Consensus Reports and Recommendations to Prevent Retained Surgical Items

Transcription

1 Consensus Reports and Recommendations to Prevent Retained Surgical Items Summary by the Institute for Population Health Improvement, UC Davis Health System Category Items included in surgical count When counts are performed Sponges/soft goods [1-9], sharps [1-8], misc. items [1-8], instruments [1-5, 7, 8] Prior to procedure: -When instruments/sponges are opened [5] -Baseline (before patient enters surgical suite) [2-5, 7, 8] During procedure: -Before closure of a cavity within a cavity [2-5, 7, 8] -Before wound closure [2-5, 7-9] End of procedure: -Final (post-procedure) [3-5, 7, 8] Additional counts performed: -Any time any team member has concern over the accuracy of the count [3, 4, 6, 8] -If any additional items are added to the field intra-operatively [2-4, 6, 7] -When closure of a wound is temporarily delayed [8] -When there is a permanent change in the circulating RN or scrub person [2-4, 6-8] -When temporary implants or packing are used [8] -When a wound is closed temporarily with a non-radiopaque item [8] -Immediately before delivery pack is used [6] -At the end of delivery [6] Counting procedure Count and record: -Two individuals (e.g., circulating RN and scrub technician) directly view items and count audibly [2, 5-8] -Documentation of all counts on whiteboard or visible format [3, 4, 6, 8] -Surgeon must receive verbal confirmation of correct or incorrect counts [2, 3] -Time-out during final count [5] Order of count: -Order of item counting sequence is standardized [2-5, 7, 8] -Counts begin at surgical field and move away from patient [8], e.g., surgical field, Mayo stand, back table, round basin, kick bucket(s), discarded/bagged sponges [2-4] -Order of counting of types of sponges should be standardized (e.g., smallest to largest) [2] 1

2 Item management during the count: -Sponges/soft goods separated, un-balled and counted individually [2, 6, 8] -Sponges should be placed in clear bag while performing final counts [4, 5] -Sponges/soft goods have visual verification that radiographic detectible indicator is present [6, 8] -Instruments are counted in sets [4, 8] -Use of numbered sponges and instruments [4, 5] -Used sharps are placed into needle box and counted [4, 6] -Soft goods used as therapeutic packing should be communicated and have standard practice for eventual removal [4, 7] -Facility has process for managing precipitous deliveries [4, 6] Management of surgical items Requirements: -Use of radiopaque items only [1-3, 5-7, 9] -Use of preformatted whiteboard for counts [4, 8] -Kick buckets/receptacles should be lined with clear plastic bags [4] Maintenance and instructions for use: -Instruments and sharps are to be inspected for broken or missing pieces [4, 6-8] -Sponges/soft goods should not be altered or cut in any way [2-4, 7, 9] -Radiopaque items/sponges should not be used for dressing [2, 4] -Prepackaged sterile items should be counted using standard practices prior to use, not assumed to be correctly counted [3] Post-procedure management: -All counted items must remain in surgical suite until counts are reconciled [2-8] -Any counted items accompanying patient out of surgical suite should be communicated and documented [6-8] -All counted items must be removed from surgical suite after all counts are reconciled [2, 3, 6, 8] -Whiteboard cleaned at end of procedure [8] 2

3 Required documentation When a count may be waived -All counts [1, 3, 6-8] -Specific information: types of counts, number of each item, names and titles of surgical team members performing counts, results of counts [2] -Count results as correct, incorrect, or miscount (discrepancy during an interim count but reconciled by final count) [4] -Any items added to surgical field [3, 8] -Actions taken to reconcile count discrepancy [1, 2, 4, 6, 7] -Explanation for counts not performed [2, 4] -Relief personnel [3] -Items and instructions for items left as packing or remaining in patient after procedure [1, 6, 8] -Defects or packaging error of surgical items, medical device or instrument fragments [4] Situational determination: -Suspension of protocol in life-threatening situations [1] -Facility defined situations (e.g., cystoscopy and ophthalmology procedures) [2] -Emergency procedures (e.g., trauma, abdominal aortic aneurysm, Cesarean section) [2, 3] -Procedures that utilize a large number of surgical items that prohibits an expeditious and timely count (e.g., major joint replacement) [3] Interventional radiology procedures only: -If a thorough visual and tactile search of the incision or cavity is completed, no count is required [9] Recommendation for imaging: -If patient condition does not permit counting, perioperative and further postoperative imaging should be taken [6, 8] For instrument counts only: -Facility defined situations (e.g., complex procedure involving a large number of instruments, trauma, procedures requiring large number of instruments with small parts, and procedures where the incision is too small to retain an instrument) [7] Methodical wound examination Wound exploration: -Required prior to closure of wound [1, 3-5, 8, 9, 16] -Required in the case of an incorrect count [2, 7] -Genital tract explored in case of incorrect count [6] 3

4 Count discrepancy protocol Notification: -Circulator or scrub nurse reports number and type of item missing to surgical team [2, 4, 6-8] Search: -Wound closure suspended [3, 4, 7, 8] -Wound/cavity exploration is performed [2-4, 6-8] -Manual and visual inspection of sterile field and surgical suite is conducted [2-4, 6-8] -Count is repeated and verified [6, 8] Recommendation for further measures: -Imaging obtained if count remains incorrect [2-4, 6-8] Imaging requirements During procedure, portable intraoperative imaging required prior to wound closure if: -Incorrect count [2-4, 6, 7] -Patient condition does not allow for count [3, 4, 6, 8] -Surgical team member has concerns about count accuracy [6, 8] -Initial sponge count could not be performed (e.g., in emergency procedure) [2] -High risk for RSIs (e.g., emergency procedures in a body cavity, more than one team involved, nursing staff change, blood transfusions >4 units red blood cells, morbidly obese patients, bariatric patients, long procedures, conversion from laparoscopic to open) [3, 5] -Procedure utilizes large number of surgical items that prohibits an expeditious and timely count [3] -Wound closure delay [8] -Open wound packing [8] After procedure, postoperative imaging required if: -Not necessary if counts are reconciled [8] -Closing radiography recommended for all patients [5] -Patient condition does not allow for intraoperative imaging [6, 8] -Entire anatomic area was not included in portable imaging [6, 8] -Intraoperative imaging failed to locate the item [4, 6, 8] Interventional radiology procedures only: -Fluoroscopy required if visual and tactile search cannot be performed or there s concern of possible retention of a needle or instrument [9] Specific requirements for imaging: -Imaging requests must be sent to the radiologist with detailed information [2-4, 7, 8] 4

5 -Information includes: number and type of missing item, patient location and status, callback number and physician name [6, 7] -Radiologist must obtain, process and make available the imaging within 30 minutes of the request [3, 4, 7, 8] -Radiologist provides results and two views of the region for each imaging request looking for a missing item [4] -Mechanism of communication between radiologist and surgical suite necessary [3, 8] -Post-delivery imaging required if a count is not reconciled [6] Adjunct technology suggested Safe environment Ongoing education Policies and procedures -Radiofrequency identification (RFID) systems [1, 4, 5] -Computer assisted counting method (e.g., bar coding) [1, 4, 5, 7] -Maintain optimal focused surgical environment free of distractions and interruptions [1] -Promote and maintain collaborative and ethical work environment [5] -Develop a staff education model with ongoing training and feedback for OR staff consistent with national criteria [4-7] -Policies and procedures for preventing RSIs should be developed, monitored, measured, reviewed, revised, and readily available [1, 4, 6, 7] 5

6 References 1. American College of Surgeons, [ST-51] Statement on the prevention of retained foreign bodies after surgery, in Bulletin of the American College of Surgeons, 2005, American College of Surgeons. 2. AST Education and Professional Standards Committee, Recommended Standard of Practice for Counts, 2006, Association of Surgical Technologists. 3. Veterans Health Administration, Prevention of Retained Surgical Items, in VHA Directive, 2010, Veterans Health Administration: Washington, DC. 4. Gibbs, V.C., NoThing Left Behind: Prevention of Retained Surgical Items Multistakeholder Policy v5, 2013, NoThing Left Behind. 5. Agency for Healthcare Research and Quality, PSI 5: Foreign Body Left in During Procedure, in AHRQ Quality Indicators Toolkit, 2011, Agency for Healthcare Research and Quality. 6. Institute for Clinical Systems Improvement, Prevention of Unintentionally Retained Foreign Objects During Vaginal Deliveries, in Health Care Protocol, 2012, Institute for Clinical Systems Improvement. 7. Association of perioperative Registered Nurses, Recommended Practices for Prevention of Retained Surgical Items, in Perioperative Standards and Recommended Practices, R. Conner, et al., editors. 2012, AORN, Inc.: Denver, CO. p Institute for Clinical Systems Improvement, Prevention of unintentionally retained foreign objects in sugery, in Health Care Protocol, 2007, Institute for Clinical Systems Improvement. p Statler, J.D., et al., Society of Interventional Radiology position statement: prevention of unintentionally retained foreign bodies during interventional radiology procedures. J Vasc Interv Radiol, (11): p Egorova, N.N., et al., Managing the prevention of retained surgical instruments: what is the value of counting? Ann Surg, (1): p Lutgendorf, M.A., et al., Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery. Mil Med, (6): p Garry, D.J., S. Asanjarani, and D.M. Geiss, Policy for prevention of a retained sponge after vaginal delivery. Case Rep Med, : p Kaiser, C.W., et al., The retained surgical sponge. Ann Surg, (1): p Greenberg, C.C., et al., The frequency and significance of discrepancies in the surgical count. Ann Surg, (2): p France, D.J., et al., Emergency physicians' behaviors and workload in the presence of an electronic whiteboard. Int J Med Inform, (10): p Whang, G., et al., Left behind: unintentionally retained surgically placed foreign bodies and how to reduce their incidence--pictorial review. AJR Am J Roentgenol, (6 Suppl): p. S