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Prevent the retention of accountable items - 'The Surgical Count'

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ella gamble

on 30 April 2015

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Transcript of Prevent the retention of accountable items - 'The Surgical Count'

Critically analyse the standards and research that prevent the retention of accountable items
'The Surgical Count'
By Christine Currie, Lee Edwards, Ella Gamble & Jessica Gerada
As per the ACORN standards, each hospital will develop a policy which clearly defines the procedures which require management of accountable items, clearly defines what items are classified as accountable and clearly identifies any variations to the management of accountable items. (ACORN 2014)
According to ACORN 2014-2015, a minimum of two surgical counts is required, however, when a cavity is entered an additional count needs to be performed on closure of each cavity. (ACORN 2014)
Accountable items include-
Swabs- patties, peanuts, raytec, packs
Sharps- suture needles, blades, diathermy tips
Vascular items- vascular loops, tapes, vascular clamps, clip cartridges

They are classified as foreign objects to the patient and must be accounted for at all times to prevent retention and injury to the patient (NSW Health 2013)
(ACORN 2014)(The Royal Children’s Hospital 2013)

Hospitals are encouraged to have a policy in regards to an incorrect count.

In extreme emergency situations when a count has not occurred, both instrument and circulating nurses are to inform the surgeon, attempt to complete a count when able and document the events on the count sheet (ACORN 2014)

The ACORN standards are reviewed by individuals including clinicians, researchers, managers, educators, academics and industry representatives who can give the greatest possible mix of knowledge base, perioperative competence, and experience. Evidence on each individual standard is researched and then the evidence is critically appraised. (ACORN 2014)

Post review of all of the hospital policies it has been found that all polices in fact align with the standards set by ACORN.

As all are derived from these standards.
ACORN standard “This standard provides guidance on the best practice related to the management of accountable items used during surgery/procedures in the perioperative environment”.

The Surgical Count
The surgical count is imperative to patient safety in the operating suite, It is also a legal safeguard for the surgical team. This reduces the risks of patients having retained items at the completion of the surgical procedure.
The purpose of the surgical count is to ensure that a record of all of the accountable items and instruments used during a surgical procedure in a document (hospital A, B, C, & D).
Hospital B’s had incorporated the most amount of research into there policy, This shows that their hospital count policy is the most evidenced based out of the four that were reviewed for the purpose of this assessment.

The rest of the hospitals had utilized the ACORN standard and the NSW department of health 2005 standard for handling of surgical items for the production of their surgical count policy’s.
All policies had review dates present.
Unfortunately hospital C and D are both past the revision date.
Hospital B’s policy review is due until November this year.
Hospital A had their policy last reviewed in February this year.
Many similarities were found during the reviewing of these policies.
All hospitals policy's reviewed have similar policies with recommendations for:
Purpose of the count or rationales for the count.
Counting procedure
Accountable items with examples
Subsequent counts
Emergency counts and procedures
Counting off items
The policies for hospital A, B and C are quite extensive ensuring that all areas are being covered in the surgical count and any issues that may arise during this.
Hospital D’s policies are quite broad in most areas.
Hospital B has gone into further detail outlining all the roles of the surgical team.
Hospital B’s policy is fairly lengthy.
Hospital D explained the procedures and counts required deeming when each count should be commenced in additional detail.
Detail of the policies
Hospital policies from hospital A, B, C and D have been reviewed for the purpose of this assessment.
Despite our efforts Retained Instruments still occur

Maintain and enforce surgical safety policies

Enforce a zero tolerance to defiance of policies

Developmental work required towards technology supported approaches

Consider a National Initiative
(Stawicki, Moffatt-Bruce, Ahmed, Anderson, Balija, Bernescu, 2013, p.18-19)
Radio Frequency Identification tags in packs

‘In’ Scanner unit

‘Out’ Scanner bucket

Smart Wand
‘SmartSponge System’
Retained Sponge in 3 y/o
Mass Education
Research alternative counting processes

Spongebag Containment Systems
Bar Code Technology
Radiofrequency Technology
(Norton, 2014, p.5)
Case Study & Future Technology in prevention of retained instruments
Emergency Surgery
Unexpected Changes
High Body Mass Index
Multiple Surgical Teams
Nursing Staff Changes
Communication Breakdown
Length of Surgery
(Norton, 2014, p.5)
Increased Risks for Retained Instruments
Intestinal Obstruction
(Norton, 2014, p.5)

$63,361 in medical and liability costs to the health care facility (ClearCount Medical Solutions, 2010)
Harm caused by Retained Instruments
Since implementation of ‘SmartSponge’ System, no incidents of retained sponges have occurred within the organisation
(Norton, 2014, p.6)
From January 2003 – December 2009: Total of 59 retained instrument cases
45 of these had correct final counts documented
Radiographic Imaging used in 51 of these cases prior to closure
Still 13 retained instruments occurred
Radiofrequency Tagging used in 32 of these cases prior to closure
Still 2 retained instruments occurred
(Stawicki, Moffatt-Bruce, Ahmed, Anderson, Balija, Bernescu, 2013, p.18-19)
Comparison of technology
Enforcing guidelines and hospital policies

Wound Exploration

Regular Education
(D’Lima, Sacks, Blackman, Benn, 2013, p.103)
How do we prevent Retained Instruments?
Three primary causative areas
Interruptions: Surgical requests,
Multitasking: Aiding surgical requests, preparations for closure
Distractions: Music, theatre conversations, surgical requests
(Jun, Blaha, 2012, p.35)
Causes for incorrect counts
One in every 18,000 surgeries

One in every 1,000 abdominal procedures

62-80% documented correct final counts ((Jun, Blaha, 2012, p.35)

Gauze/Sponges account for 48-69%

Abdomen most often the cavity involved (Steelman, Cullen, 2011, p.132)
Statistics of Retained Instruments
In/Out Scanner Bucket
Radiofrequency Identification Tagged Sponges
Prevention of retained surgical items, whole team responsibity
Specifically identified by WHO in 2007
Policy & Guidelines exists because known risk to patients
Will look at:
ACORN-who they are, what they do & their 'Count' recommendations
HOSPITAL POLICY-comparison between hospital policies
RESEARCH-Causes & risk factors, new technology
NATIONAL QUALITY STANDARDS-what they are, how they came about, application to the 'count' & evaluation of accreditation on patient safety
What are the ACORN Standards?
The ACORN standards provide guidelines pertaining to standard practice and expectations of specific perioperative roles

Each ACORN standard has a purpose, a background and principle (ACORN 2014)
Difficult to transfer practical experience to rigorous evidence capable of being peer reviewed
Evidence-based tools by which standards are created, circulated, strengthened, reviewed and appraised are needed
The factors that promote or act as barriers to implementation of standards was found to be lacking (Greenfield et al. 2012)
More research into healthcare accreditation needed (Hinchcliff et al. 2012) & (Braithwaite et al. 2010)
Positive relationship between accreditation and high performance of clinical performance (Braithwaite et al. 2010)
However minimum level of clinical performance are difficult to measure (Hinchcliff et al. 2012)
Patient satisfaction and hospital accreditation scores minimal relationship (Hinchcliff et al. 2012)
‘Absence of evidence is not evidence of absence’ (Hinchcliff et al. 2012, p. 987)
Began internationally in the 1970s

Accepted that these programs do improve patient safety

Anecdotally true BUT evidence base not been assembled and reviewed (Greenfield & Braithwaite 2008, p. 172)

Standards changing staff and organizational behavior is at best ambiguous

Little evidence to support the time and cost of the development, writing and implementation to the organisations (Greenfield et al. 2012, p.12)
Communication breakdown highlighted in many sentinel and adverse events both inside and outside the operating room
16% of all sentinel events were contributed too by written and verbal communication breakdown
43% contributed too by facility policies and procedures
(Australian Institute of Health and Welfare (AIHW) and Australian Commission on Safety and Quality in Health Care (ACSQHC)
WHO recognised this, stresses the importance of effective communication and clear documentation within operating rooms (World Health Organisation 2009, p. 1025)
Part of the Health Services Safety and Quality Accreditation Scheme
Endosed 2011by Health Ministers,
Compliance by 2013

8 clinical areas and 2 corporate governance (Australian Commission on Safety and Quality in Health Care (2011)

Public protection & quality of healthcare
Minimal standards across the healthcare industry & promote patient safety

Link between patient safety & accreditation difficult to prove

Standards 1 & 6 indirectly apply to surgical count as communication & adherence to policy & procedures
Standard 1: Safety & quality policies & procedures for patient safety

Standard 6: Clinical Handover both specific to the surgical count.

Great communication & teamwork vital in making the count work
The count is a form of clinical handover
(Australian Commission on Safety and Quality in Health Care 2011)
The National Safety and Quality Health Services Standards (NSQHS)
Count Specific Standards
Does accreditation work?
Does accreditation work ?
Clinical standards primarily rely on practice change (Twigg, Duffield & Evans 2013, p. 543)
Nurses play a major role in implementation, around 58% of the health practitioners registered in Australia are nurses (Australian Institute of Health and Welfare 2015)
Minimum for facilities and quality improvement tool (Australian Commission on Safety and Quality in Health Care 2011, p. 3)

External peer assessment ability to demonstrate minimum requirements (Australian Council on Healthcare Standards 2015)

Promotion of quality performance within the healthcare service (Hinchcliff et al. 2012)

Link between accreditation and safe patient care disputed (Greenfield & Braithwaite 2008
Australian College of Operating Room Nurses & Australian College of Operating Room Nurses Ltd 2012, ACORN standards for perioperative nursing: Including nursing roles, guidelines, position statements, competency standards, (new ed.), Adelaide, South Australia , Australian College of Operating Room Nurses.

ACORN 2014, 2014-2015 Acorn Standards for Perioperative Nursing, The Australian College of Operating Room Nurses Ltd, Adelaide, South Australia.

Australian Commission on Safety and Quality in Health Care, (ACSQHC) 2011, National Safety and Quality Health Service Standards, September 2012, Australian Commission on Safety and Quality in Health Care, Sydney, AUS

Australian Council on Healthcare Standards, (ACHS) 2015, What is accreditation?, Australian Council on Healthcare Standards, retrieved 15th April 2015, <http://www.achs.org.au/about-us/what-we-do/what-is-accreditation/%3E>

Australian Institute of Health and Welfare, (AIHW) 2015, Workforce: Health workforce, Australian Government, Australian Institute of Health and Welfare, retrieved 15th April 2015, <http://www.aihw.gov.au/workforce/%3E>

Australian Institute of Health and Welfare, A 2007, Sentinel events in Australian public hospitals 2004-05, Australian Institute of Health and Welfare, 13th April 2015, <http://www.aihw.gov.au/publication-detail/?id=6442468005%3E>

Braithwaite, J, Greenfield, D, Westbrook, J, Pawsey, M, Westbrook, M, Gibberd, R, Naylor, J, Nathan, S, Robinson, M, Runciman, B, Jackson, M, Travaglia, J, Johnston, B, Yen, D, McDonald, H, Low, L, Redman, S, Johnson, B, Corbett, A, Hennessy, D, Clark, J & Lancaster, J 2010, 'Health service accreditation as a predictor of clinical and organisational performance: a blinded, random, stratified study', Quality & Safety Health Care, vol. 19, no. 1, pp. 14-21.

ClearCount Medical Solutions, The SmartSponge System: The only system to count and detect sponges, Medline Industries 2010, Retrieved April 12, <www.clearcount.com/>.

D’Lima, D, Sacks, M, Blackman, W, Benn, J, 2013, ‘Surgical swab counting: a qualitative analysis from the perspective of the scrub nurse’, pp. 103-111, retrieved 13 April 2015, EBSCOhost.

Edel, E, 2012, ‘Surgical count practice variability and the potential for retained surgical items’, AORN Journal, pp 228-238, retrieved 11 April 2015, EBSCOhost.

Greenfield, D & Braithwaite, J 2008, 'Health sector accreditation research: a systematic review', International Journal for Quality in Health Care, vol. 20, no. 3, pp. 172-83.

Greenfield, D, Pawsey, M, Hinchcliff, R, Moldovan, M & Braithwaite, J 2012, 'The standard of healthcare accreditation standards: a review of empirical research underpinning their development and impact', BMC Health Services Research, vol. 12, no. 329.

Hinchcliff, R, Greenfield, D, Moldovan, M, Westbrook, J, Pawsey, M, Mumford, V & Braithwaite, J 2012, 'Narrative synthesis of health service accreditation literature', BMJ Quality & Safety, vol. 21, pp. 979-91.

Hospital A 2015, ‘Counting accountable items in the operating suite’ retrieved 2nd April 2015.

Hospital B 2012, ‘Perioperative surgical count’ retrieved 10th April 2015.

Hospital C 2012, ‘Counting of accountable items protocol’ retrieved 25th March 2015.

Hospital D 2011, ‘ Count procedure’ retrieved 1st April 2015

Jun, K, Blaha, J, 2012, ‘Avoiding retained instruments’ OR Nurse Journal, pp 34-40, retrieved 13 April 2015, EBSCOhost.

Medical Technology Association of Australia 2014, ACORN, retrieved 2nd April 2015 <http://www.mtaa.org.au/professional-development/training/acorn-standards>

Norton, E, 2014, ‘Using technology to prevent retained sponges’ AORN Connections, pp 5-6, retrieved 10 April 2015, EBSCOhost.

NSW Health 2013, Management of Instruments, Accountable Items and Other Items used for Surgery or Procedures, retrieved 2nd April 2015, <http://www0.health.nsw.gov.au/policies/pd/2013/pdf/PD2013_054.pdf>

Royal Children’s Hospital 2013, Surgical Count, retrieved 2nd April 2015, <http://www.rch.org.au/surgery/local_procedures/Surgical_Count/>

Stawicki, S, Moffatt-Bruce, S, Ahmed, H, Anderson, H, Balija, T, Bernescu, I, Chan, L, Chowayou, L, Cipolla, J, Coyle, S, Gracias, V, Gunter, O, Marchigiani, R, Martin, N, Patel, J, Seamon, M, Vagedes, E, Ellison, E, Steinberg, S, & Cook, C 2013, 'Retained surgical items: a problem yet to be solved', Journal Of The American College Of Surgeons, 216, 1, pp. 15-22, retrieved 10 April 2015, CINAHL Complete, EBSCOhost.

Steelman, V, Cullen, J, 2011, ‘Designing a safer process to prevent retained surgical sponges: A healthcare failure mode and effect analysis’ AORN Journal, pp 132-141, retrieved 18 April 2015, EBSCOhost.

Twigg, D, Duffield, C & Evans, G 2013, 'The critical role of nurses to the successful implementation of the National Safety and Quality Health Service Standards', Australian Health Review, vol. 37, no. 4, pp. 541-6.

World Health Organisation, (WHO) 2009, WHO Guildelines for Safe Surgery 2009, Geneva, Switzerland.
Surgical Count necessary for patient safety

ACORN peer created & reviewed

ACORN used by facilities

Guidelines & Policy are continuously evolving

Guidelines & Policies are only useful if staff adhere to them

(ClearCount Medical Solutions, 2010)
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