P R E S E N T E D B Y:

Sponge ACCOUNTingGetting to 0 in ’10!

Lisa Gentile Dorinda Roberts

February 11, 2009

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BACKGROUND:

Surgeons and operating room teams rely upon the practice of sponge, sharp and instrument counts as a means to eliminate retained surgical instruments.

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BACKGROUND:

Counts are also a method of infection control and inventory control, and a means to prevent injury from contaminated sharps and instruments.

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The PROBLEM:

The process by which counts are performed is not standardized and is often modified according to the individual hospital policy.

Even when present, counts are frequently omitted or abbreviated in emergency or transvaginal surgeries, or for vaginal deliveries.

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RETAINED SPONGES:

• In cases with retained sponges, sponge counts had been falsely correct in 76% of non-vaginal surgeries; in 10% of these cases no sponge count had been performed at all.

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RETAINED SPONGES:

• Falsely correct sponge counts were attributed to team fatigue, difficult operations, sponges "sticking together," or a poor counting system.

• Incorrect sponge counts that were accepted prior to closure resulted from either surgeons' dismissing the incorrect count without re-exploring the wound, or nursing staff allowing an incorrect count to be accepted.

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Retained Surgical Sponges

Retained surgical sponges result from faulty Operating Room practices.

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IMPLEMENTING CHANGE:

• The existing system of sponge and instrument counts probably works well, but we have no evidence to describe its actual failure rate.

• The little existing evidence suggests that it fails due to human-related factors (i.e., the count not performed, or is ignored, and that ancillary methods such as x-rays are also weak).

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Retained Sponges

Sponges:• Most common retained surgical item.

• Detection can be difficult.

Surgical Sponge

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CHW History and Goal

FY2008 FY2009FY2006 FY2010FY2007

Small changes in our practice

SPONGE

ACCOUNTING

17 0?1615

Number of Retained Sponges

Goal!

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CHMC’s CURRENT PRACTICE

• The responsibility for preventing retained sponges has relied on the practice of “counting.”

• At the end of the case we ask “What is the count?”

• Error rates with counting are approximately 10-15%

• In 80% of retained sponge cases the count has been falsely called “correct”.

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PROBLEM WITH OUR CURRENT PRACTICE:

Having your entire system rely on only one faulty element is not a very safe system

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ALTERNATIVE APPROACH

• Now we need to ask a different question:“WHERE ARE THE SPONGES?”

• Change the focus away from counting and towards a system that requires accounting and visible confirmation for verification.

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PLAN TO PREVENT RETAINED ITEMS:

• Establish a systematic process.

• Every case should have a sponge count performed.

All wounds are at risk--- vaginal deliveries too

• Retained sponges occur with low sponge count cases (≤20 sponges).

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SPONGE ACCOUNTing ROLES IDENTIFIED:

• Nurses will use a standardized process to put all sponges in hanging sponge holders and document the sponge counts on a white board in each Operating Room.

• Surgeons will perform a methodical wound exam before closing in every case and verify with the nurses before leaving the Operating Room that all the sponges are in the holders.

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APPROPRIATE COMMUNICATION:

It’s what is right not who is right– Between nurses and surgeons

• “We’re missing a sponge.” “Lets re-explore the wound!”• “I am going to place the used and unused sponges in

the holders now so we can do a Final Count.”

– Between nurses• “Separate each raytex so we can make sure we don’t miss one!”• “Let’s verify the sponge holders before we complete Change of

Shift Sign-Off.”

– Between surgeons• “Make sure you check behind the uterus for that raytex I stuck

there before you close.”• “Let’s do our wound exam and look for sponges before we close.”

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Legal Recap

Preventing retained sponges is a joint and shared responsibility!

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Sponge ACCOUNTing

New items to help implement the change...

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NEW Plastic Hanging Sponge Holders

• The Hanging Sponge Holders are now blue-backed to assist in visualization of the sponges (compared to the previous clear-backed holders).

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NEW Plastic Hanging Sponge Holders (continued):

• Each contain 5 pouches. Each pouch has a thin center-divider which separates each pouch into 2 pockets. One sponge will be placed in each pocket. Each holder can accommodate 10 sponges.

• The sponge holders are held on racks mounted to IV poles. Each rack can usually accommodate 10 sponge holders (5 on each side) which is 100 sponges!

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NEW Clear Plastic Lined Kick Buckets:

• To aid in the visualization of bloody sponges in the procedure, the plastic bags lining the kick buckets will now be changed from red to clear plastic.

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NEW Dry-Erase Boards in the ORs

• New dry erase boards have been created to help standardize the process in our Operating Rooms.

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Sponge Holders In Practice:

Guidelines:• Use sponge holders for laps and raytex

on all cases that require a sponge count. • Use a separate holder for each sponge

type (i.e. one holder for laps & separate holder for raytex).

• Used sponges coming from the operative field should be placed into the CLEAR plastic bag-lined receptacle (i.e. kick buckets).

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Process for Loading the Sponge Holders:

• Each used sponge will be taken from the kick bucket receptacle and placed in a pocket on the Sponge Holder.

• The folded sponge will be placed in the pocket with the blue tag or blue stripe visible.

• This is what differentiates a sponge with a radiographic marker from a dressing sponge.

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Process for Loading the Sponge Holders (continued):

• The first sponge will be placed in the LAST pocket in the bottom of the holder. The Holder will be loaded horizontally from the bottom row to the top row, filling first the bottom two pockets and continuing upwards. This process (going from the bottom to the top) will make visual determination of the filled holder easier to see from the OR table.

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Process for Loading the Sponge Holders (continued):

• Periodically throughout the case the used sponges will be placed in the holder.

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The NEW Dry-Erase Boards In Practice:

New Guidelines:

• Now it is a ‘running total’

• Recorded as: 10102010301040• Always in factors of 10 (sponge packs can

only be added in groups of ten now).

• Standardized system for all ORs (L&D and Main OR will be practicing this way).

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The NEW Dry-Erase Boards In Practice (continued):

• When adding a set of ten laps, the new set is added by setting the ten quantity set above the current total.

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Wound Review: Checks and Balances

The Methodical Wound Exam

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Methodical Wound Exploration

• A methodical exploration of the operative wound must be conducted prior to closure in every operation.

• The space to be closed must be carefully examined. Special focus should be given to closure of a cavity within a cavity (i.e., heart, major vessel, stomach, bladder, uterus, and vagina).

• Surgeons should strive to see and touch during the exploration whenever possible; reliance on only one element of sensory perception is insufficient.

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MWE Recap

• The surgeon should visually and manually make every effort to assure that no unintended surgical items have been left in body cavities.

• The general process is to look and feel in the recesses of the wound and examine under fatty protuberances and soft-tissue appendages.

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Steps Behind the Methodical Wound Exam:

Unless clinically contraindicated for a specific patient, a systematic approach

should be used for procedures performed in the abdomen or pelvis.

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Steps Before Removing the Retractors:

These steps should be performed before removing stationary or table

mounted retractors.

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Steps Before Removing the Retractors:

Examine all four quadrants of the abdomen with attention to: • Lifting the transverse colon • Checking above/around the liver and above/around the spleen

• Examining within and between loops of bowel

• Inspecting anywhere a retractor or retractor blades were placed

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Steps Before Removing the Retractors:

Examine the pelvis • Look behind the bladder, uterus,

and around the upper rectum.

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Steps Before Removing the Retractors:

• The vagina should be examined if it was entered or explored as part of the procedure.

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Three Phases for Timing the Counts:

There will be three standard times to count in our procedures now:

• IN Count

• Closing Count

• Final Count

1010201030

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Three Phases for Timing the Counts:

IN COUNT • Documentation on the Dry-Erase board

of the initial count of opened items• Only X-Ray detectable sponges or

towels can be used.

(Between the Surgical tech and the Circulating Nurse).

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Three Phases for Timing the Counts:

CLOSING COUNT • “Pause for the Gauze” • The surgeon performs a Methodical Wound

Exam while the circulating nurse performs the Closing Count Call Out “I think all the sponges are out.”

• Then the surgeon can ask for the closing suture. (Exchange of information between the surgeon and the nurse).

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Three Phases for Timing the Counts:

FINAL COUNT • This is the ‘Verification step’• The surgeon says “Show Me”

and looks at all of the Sponge Holders. • Then the surgeon should dictate in the

Post-Op Report “a MWE was performed and all items are ACCOUNTed for.”

(Exchange of information between the surgeon and the nurse).

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In the Event of a Sponge Miscount:

• If the surgeon is informed of a missing object by the circulating nurse, while the OR staff are looking for the surgical item, the surgeon should stop closing the wound and repeat the methodical wound examination.

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In the Event of a MISCOUNT:

• On occasion, an incorrect count is obtained and under these circumstances an intra-operative X-Ray is required.

• A written request for a “STAT image for foreign body detection” will be generated by the circulating nurse under the name of the attending surgeon listed in the operation record as being responsible for the conduct of the operation.

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In the Event of a MISCOUNT (continued):

• Upon receiving the request, a radiology tech will take an X-Ray of the appropriate site. The elapsed time should never exceed twenty minutes. The tech will note time request received and time X-ray taken on the request slip.

• The tech taking the X-Ray will call ahead to alert the radiologist on duty that a wet read is needed from L&D OR.

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In the Event of a MISCOUNT (continued):

• The radiologist on duty will review the film or the digital images of the X-Ray and will call the specified OR with the results of their examination or with a request for additional views to be obtained.

• The elapsed time should never be greater than twenty minutes.

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Vaginal Delivery Considerations:

• The Sponge ACCOUNTing process will also be carried over to our Vaginal deliveries.

• The vagina is the ‘open’ wound for vaginal deliveries.

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Vaginal Delivery Considerations (continued):

Some small changes:

• Now there will be only ten Raytec provided with a Vaginal Delivery table.

• There will be a small Dry-Erase board in each Delivery Suite for the nurse to record the Sponge count.

• There will be a clear plastic lined kick bucket in each Delivery Suite.

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Vaginal Delivery Considerations (continued):

There will be three counts verified throughout the delivery:

• IN Count

• Closing Count

• Final Count

Labor & Delivery LDR Sponge ACCOUNTingRoom #: Date: Visualized/

Verified?Patient Initials:

Sponges Quantity In Count

Closing Count

Final Count

Raytec

Lap Sponge

Needles

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Vaginal Delivery Sponge ACCOUNTing Process:

IN COUNT • Documentation on the Dry-Erase board of

the initial count of Raytec (ten included in pack will be the standard).

• If manufacturer error found, then the package should be discarded.

(Performed by the Delivery Nurse).

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Vaginal Delivery Sponge ACCOUNTing Process:

CLOSING COUNT • “Pause for the Gauze” • The Delivery Provider performs a

Methodical Wound Exam of the vagina to search for any remaining sponges.

• This will be performed after the delivery of the placenta. Once the count is verified, the Provider can continue with any laceration/ipis repair.(Exchange of information between the Provider and the nurse).

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Vaginal Delivery Sponge ACCOUNTing Process:

FINAL COUNT • This is the ‘Verification step’• The Delivery provider says “Show

Me” and looks at the Sponge Holder.

• Then in the Delivery Record, the nurse will document that the ‘Provider and RN verified the count.’ The Delivery note by the Provider should reflect that a MWE was performed.

(Exchange of information between the Delivery Provider and the nurse).

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HOW DO YOU MEASURE SUCCESS?

• Systematic implementation

• Patient centered care - every case, every patient, every time

• Working together for the patient’s best interest

• Goal is ZERO retained sponges in ‘10!

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Zero Retained Sponges in 2010!

The End!