The Surgical Count in Perioperative Nursing - Research Paper Example

?The Surgical Count in Perioperative Nursing (Evidence-Based Practice and Applied Nursing Research) Can you imagine a person living with a surgical instrument like sponge or adson tissue forceps negligently left inside his body after an appendectomy surgical procedure? This may sound strange but evidence of research and studies proved that incidence of retained sponges and instruments (RSI) happen. This paper presents the observed conformity of evidence-based practice on surgical counts procedure with respect to applied nursing research, taking into consideration the observations and experiences I earned during my actual clinical exposure in a healthcare facility’s operating room (OR) setting where surgical procedure is done. It aims to identify any observed flaws in the procedure base on my personal observation and to determine the common causes of discrepancies in surgical counts in spite of the strict adherence to a standardized guideline adaptable in international surgical settings. To begin with, surgical counts, according to Spry (2005, p. 168), is the “counting of sponges, sharps such as blades and needles, and instruments that are opened and delivered to the field for use during surgery.” The International Federation of Perioperative Nurses (IFPN n.d.) provided the basis for the surgical count practice in order to promote safe, quality perioperative patient care internationally, that is intended to standardize sponge, sharp and instrument counts and includes basic principles as guidelines adaptable in surgical settings internationally. The certified surgical technologist and the circulator (circulating nurse) are responsible in the proper performance of surgical count (Association of Surgical Technologists 2006), but according to Belton and Berter (2004), either a surgical technician or a registered nurse can fill the scrub nurse role in performing the surgical count after surgical hand scrub and aseptically donned a surgical gown and gloves. The surgical count is done to ensure that all items used during the surgical procedure are removed and can be accounted for completion of the procedure (Hamlin, Richardson-Tench, & Davies 2009, p. 88). All surgical items delivered to the sterile field prior to the incision and during the actual surgery are reconciled for completeness to the inventoried items after the end of the surgery (Spry 2005, p. 168). Moreover, the surgical count plays a vital role in enabling the perioperative practitioner and surgical team to enhance the patient’s safety (Rothrock 2002). Rothrock emphasized that surgical items used by the surgical team in performing invasive procedures are foreign bodies to the patient and must be accounted for at all times to prevent retention and injury to the patient. The International Federation of Perioperative Nurses (2009) or IFPN promulgated the general guidelines in surgical count covering surgical count standards as to general criteria, sponge count, sharp count, instrument count, documentation, and count discrepancies. This guideline established by the IFPN (n.d.) was conformed by the Australian College of Operating Room Nurses (ACORN), Association for Perioperative Registered Nurses (AORN), National Association of Theatre Nurses (NATN), Operating Room Nurses Association of Canada (ORNAC), and South African Theatre Nurse (SATS). In spite of the crucial adherence to standardized surgical count procedure, there were evidences showing that discrepancies exist. According to Greenberg, Regenbogen, Lipsitz, Diaz-Flores, and Gawande (2008), “one in 8 surgical cases involves a surgical discrepancy in the count; the majority of which were unaccounted-for sponges and instruments, representing potential retained sponges and instruments.” In the report of amednews staff Kevin B. O’Reilly (September 2008), he stated that “While cases of retained foreign objects are rare, discrepancies in counts happen in 13% of surgeries, according to an August Annals of Surgery study.” O’Reilly (2008), as he cited the Annals of Surgery study, said that most discrepancies happen when nurses or surgical technologists misplaced items in the operating room, usually sponges, and it takes an average of 13 minutes to resolve this problem. Doctors Verna Gibbs and Andrew Auerbach (n.d.) of University of California, San Francisco School of Medicine, also supported some evidences cited from various studies about the prevalence of retained sponge and instrument in perioperative procedures. According to the review of these authors, “one study from a medical malpractice insurance company reported 40 cases in a 7-year period, or about 1% of all claims.” Another review of its prevalence ranging from 1/100 to 1/5000, and an associated mortality ranging from 11 to 35% (Gibbs & Auerbach n.d.). Consequently, due to the lengthy complete surgical count guideline of the IFPN, it shall be noted that only the general criteria will be presented on this paper and the analysis will focus on parts of the guideline which I have observed as often neglected by perioerative nurse during my actual OR duty. The following are stipulated in the general criteria of IFPN standard surgical count: (1) Each facility should have a policy and procedure of surgical counts that specify: when counts should be performed, by whom, items to be counted, documentation of counts, including incorrect counts, and any additions and deletions of counts for specified purposes according to defined risks; (2) A full count of sponges, sharps, miscellaneous items, and instruments shall be performed when peritoneal, retro peritoneal, pelvic, and thoracic cavities are entered. Counts should be done for any procedure in which sponges, sharps, miscellaneous items, and instruments could be retained in the surgical patient; (3) The registered nurse is accountable for counts during the surgical procedure; (4) Count procedure should be performed by two persons (scrub and circulating nurse), one of whom shall be a registered nurse; (5) In the absence of the scrub nurse, the count should be done by the surgeon and circulating nurse; (6) An interrupted count shall be recommenced; (7) When one of two count partners is changed, a complete count shall be performed; (8) Items are counted audibly and correctly as viewed; (9) All items should be separated during a count; (10) Count should be done in the same sequence as sponges, sharps, miscellaneous items, and instruments at the surgical site and immediate area, the mayo stand, the back table, and the discarded items; (11) Additional items during the procedure shall be counted and recorded immediately; (12) Count sheets are included in the patient’s record; (13) The scrub nurse should be aware of the locations of all items throughout the procedure; (14) No items shall be removed from the OR until the final correct count is completed; (15) Results of counts are audibly announced to the surgeon who verbally acknowledges the count; (16) In case of reopened incision, closure count shall be taken again; and (17) If a count cannot be performed, an X-ray should be taken prior to patient leaving the OR if permissible or possible (IFPN Guideline n.d.). In IFPN (n.d.) surgical count guideline for sponges (gauze, laparotomy sponges, cottonoids, peanuts, dissectors), the counting is done four times through the entire surgical case: (1) before the start of the procedure; (2) before closure of a cavity within a cavity; (3) before wound closure at first layer; and (4) at skin closure. In my OR observation, there were times that the counting was only done 3 times instead of four. Soiled sponges, according to IFPN guideline, should be discarded off the sterile field but I realized an irony on this part because the scrub nurse should maintain strict sterility during the entire procedure and if soiled sponges are discarded off the sterile field, either one of the two requisites in OR protocol will be impaired: (1) if the scrub nurse will get the soiled sponge for counting, it would impair his/her sterility, and (2) if the nurse will maintain sterility and just imagine the number of soiled sponges without physically counting it, there would be a greater possibility of counting error. In the surgical count for sharps (needles, suture and hypodermic, blades, safety pins), the IFPN guideline is the same with sponges being counted four times during the entire surgical case. Based on my actual OR experience, no major circumstance of breaking the guideline was noted except on the part where, according to IFPN, a package of multiple suture needles should be verified with the circulator once opened, as this is sometimes not done in the actual setting. For instrument count, this is done twice: (1) before the start of the procedure, and (2) before wound closure. The guideline was followed correctly in the actual setting. In conclusion, I have observed that most surgical procedure of the OR team in the healthcare facility I have worked with were in conformity to the IFPN surgical count standard. The only conflict I have observed with the IFPN standard is on the surgical count of sponges where soiled sponges are discarded off the sterile area and this creates confusion because the scrub nurse who is responsible for the counting of sponges is the same person who will supposedly count the soiled discarded sponges but which are already located on a non-sterile area. Thus, either sterility or correctness of count is more likely to be impaired in this conflicting guideline. Because of this observation, suggested that there shall be an in-depth investigation of study on this specific area of concern to ascertain if, indeed, this conflicting portion of the guideline is attributable to the common discrepancies of retained sponge and instrument cases in perioperative procedures. Overall, strict adherence to the IFPN surgical count guideline must be observed in all perioperative cases to uphold patient safety. References Association of Surgical Technologists. (2006). Recommended standard of practice for counts. Retrieved from http://www.ast.org/pdf/Standards_of_Practice/RSOP_Counts.pdf Belton, L., & Berter, B. (2004). Perioperative nursing. Retrieved from http://www.nsna.org/pdf/career/Berter4.pdf Gibbs, V.C., & Auerbach, A.D. (n.d). Chapter 22: The retained surgical sponge. Agency for Healthcare Research and Quality: Archive. U.S. Department of Health and Human Services. Retrieved from http://archive.ahrq.gov/clinic/ptsafety/chap22.htm Greenberg, C.C., Regenbogen, S.E., Lipsitz, S.R., Diaz-Flores, R., & Gawande, A.A. (2008). The Frequency and Significance of Discrepancies in the Surgical Count. Annals of Surgery, 248 (2) 337-341. doi: 10.1097/SLA.0b013e318181c9a3. Retrieved from http://journals.lww.com/annalsofsurgery/Abstract/2008/08000/The_Frequency_and _Significance_of_Discrepancies_in.26.aspx Hamlin, L., Richardson-Tench, M., & Davies, M. (2009). Perioperative nursing: An introductory text, (p. 88). Chatswood, NSW: Mosby Elsevier Australia. International Federation of Perioperative Nurses (IFPN). (n.d.). 1002 Surgical Counts: IFPN Guideline for Surgical Counts – Sponges, Sharps and Instruments. Retrieved from http://www.ifpn.org.uk/guidelines/1002_Surgical_Counts.phtml O’Reilly, K.B. (2008, September). Sponges, surgical instruments miscounted in 13% of surgeries. Amednews.com. Retrieved from http://www.ama-assn.org/amednews/2008/09/22/prsc0922.htm Rothrock, J. (2002). Rothrock J in: Alexander's care of the patient in surgery. (pp. 36-37). London: Mosby. Spry, C. (2005). Essentials of perioperative nursing (3rd Ed.) (p. 168). Sadbury, MA: Jones and Bartlett Publishers, Inc. Read More