Overview/Procedure Description
It is essential for the safety of the patient that a national standard for counting procedures be employed.
Accountable items are instruments and other items, which by their nature are at risk of being retained in the patient and require mandatory documentation.2
If there is no possibility of an item being retained a surgical count does not need to be performed. Both nurses responsible for the count must agree that a count is not required and the surgeon and operative team must be informed that no count will be completed for that procedure.
Definition of Terms
Surgical Count: the process of counting any item that may however remote be retained in a patient during a surgical procedure.
ORMIS: Operating Room Management System – computerised log.
Accountable items – includes but are not limited to:
- Absorbent items including sponges, raytec swabs, patties, peanuts, strolls, cotton wool balls, prep balls
- Sharps including atraumatic needles, detachable blades, diathermy tips, hypodermic needles including caps, plegia needles
- Vascular items including vessel loops, snuggers, cardiac snares, tapes, ligareels, ligaboots, clip cartridges and disposable bulldog clamps
- Rubber bandsSurgical catheters such as feeding tubes that are not intended to be left as drains
- Additional and parts of instruments (including loan instruments)
- Disposable instruments such as suckers
- Disposable retraction devices such as fishhooks and visceral retractors.
Note: Due to the rapidly changing technology in procedural and peri-operative environment – items accounted for should not be limited to those outlined in this procedure.
If you think an item should be counted then do so.
Procedure Details
All accountable items that are used during surgical procedure shall be handled in a manner that reduces the risk of the item being retained. Disposable, accountable items shall comply with Australian standards.
- Sponges and swabs etc., shall be radio opaque.
- Raytec detectable items shall never be used as dressing.
- Accountable items shall never be cut.
- Accountable items should never be used for wrapping article for sterilisation.
- Green gauze swabs (unsterile) to be used by the anaesthetic team and shall not be taken on to the sterile instrument trolley.
- White gauze (sterile without x-ray detectable marker) may be used by the anaesthetic team. If used for the surgical dressings they should be opened at completion of final count.
- Surgical dressing shall not be opened onto the sterile field until after incisions are closed or the final count
The nurses shall:
- Use paper based intraoperative record MR810/AEnsure that two nurses, one of whom shall be a registered nurse, perform the initial count immediately prior to the commencement of the surgical procedure.
- Count aloud and record accountable items at the commencement of the closure of any cavity or wound.
- Record on the intraoperative record MR810/A any non accountable items deliberately retained in the patient for removal at a later stage e.g. drains, dental gauze.
- Ensure that all articles remain in the operating room until the surgical procedure is completed and all counts have been performed. Should it be necessary for an item to be taken from the room intraoperatively e.g. with a specimen, then a notation is made on the intraoperative record MR810/APerform and document any additional counts at the discretion of the instrument or circulating nurse.
- Notify the surgeon and the operative team of the outcome of each closure count including any discrepanciesDocument and sign the outcome of the counts.
- Where no accountable items are used the words ‘no count required’ are written and signed on the intraoperative record MR810/A
- The circulating and instrument nurse shall be accountable for the surgical count
Two nurses perform the surgical count, one of whom shall be a RN. Whenever possible the same two nurses retain responsibility for all surgical counts during the procedure.
If either of the nurses need to be permanently replaced during the procedure, a complete count is conducted, recorded and signed by the incoming and outgoing nurses on the intraoperative record MR810/A and a notation is made of any items that are inaccessible for counting purposes and documented on MR810/A.
ORMIS documentation must be completedShould it become necessary to relieve the circulating nurse temporarily, the relieving circulating nurse follows the standard counting procedure, signs the count sheet, initials any additions to the count and documents the time of relief on the intraoperative record on MR810/A and ORMIS. The outgoing circulating nurse will provide a concise handover of the case, before leaving.
The nurse in charge shall ensure that the instrument nurse responsible for the surgical count is not required to act as a surgical assistant in operative procedures where a body cavity is opened. If, in an emergency situation, should it become vital to do so, the surgeon shall allow time for the instrument nurse to complete the count.
The nurse shall ensure that when accountable items are deliberately retained in the patient, the number retained is recorded on the intraoperative record. The totals in the final count are minus the number left in the patient. The record shall show that the count is incorrect, however the retained items shall be documented on the comments section of the intraoperative record.
The retained items shall also be recorded in the patient’s inpatient progress notes clearly stating that these items have been deliberately retained by the surgical team and to be removed at a later date.
The nurse shall ensure that when accountable items deliberately retained in a patient are moved at a subsequent operation, the number removed is recorded on the intraoperative record. The final count reflects the addition of the items removed. The record shall show that the count is incorrect, however the removed retained items shall be documented on the comments section of the intraoperative record.
The removed retained items shall be recorded in the patient’s inpatient progress notes. Clearly stating that these retained items have been recovered and accounted for by the surgical team.
Should it become necessary to deliberately retain accountable items in the patient again, the previous steps should be followedThe nurse shall ensure that if any accountable items e.g. raytec swabs are dropped/contaminated, the items are counted and included in the count. If this occurs prior to the first count, the items shall be removed from the operating room together with their packaging
- The two nurses shall:
Utilise a tray list as a risk management and inventory toolEnsure that the contents of each tray are checkedUtilise the tray lists to confirm the presence of each item.
Ensure the list is present, on each instrument tray used and has been checked and signed off by the sterilising department prior to sterilisation. If a tray is deemed incorrect the In Charge CSSD technician is notified and a note shall be made on the check for the count procedure.
Utilise the tray list to confirm the presence of all items at the completion of the surgical procedureA tray lists must be returned to CSSD with the trays at the completion of the procedure. A tray list must include identification of the date, theatre, instrument and circulating nurse
- The instrument nurse shall:
- Ensure accountable items remain intact in their inner packaging until counted. Ensure both nurses count aloud. Recommence the count if any interruptions occurEnsure that each accountable item is separated during the count procedure. Identify the x-ray detectable marker. Counting items as per original packaging e.g. multiple packs of raytec may been counted in a running total.
- The circulating nurse shall:
Ensure that, in the event there is an incorrect number of sponges etc., in a newly opened pack the entire packet is removed from the operative field, bagged, marked appropriately and paced to one side. It is not included in the count but not removed from the operating room while the procedure is in progress. This must be returned to the manufacturer for investigation
- When simultaneous procedures are undertaken and:
More than one surgical team is involved with only one instrument nurse, one count sheet shall be used.
Two or more surgical teams are involved and two or more instrument nurses multiple individual count sheets shall be used.
However:If the proximity of the surgical sites makes it difficult to ensure separation of the two team’s instrumentation and surgical supplies then one count sheet may be used and one instrument nurse shall perform the count.
- When sequential procedures are undertaken on the same patient, or when a two stage procedure is performed, which requires two separate ‘set ups’, and:
The operating room is cleared between procedures with different ‘set ups’ being used a separate count sheet is used for each procedure. The operating room is not cleared between procedures with the same ‘set ups’ being used, instruments and other accountable items from the first stage of the procedure are isolated from the second stage and a separate count sheet is usedIf able to the nurses may perform a final count for Stage 1 and close off that procedure’s count sheet.
The Stage 1 trolley will be covered and considered unsterile and the corresponding count sheet will be separate from the second stage procedure. The accountable items shall not be removed from the operating room until all procedures have been completedIf unable to finalise the Stage 1 procedure count then the final count of the first procedure is carried over to be the first count of the second procedure and so on. The accountable items shall not be removed from the operating room until all procedures have been completed.
The circulating nurse shall ensure when a second count sheet is required for continuation of the count that the second sheet is stapled to the first and labelled ‘count continued’ and pages numbered sequentially.
- A minimum of two surgical counts (first and final) shall be performed whenever accountable items are used:
Where a body cavity is entered, an additional count shall be performed on closure of that cavityThis includes minimally invasive procedures.
Reference
ACORN Standards for Perioperative Nurses 2012-2013
S3 – Management of Accountable items used during surgery/procedures in the perioperative environment.