Module 6 Surgical Count PDF RPN2023

MODULE 6: Surgical Counts Suggested Readings Alexander’s Care of the Patient in Surgery (2022) p.1 8 9 - 197 ORNAC Standards 2023 Section 3: p. 3-80 – 3-97...

MODULE 6: Surgical Counts Suggested Readings Alexander’s Care of the Patient in Surgery (2022) p.1 8 9 - 197 ORNAC Standards 2023 Section 3: p. 3-80 – 3-97 Association of Perioperative Registered Nurses (AORN) 2016 Learning Outcomes Describe sponges, sharps, miscellaneous items, and instruments. Describe the surgical items that are counted for minor and major counts. Classify the required surgical counts for initial, closing, final, and changeover counts. Describe when required counts (initial, closing, final, changeover) should be performed during minor and major procedures. Explain the best practices related to surgical counts during elective, emergencies, and incorrect counts as per ORNAC Standards. The surgical count is a fundamental practice of perioperative nurses. Surgical counts are undertaken to ensure that sponges, sharps, miscellaneous items, and instruments are not retained inside the patient after surgical wound closure. All items that can potentially be left inside the wound should be counted. Institutional procedures and policies establish when and what items may be included and excluded from counts. There are variations in institutional policies related to surgical counts, but all are based on current ORNAC Standards. Surgical Items The surgical items that are counted fall under the following categories: sponges, sharps, miscellaneous items, and instruments. These items are counted and documented on the surgical count sheet. To prevent retained objects inside the patient, all surgical items shall be radiopaque. Once the initial count is completed, items shall not be removed from the OR until the final count is concluded. Laundry and garbage shall remain in the room until the final count is complete. Surgical items may be added or removed as the operation progresses. A tally of the surgical items is counted during the closing and final counts. A list of surgical items is summarized in this section. Module 6: Surgical Count Sponges - Soft goods that with absorbent materials, such as: 12x12 sponges, 4x4 gauze, 4x8 gauze, towels, peanuts or pushers, cotton, etc. Sponges should be counted in all phases of a surgical count, including but not limited to: initial, closing, and final counts. Sponges shall be radiopaque and uncut during the procedure. Sponges are counted in the same increment that they were packaged. If sponges are removed from the surgical field and count sheet, perioperative nurses shall count and bag the sponges in the same increment they were packaged. For laparotomy sponges (12x12 sponges) the scrub nurse must pull the tape/tag to verify secure attachment to the whole sponge. Small sponges, such as peanuts, shall be loaded on an instrument when they are used inside the cavity. Sharps - Cutting objects, such as: suture needles, cautery tips, hypodermic needles, and scalpel blades. Miscellaneous Items - Small items that include, but are not limited to, tip protectors, clip cartridges, ligaclip bars, vessel loops, inserts, umbilical and hernia tapes, and small endoscopic parts such as trocar sealing caps, valves, washers and any other small items. Instruments - Tools or device that are usually made of stainless steel, designed to perform a specific function, such as grasping, holding, cutting, dissecting, retracting, or suturing. The healthcare institution shall establish policies describing what instruments should be counted and under what circumstances a full instrument count is required. The surgical procedure will often determine if instruments are counted during the initial and closing counts. If the cavity is entered and the incision is greater than 10mm long, the instruments along with the sponges, sharps, and miscellaneous items will be counted for the initial and closing counts. The final count will include sponges, sharps, and miscellaneous items. Sequence of Counting Surgical Items The recommended sequence of counting the surgical items for the initial, closing, and final counts is as follows: Sponges → Sharps → Miscellaneous Items → Instruments (If applicable) Major and Minor Surgical Counts Most surgical procedures require perioperative nurses to complete 3 counts, initial, closing, and final counts. What is counted during each surgical count is dependent on the proposed procedure and institutional policies. In this section, we focus our attention to major and minor counts. Module 6: Surgical Count Minor Counts A minor count involves counting of sponges, sharps, and miscellaneous items. A minor count may also be referred to as a small count or back page count. A minor count is completed during initial, closing, and final counts if there is no risk of entry into a body cavity during the procedure. For example, breast biopsy, parathyroidectomy, and bronchoscopy only require a minor count for initial, closing, and final counts. The surgery determines whether a minor or major count is completed for the initial and closing counts. The entry into a cavity and the size of the incision determines whether a minor or major count is required for the initial and closing counts. The final count always involves a minor count. Major Count A major count involves counting sponges, sharps, miscellaneous items, and instruments. A major count may also be referred to as a full count. The surgery and its modality determine whether a minor or major count is completed for the initial and closing counts. A minor count is always completed for the final count. “Open” Procedures - A major count is completed for the initial and closing counts if there is confirmed entry into a cavity (e.g. abdomen, pericardial, pleural cavity) with a large incision greater than 10mm. The final count involves a minor/small count of the sponges, sharps, and miscellaneous items. For example, a laparotomy for bowel resection involves entry into the abdominal cavity with a large incision. This procedure will require a major/full count for initial and closing counts. A minor/small count is completed for the final count. In certain procedures, such as inguinal hernia repair, there is may be a risk for entering the cavity. Depending on the situation, the surgeon may or may not enter the abdominal cavity. In these cases, the perioperative nurses must always complete a major/full count for the initial count. If the abdominal cavity is entered, a major/full count is completed for the closing count. A minor/small count is completed for the final count. If the abdominal cavity is not entered, a minor/small count is completed for the closing count. A minor/small count is completed for the final count. Minimally-Invasive Procedures - Minimally-invasive surgery, such as laparoscopy, is a surgical modality that warrants unique surgical counts. The initial, closing, and final counts may vary depending on the size of the incisions/port sites. In laparoscopies, there is entry into the abdominal cavity, however, the incision/port sites are small, usually 5 to 10mm. There are typically 3 to 4 incisions/port sites that are 5 or 10mm long. In minimally invasive procedures such as this, there is a potential to convert to a laparotomy with a large incision greater than 10mm. In these cases, the perioperative nurses must always complete a major/full count for the initial count. If the incision is extended to a Module 6: Surgical Count laparotomy greater than 10mm, a major/full count is completed for the closing count. A minor/small count is completed for the final count. If the incisions/port sites remain small with less than 10mm, a minor/small count is completed for the closing count. A minor/small count is completed for the final count. Intraoperative Surgical Counts Counts shall be completed during certain periods of the surgical procedure. According to ORNAC Standards, counts shall be completed before the procedure (initial count), at the first layer of surgical wound closure (closing count), and skin closure when surgical items are no longer being used (final count). There are additional counts that may be required (e.g. nursing staff changeover, multiple incision sites, cavity within a cavity). This will be discussed in more detail later in this module. Once initiated, a surgical count should be completed in its entirety without interruptions. If interruptions do occur, the count should resume at the last recorded item. Initial Counts The initial count is carried out before the surgical procedure by two perioperative nurses, one of whom is a Registered Nurse (RN). Surgical items shall remain together until the initial count is completed. Once the count is completed, the scrub nurse may set up her/his sterile table. All surgical items shall not be removed from the OR until the final count is completed. Laundry and garbage shall remain in the room until the final count is concluded. Adding and Removing Surgical Items from the Sterile Surgical Field During the procedure, there may be sponges, sharps, miscellaneous items, or instruments that are added to or removed from the surgical field and count sheet. Both nursing professionals, one being a perioperative RN, shall audibly and visibly confirm all surgical items that are added to or removed from the surgical field and count sheet. The added or removed surgical items shall be counted, recorded, and initialed by the circulating nurse on the count sheet immediately to ensure accurate documentation. Closing Counts The closing count is carried out at the first layer of wound closure. For example, during a laparotomy, the peritoneum is considered the first layer that is approximated. The items that are counted during the closing count should no longer be in use. Closing count is completed when the items are no longer being used. A tally of the surgical items is documented in a specific column on the count sheet for the closing count. The recommended sequence of the closing and final surgical counts is as follows: Sterile Field →Mayo Stand →Back Table →Items removed from sterile field Module 6: Surgical Count Final Counts The final count is carried out during skin closure. During the final count, all surgical items shall be totaled and clearly documented in a designated column on the count sheet. The recommended sequence of the final surgical counts is similar to closing counts: Sterile Field →Mayo Stand →Back Table →Items removed from sterile field Upon completion of the final count, the circulating nurse shall verbalize the results of the count to the surgeon. The circulating nurse shall obtain verbal acknowledgement from the surgeon. Documentation Surgical counts are to be completed by two perioperative nurses, one whom is a Registered Nurse (RN). Concurrently, both nurses audibly and visibly count each surgical item during the initial, closing, final counts, and/or changeover counts. The circulating nurse documents all the counted surgical items on the count sheet. If there is no scrub nurse present during a count, a surgeon may count with a perioperative RN, if this is permitted by the institutional policy. Physician signatures may be required, as per institutional policy. All perioperative nursing professionals involved in the surgical counts shall have their names recorded on the surgical count sheets. Full signatures legibly written with identifying initials shall be recorded on the count sheet, according to healthcare institution’s policies. The count sheet is kept in the patient’s health record. The results of the closing, final, and additional counts should be recorded on the perioperative record, as well as the patient’s chart. If the surgical counts are incorrect, an incident report shall be completed. The surgical wound and OR are searched. Postoperative X-ray of the surgical wound may be ordered, if the patient’s health condition permits. Actions taken following an incorrect count are recorded in the perioperative record. Additional Surgical Counts The surgical procedures may require other surgical counts in addition to the initial, closing, and final counts. As mentioned previously, the institutions establish their surgical count policies to ensure foreign objects are not retained in the surgical wound. The surgical count policies and procedures may vary from institution to institution, therefore, it is imperative that you familiarize yourself with the surgical count policies in addition to the relevant perioperative nursing association standards, such as ORNAC Standards. Changeover Counts When there is a permanent relief of scrub and/or circulating nurse/s, a minimum surgical count of the sponges, sharps, and miscellaneous items shall be completed. The healthcare institution Module 6: Surgical Count establishes whether a full count of the sponges, sharps, miscellaneous items, and instruments are required for changeover counts. The healthcare institution shall create policies for situations when visualization of the required surgical items is not possible during a completion of a changeover count. Cavity within a Cavity If there is a closure of a cavity within a cavity (ie. vaginal vault closure in hysterectomy) a minor count will be required. The subsequent cavity closure will require a closing count, which includes instrumentation. Multiple Surgical Set-ups If there are multiple surgical set-ups (e.g. abdominoperineal resection), a separate count sheet will be designated for each surgical set-up. A closure count is completed for each incision site. The final count is confirmed with the surgeon after closure of the last incision. Items are not to be exchanged between the two set-ups. Reopened Incisions If the surgical incision is re-opened after the final count is completed, an additional closing count shall be carried out and documented during wound closure to ensure that there are no retained items in the surgical wound. Intentional Retained Surgical Items In some cases, the surgeon may intentionally leave surgical items inside the patient’s wound. The patient will then be scheduled to return to the OR for removal of the surgical items and for final wound closure. For example, a surgeon may insert packing of 12x12 sponges inside the patient’s abdomen to stop the liver’s bleeding. Refer to ORNAC Standards for best practices related therapeutic packing. Emergency Counts During an emergency procedure, efforts are made to complete an initial count before the procedure. However, an initial count may not be performed during such critical and urgent procedures. If an initial count is not completed to establish a baseline count prior to surgery, the perioperative nurse shall complete the following actions: Notify the surgical team. Document the reason for an incomplete initial count and actions taken after the procedure in the perioperative record. Module 6: Surgical Count  Consult with the surgeon to arrange for an X-ray after the procedure; before the patient is transported to the recovery room if the patient’s condition permits. If the surgeon refuses an X-ray for the patient postoperatively, document according to the healthcare institution’s policies. Complete an incident report. Count Discrepancy Incorrect counts may occur and they are uncovered during the closing, final, and/or changeover counts. If an incorrect count occurs, the following actions are taken: Circulating nurse notifies the surgeon of the incorrect count, at which point the surgeon suspends the wound closure and conducts a wound search. Recount Scrub nurse searches the surgical site, drapes, and sterile set-up. Search laundry, garbage, and floor. Notify charge nurse regarding the potential surgical delay. Consult with the surgeon regarding X-ray after procedural completion before transporting the patient to the recovery room, if the patient’s condition permits it. Complete an incident report. Record the count as incorrect and document actions taken in the perioperative record. Discuss with the surgeon the potential disclosure of the incorrect count to the patient. Incorrect counts do occur, but they may be prevented by every member of the OR team. Concerted efforts must be made by OR team members to prevent incorrect counts. Preventative measures include: avoiding disruptions during surgical counts, immediate documentation of added/removed items, awareness of all surgical items intraoperatively, legible documentation, and clear communication between OR team members. Module 6: Surgical Count  Summary of Surgical Counts Surgical Counts When to Count What to Count Additiona l Initial Count Before the procedure Major count if there is Comment The initial count confirmed or potential will svary entry into a cavity E.g. depending on the Laparotomy or risk of entry into a laparoscopy cavity. OR Minor count if there is no confirmed or potential cavity entry E.g. Bronchoscopy Closing Count During the first layer Major count if the The closing count of wound closure cavity is opened will vary greater than 10mm depending on the E.g. Thoracotomy cavity entry and size of the incision OR into the cavity. Minor count if the cavity is not entered E.g. Breast Biopsy Minor count if the cavity is opened less than 10mm for minimally-invasive procedures E.g. Laparoscopy Final Count During skin closure Minor count E.g. The final count is Laparotomy, completed during Laparoscopy the closure of the final layer of the wound. Module 6: Surgical Count  Changeover Count During a permanent Minor count, Some institutions change of scrub based on may require a and/or circulating institution policy major count of all nurse surgical items Module 6: Surgical Count