Instrument counts:Controversial, but vital
One of the best ways to avoid surgical incidents is instrument counts, same-day surgery experts agree. However, instrument counts are controversial. Same-day surgery programs report that they aren’t doing them for all cases, such as ones involving complex instrument sets and laparoscopic procedures.
"AORN would not recommend that practice because, even on a lap chole, even though practitioners are becoming quite adept at doing those procedures now, there is possibility of having to open," says Ramona Conner, RN, MSN, perioperative nursing specialist at the Association of periOperative Registered Nurses (AORN) in Denver.
If you haven’t done an initial count, and you have an open wound, you won’t know for certain whether you’ve inadvertently left an instrument in the open wound, Connor emphasizes.
Hundreds of items to count
In the outpatient setting, instrument counts often are avoided with complex procedures, such as fracture fixations. "There could be hundreds of items in one instrument set," Connor acknowledges.
However, the number of instruments doesn’t let providers off the hook, she emphasizes. "It’s absolutely critical that you do an instrument count to avoid accidentally leaving an instrument in the surgical wound," Connor says. Consider these suggestions:
• Establish systems for instrument sets.
"Facilities that haven’t set up an efficient system for setting up the instrument sets to begin with, and inventorying that set, and a routine method of setting up the same way every time, those are facilities that struggle most with instrument counts," Connor says. Use a preprinted instrument count sheet, she advises. "It’s set up in the same sequence every time."
When the set arrives at the field, the scrub nurse and circulator follow the order on the preprinted sheet to count instruments. At closing, they follow the same order to count. When the instruments go to the decontamination area, personnel in the instrument room can use that same count sheet to verify they received the same instruments they sent out, Connor says. "It’s not only a good inventory control system, but a good checks and balance for the instrument count itself," she says.
• Count instruments in all procedures in which there is the likelihood that an instrument could be retained.
You should count instruments with any procedure that is open or could become open, Connor advises. "Some choose to do instrument counts on every procedure for inventory control."
Regardless of the type of procedure, however, staff should perform sponge and sharp counts, she says. "It’s possible to leave a suture needle, or a portion of a suture needle, which could break off inside the wound," Connor points out.
In some cases, such as ophthalmology cases, suture needles are fine and difficult to keep track of, she says. Counts ensure patient and employee safety, she emphasizes. (See AORN’s policy on counts, inserted in this issue.)
• Establish a system for count discrepancies.
When a discrepancy occurs in the count, notify the surgeon, Connor says. Next, search the immediate field, while the surgeon checks the wound. Next, expand the search to the floor, wastebasket, etc.
When the search is completed without finding the missing item, notify surgeons and X-ray before the patient leaves the OR, Connor says. "If you do locate the item inside the wound, the patient can be reopened, and the item retrieved, without subjecting the patient to additional surgery and anesthesia," Connor says.
Count practices need to be clearly defined and distributed to surgeons and staff, she advises. And be consistent in your practice, she emphasizes. "In other words, you can’t do the procedure for one surgeon and not another," she says.
For more information on instrument counts, contact:
• Ramona Conner, RN, MSN, Perioperative Nursing Specialist, Association of periOperative Registered Nurses, 2170 S. Parker Road, Denver, CO 80231. Telephone: (800) 755-2676. Fax: 303-338-5165. E-mail: [email protected].
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