Webinar SURGICAL OBJECT SURVEILLANCE Kyung Jun, RN, MSN, CNOR January 22, 2014
TITLE Please vote for best title regarding preventing retained surgical item SOS : Surgical Object Surveillances? What Goes In Must Come Out? Seek and Sweep? FOFO: Free of Foreign Object?
OBJECTIVES Share our journey of what has worked and what has not Provide opportunity to network with other hospitals on this issue Allow time for feedback and questions
OUR JOURNEY 950 beds Teaching hospital with both faculty and private physicians Over 43 operating rooms on 8 separate locations Over 30,000 surgeries per year
EARLY ON Increased Risk Emergency surgeries Unplanned changes in procedure (e.g. intraoperative hemorrhage, code blue) Increased body-mass index Multiple surgical specialties Multiple nursing staff hand-offs Intervention Anticipate cases with high probability of RFO Call out packed items and write on the board Surgeon to surgeon report RN to RN report using SBAR Sweep or Peep (visual/manual inspection of site) prior to closure X-ray For incorrect count or missing item Inform radiologist: item in question, operative area, drains, and lines Radiologist must speak to the Surgeon to convey the result Do not close skin until x-ray is negative Surgery end time is defined as last stitch in Adapted from Gawande, Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2009; 35 (3): 229-35
HISTORY In 2008, had a peak in RSI Initiated RFO Oversight Committee Importance of Oversight Committee Multidiscipline Physician & nurse involvement PI facilitator keep project on tract Aimed to achieve goal within 12-18 months
PERFORMANCE MEASURE: NEVER 27 EVENTS- RFO COMMITEE/OWNER: OPERATING ROOM CONCLUSIONS/RECOMMENDATIONS Standardize the White Board List all countable items RFO Squad: TOC for 3 months Eliminate confusion over Xray criteria by changing requirements for xray to 1) incorrect count 2) inability to count 3) when member of the team requests it 4) bring back patients with packed laps Check Out Process pause, MD/RN/ST account for all items, methodical wound exploration ACTION PLAN/FOLLOW-UP Complete standardizing White Board Present Check Out Process to RFO Oversight Committee Involve MD/RN committee and UPC on Check Out process Finalize decisions on instrument count protocol Continue RFO Class Separate out all instruments used from fascia to skin closure and reconcile at end
# of RFOs PERFORMANCE MEASURE: NEVER 27 EVENTS- RFO COMMITEE/OWNER: OPERATING ROOM 2 1 0 RFO Oversight CTE OR RFO CTE Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09 Never 27 Events (RFO) Target 0
TASK FORCE STRUCTURE Clinical Improvement Committee RFO Taskforce Oversight Committee (Meets Monthly) RFO Integration Team RFO Prevention in the O.R. Team Leaders: OB, MD, Surgery, MD, OR, RN RFO Prevention in other Procedural Areas Team Leaders: ED, MD Medicine, MD Med-Surg. Adm., RN New Technology to Prevent RFO Team Leaders: Surgery, MD Clinical Engineering Education & Communication Team Leaders: OB, MD Nursing Adm. PhD Nursing Ed.
Zero RFOs in the Operating Room Team Leaders: OB, MD OR, RN Surgery, MD PI Facilitator: Team Members: Nursing OR, RN Nursing adm., RN Nursing OB, RN Nursing OR, RN Surgery, MD Trauma, MD Ortho Surgery, MD Surgery, MD ID MD, MD Surgery, MD Team Members: Medicine, MD OBGYN, MD Surgery, MD OBGYN, MD Nursing OR, RN OBGYN, MD OBGYN, MD Surgery, MD Team Charge - Review & analyze the effectiveness of the current CSMC RFO prevention process in the OR - Critical evaluation of the current count practice along with distracting factors - Highlight prevention gaps and offer recommendations - Test recommendations and implement improvements
SURVEY 12 questions to test staff, surgeons, and anesthesiologists knowledge about the count process, when to take an x-ray and to get input on what we need to change Survey sent to OR nurses, techs, surgeons, OBGYN, anesthesiologists, interventionalists
SURVEY Most valuable questions asked were: What distractions interfere with the count? Rank 1-5 with 1 being the most distracting Multitasking Music Computer entry Too many people in the room other If you had one suggestion to reduce the risk of retained foreign objects in the OR, what would it be?
Documentation Standardization Whiteboard Standardization in the Operating Room Larger whiteboards installed First test: magnet standardization, magnets finalized on May 18 Other considerations: add permanent lines, add permanent item locations Next steps: collect feedback from the staff and follow-up on best practices from the Patient Room Whiteboard Standardization Project BEFORE AFTER
Angiocath Cottonoid fred Iodoform gauze Penrose drain Safety pins Sternal wires Umbilical tapes Cottonballs House Mayfield pins Q-tips shoestring Bulldog reels CiP Fish hooks Pacing wires Rubber band Alcohol wipes ENT gauze Hypo needles Stapler cartridge Surgical Items Vessel loop Mayfield pins Suction tips Suture boots Weck cell Shoe strings Throat packs shods Vag packs Bovie scratch Instrument caps Peanuts seprafilm
EDUCATION In-service for every one Small groups RFO Prevention Month in October Audits
PRIOR TO SURGERY Survey the room: remove labels, remove opened sutures, clear whiteboard, check kick bucket and sharps container Count instruments/ sponges/ needles BEFORE pt enters Use standardized board (needles, microneedle) no exception
COUNTING PROCESS Count from surgical field (pick up laps, open them), mayo stand, back table, to sponge counter bag Circulating RN calls out items to be counted Pick up laps, open them, insert into bag with radiopaque string visible Create distraction free environment during counts- stop the music, etc..
DURING SURGERY Keep tally of needles and sponges throughout case NO ST and RN should break at the same time Only primary circulator gives countable item Use Sponge counter bags (5 laps with blue tag showing, 10 raytecs)
SPONGE COUNTER BAGS Must use for every case (no exception) Show blue radiopaque tags 5 laps; 10 raytecs show me Pass off all sponges and raytecs to fill the sponge counter bags See it; touch it; open it; feel it
Show Me from Dr Verna Gibbs
X-RAY X-ray criteria Incorrect count After removal of packed sponges Inability to count for any reason When a member of surgical team requests it
Avoid cutting cottonoids, tapes, and sponges Tapes, cottonoids are cut, all portions must be accounted for When cutting gauze, vag pack and molding cotton or others, have a count of 5 s Put this on the board PACKED ITEMS When packing (throat, abdomen, chest, vagina) put this on the board Other methods (clamp on your gown)
INSTRUMENTS Count done by RN & ST for open cavity and vaginal cases RN/ST count BEFORE the patient enters room: nurse with protocol reads, ST counts Instrument count should be included in the FINAL count Most commonly left item: sponge, needle, clamps, retractors, malleable
Surgeons busy operating JOINT ACCOUNTABILITY Accounting was sole nursing responsibility Must have joint accountability through Check Out Methodical Wound Exam Count uninterrupted Closing suture
Defining Methodical Wound Examination A methodical wound examination is necessary to prevent RFO Minimum requirements for a methodical wound exam: Space to be closed must be carefully examined Special focus should be given to closure of a cavity within a cavity (heart, major vessel, stomach, bladder, uterus, vagina) Strive to see & touch reliance on one element of sensory perception is insufficient Look and feel in the recesses of the wound and examine under fatty protuberances and soft-tissues appendages If the surgeon is informed of a missing object, while the OR staff are looking for the surgical item, the surgeon should stop closing & repeat the methodical wound exam We need your help to define the methodical wound exam in your discipline Goal: define methodical wound exam for each discipline
Defining Methodical Wound Examination Goal: define methodical wound exam for each discipline Samples Abdomen and Pelvis Definition should not be complicated. Definition must be easy to remember while in the OR.
Defining Methodical Wound Examination Goal: define methodical wound exam for each discipline Samples Mediastinum or Thorax Definition should not be complicated. Definition must be easy to remember while in the OR.
PAUSE for the Check Out! Process Start: Surgeon announces he / she is ready to close Surgeon Perform methodical wound examination Verbally attest to completion of wound exam Close wound Nurse & Scrub Tech Perform sponge and sharps accounting Verbally attest to completion of sponge and sharps accounting Perform instrument accounting Process End: Nurse documents completion of the Check Out process
BROKEN INSTRUMENTS X-ray must be taken if broken inside patient Chain of command Midas: name of item, manufacturer, catalog number, lot number, contact person for company
RFO X-ray Test of Change X-Ray Requested in OR Contact Radiology X-Ray Performed Image Read Results Communicated When Should x-ray be called? Steps: Steps: Steps: Steps: Incorrect count Inability to count Significant deviation from planned surgery When any team member has a concern Before final wound closure for wounds previously intentionally left open or packed Call Imaging at 3-3825 Communicate the following information: 1. Patient location: floor and room # 2. Attending Surgeon 3. OR phone # 4. Missing item, be specific 5. Area of the body to image, general location of the RFO X-ray the patient X-ray a sample of the missing item Technologist will not leave the OR until image results are available Perform additional views as needed Image must be read by a staff radiologist Nurse will bring up image in the OR Attending Surgeon to remain in the OR and view the electronic image Radiology extension 3 - XXXX Attending Surgeon and Staff Radiologist to speak directly while simultaneously viewing the image Discuss image results and next steps Exception: patient is in extremis 6. Items that will show up on the image that should be in the patient (drains, pacemaker, clips, etc)
RFO X-ray Process
X-RAY Criteria Inability to count for any reason When an item is unaccounted for After packed item is removed When anyone requests it
Technology Evaluation (2010) Counts High Tech Option Status Instruments X-ray time consuming, dollar impact, not always a reliable method of detection Sponges Wand (RF Surgical) Pilot to begin Jun 2 20 wands to be tested on 3 OR, 5 OR, 6OR Meeting on May 21 st to determine needed supplies Barcode (Surgicount) Wand + Bucket (Clearcount) Focus groups did not endorse this product Question as to whether they can handle our size Needles No high-tech option available
Surgical Safety Checklist Before induction of anesthesia Before skin incision Before wound closure Sign In Time Out Check out Patient has confirmed: Site Marked / Not Applicable Anesthesia Safety Checklist Completed Pulse Oximeter on Patient & Functioning Known Allergy? No Yes No Identity Site Procedure Consent Does Patient Have: Difficult Airway / Aspiration Risk? Yes, and equipment / assistance available Risk of > 500ML Blood Loss? No Yes, and adequate intravenous access and fluids planned Do you have a specific concerns to note prior to the procedure? Confirm all team members have introduced themselves by name and role Surgeon, Anesthesia Professional, and Nurse Verbally Confirm: Patient Site Procedure Anticipated Critical Events Surgeon reviews: what are the critical or unexpected steps, operative duration, anticipated blood loss? Anesthesiologist reviews: are there any patient-specific concerns? Nursing Team reviews: has sterility (including indicator results) been confirmed? Are there equipment issues or any concerns? Has antibiotic prophylaxis been given within the last 60 minutes? Yes Not Applicable Is essential imaging displayed? Yes Not Applicable Surgeon performs methodical wound exam Surgeon verbally attests to completion of methodical wound exam Nurse and Scrub Tech perform sponge and sharp accounting Nurse verbally attests to completion of sponge and sharp accounting Visual inspection of sponge tree Surgeon begins wound closure Nurse and Scrub Tech perform instrument accounting Sign out Name of the procedure recorded Sponge and sharp counts are correct Instrument counts are correct Not Applicable (spine, hip case) Yes Nurse verbally confirms: How the specimen is labeled (including patient name) Whether there are any equipment problems to be addressed Surgeon, Anesthesiologist, and Nurse review the key concerns for recovery and management of this patient
RFO PREVENTION AUDIT 1. survey room: check sharp container, pharm bin, kick bucket, clear board, remove all labels 3. keep sponge counter bags up 4. The Check Out Addressed the following: a. Pause by all b. Count by RN and ST c. Methodical Wound Exploration by MD d. Attestation of count status by RN e. Attestation of MWE by MD 5. Include instrument count at final count for open cavity and vaginal case 6. Protocol sheet used for instrument count 7. "Show Me"- fill all spaces in sponge counter bags and show MD YES NO N/A COMMENTS YES NO N/A COMMENTS YES NO N/A COMMENTS Date: Date: Date Unit/Rm: Unit/Rm: Unit/Rm Physician : Physician: Physician: Circulating RN Circulating RN Observed MRN: MRN: MRN: Audit #1 Audit #2 Audit #3
WHERE ARE WE NOW Process of looking at other retained items (guide-wires, Always audit everything Sponge counter bags Methodical Wound Exam Study trends of near misses When are we doing x-rays Hand offs
DAYS WITHOUT RETAINED SPONGE 797