issue 7 (2008)
Grasping forceps was left in abdomen of
patient
22
2009
Metal plate inside the lumen of the forceps
Abdomen
A metallic covering defect at the end of the
70 degree telescope was found
24
A fragment of the end of telescope
Details
Contributing Factors:
Difficulty in detecting
defect of delicate
instruments.
Low awareness of
staff on checking
instruments integrity.
Recommendations:
Use LED H and
Magnifier for
facilitating checking
and inspection of
instrument integrity
To document details
of scopes sued in
surgical operations.
Causative factors to RSIs
26
Cause-effect diagram
RSIs Lap. surgery
Organization Method/Process Instrument
Work Environment PatientStaff Communication
Scrub person-Distraction bysurgeon-lack of awarenesson integrity of Instruments
-Plenty ofinstruments forcounting-Spare parts/screwseasily dislodged
-Longoperation time-Obesity
Scrub person- surgeon:No confirmation of correct counting before closure Scrub person-circulating nurse:No consistent sequencein counting
Low compliance on SAG standardsof checkingthe instruments’integrity whenclosure of wound
No structured policies to reducethe risk of RSI
-Hasty environment- Inadequate time forchecking the integrity of instruments whenclosure of cavity & wound
The swab and instrument count is essential and plays key role in enhancing surgical patient’s safety (Woodhead and Fudge, 2010).
Greenberg (2008) concluded that one in eight surgical cases involves an intra-operative discrepancy
Instruments can be retained during laparoscopic procedures, therefore, initial instrument counts should be performed (AfPP 2007, AORN 2010, ACORN 2006, SAG 2010, AST 2006)
First P:
Practical utilization of laparoscopic instruments
30
Revised
G104-01
General & Team
B
Lap. Surgery
Revised
G104-02
Team D & U
Lap.
Surgery
↓47%↓ 3% ↓17%
Created
G104-03
Team A
Lap.
Surgery
Second P:
Practical utilization of laparoscopic
instruments
31
Supplementary laparoscopic instrument
Screws
Screw x 2
Screw x 1
Screw x 2
Metal Ball (左右) x 2
鍋釘(左右) x
2
螺絲帽 x
1
Third P:
Partition of Used & Unused
laparoscopic instruments
32
Separating
Additional instrument tray
Fourth P:
“Partial Count” in Laparoscopic surgeryInitial counts 1st
Closing count 2nd
Closing count
3rd
Closing count
Before sending to CSSD
Relief count
AfPP (2007) UK / NursesAORN (2010) USA / NursesACORN (2006) Australia/ NursesACS (2005) USA / SurgeonsSAG (2010) HK / NursesAST (2006) USA / Technologists
Before the procedure
Before closure of a cavity within a cavity
Before wound closure begins
At skin closure or end of procedure
At the time of permanent relief of either the scrub person or circulator
Laparoscopic surgery After all trocars removed(Closure of peritoneum, muscle layer, and fascia
en masse in laparoscopic surgery)
Absorbent items Yes Yes Yes
Sharps & Other miscellaneous items
Yes Yes Yes
Basic instruments
Yes No Yes Yes
Laparoscopicinstruments
ALL Laparoscopic instrument
Used Laparoscopic instrument
ALL Laparoscopic instrument
ALL Laparoscopic instrument
Counted &a visual
inspection for completeness
A visual inspection for completeness Counted & a visual
inspection for completeness
Counted & a visual inspection for completeness
33
Prescriptive nature of procedure
Lack of clarity what constitutes an
‘accountable’ item
Failure to consider current technologies
and use of plastics and other X-ray
detectable items (Hamlin, 2005)
Pilot study
Phase 1
15 Elective Laparoscopic
Colorectal Surgery
5
patients excluded
2 patient convented to open
surgery
3 patients' scrub persons were not
trained
10
patients included
Phase 2
5 Elective Laparoscopic
Urological Surgery
4
patients included
1
patients excluded
1 patient convented to open
surgery
37
38
Full count
231 236
326
200
180
240
330
350
250
360
0
50
100
150
200
250
300
350
400
1 2 3 4 5 6 7 8 9 10
Time (Seconds)
Full count: 4’30”
39
Partial count
200
180
195
109
171
103
122
103
187180
65
234
183
90
0
50
100
150
200
250
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Time (Seconds)
Partial count: 2’32”
40
Full count – Partial count
4’30”
2’32”
0
50
100
150
200
250
300
Full Count (N=10) Partial Count (N=14)
Time (Seconds)
Efficiency: ↑44%
41
Number of Used Lap. instruments
2’44”
1’18”
0
20
40
60
80
100
120
140
160
180
More than 12 (n=12) Fewer than or equal to 12 (n=2)
Time (Seconds)
Efficiency: ↑52%
42
Experience of “Partial Count”
2’52”
1’59”
0
20
40
60
80
100
120
140
160
180
200
Inexperienced (n=9) Experienced (n=4)
Time (seconds)
Efficiency: ↑30%
43
Instruments -- Experience
5’06”
3’38”3’12”
1’30”
2’17”
1’5”
0
50
100
150
200
250
300
350
More than 12 Fewer than or equal to 12
Full Count (Inexperience, n=10)
Partial Count (Inexperience, n=9)
Partial Count (Experience, n=4)
Efficiency: ↑70%Efficiency: ↑55%
44
Effectiveness Efficiency
Communication Safety
Evaluation
Effectiveness
45
0%
20%
40%
60%
80%
100%
120%
Surgeons
Nurses
Q1.This modified checking procedure can enhance counting strategy development.
Rating: 95% 5% Strongly Agree90% Agree5% Disagree
0%
10%
20%
30%
40%
50%
60%
70%
80%
Surgeons
Nurses
Q2.This checking method is appropriate to apply in our OT situation.
Rating: 81%10% Strongly Agree71% Agree19% Disagree
0%
20%
40%
60%
80%
100%
120%
Surgeons
Nurses
Q3.The counting procedures are in precise and effective way.
Rating: 100%5% Strongly Agree95% Agree
RR: 95% (N=21, Doctors, n=7, Nurses,
n=14)
46
Efficiency
0%
10%
20%
30%
40%
50%
60%
70%
80%
Surgeons
Nurses
Q4.Nurse and surgeons are familiar with the counting sequence: Head-Neck-Body-Tail-(complete).
Rating: 86%14% Strongly Agree72% Agree14% Disagree
0%
10%
20%
30%
40%
50%
60%
70%
80%
Surgeons
Nurses
Q5.You believe that the turnaround OT time will not be delayed.
Rating: 72%10% Strongly Agree62% Agree28% Disagree
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Surgeons
Nurses
Q6.This is an efficient and safe counting procedure.
Rating: 100%14% Strongly Agree86% Agree
Efficiency: ↑55% >12, ↑70% ≦ 12
47
Communication
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Surgeons
Nurses
Q7.You have got the basic information introduction of Retained Surgical Items (RSIs).
Rating: 95%19% Strongly Agree76% Agree5% Disagree
0%
10%
20%
30%
40%
50%
60%
Surgeons
Nurses
Q8.(Nurse) - You have got surgeons' collaboration and understanding.
Rating: 64%7% Nurse Strongly Agree57% Nurse Agree29% Disagree7% Strongly Disagree
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Surgeons
Nurses
Q9.Surgeon shown compliance on "Pause for Counting"
Rating: 86%19% Strongly Agree67% Agree14% Disagree
48
Reducing of RSIs
Q10.It would reduce the Risk of RSIs at a lowest rate.
Rating: 95%19% Strongly Agree76% Agree5% Disagree
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Strongly Agree Agree Disagree Strongly Disagree
Surgeons
Nurses
49
Implication
Future Development
Standard Operating Procedure
(SOP)
Guideline for all laparoscopic procedures
Guidelines for Specialty Nursing
Services (Perioperative
Care)
50