PURPOSE: To prevent the retention of sponges, needles or instruments in patients. Counts are performed to account for all items and to lessen the potential for injury to the patient as a result of a retained foreign body. Complete and accurate counting procedures help promote optimal peri-operative outcomes and demonstrate the perioperative practitioner’s commitment to patient safety.

SCOPE: RN’s, Labor and Delivery Staff, OR Surgical Technicians, and Surgeons.

POLICY: Sponges, sharps and miscellaneous items will be counted on ALL surgical procedures. Initial instrument counts will be performed to establish a baseline for subsequent counts, including minimally invasive procedures (laparoscopy, thoracoscopy, robot, etc.) The possibility of any incision being extended to allow for a more extensive procedure than anticipated supports the practice of performing an initial count for all procedures. Counts will be performed:a. Before the procedure to establish a baseline.b. Before the closing of a cavity within a cavity (Uterus, Bladder, Aorta, etc.).c. Before wound closure begins.d. At skin closure or the end of procedure.e. At the time of permanent relief of either the scrub person or circulator relief.Documentation of the count (correct or incorrect) shall be made on the intraoperative record; relief counts will be documented in the operative notes section of the intraoperative record.

DEFINITIONS:1) Sponges – soft goods used to absorb fluids, protect tissues, or apply pressure or traction: X-raydetectable raytec, laparotomy sponges (baby & regular), tonsil sponges, kittner/peanuts and cottonoids.

2) Sharps – items with edges or points capable of cutting or puncturing through other items: atraumatic needles, free/eyed needles, hypodermic needles, scalpel blades, ESU cautery tips and extensions, dura hooks, Lonestar hooks.

3) Instruments (Including disposables): Surgical tools or devices designated to perform a specific function such as cutting, dissecting, grasping, holding, retracting or suturing.

4) Miscellaneous Items, which may include but not limited to: cautery tip cleaners, safety pins, "Christmas tree" connectors, bulldogs, heparin needles, umbilical and dacron tapes, vessel loops, suture reels, clip cartridges, microvascular and vascular clips, cottonballs, dental rolls, anti-fog pads, Raney clips, trocar sealing caps, inserts, coronary artery shunts, serrifines, websters and any other small item(s) that have the potential for being retained in the surgical wound.

5) Initial Count: Counting of sponges, sharps, instruments and miscellaneous items performed before an incision is made or procedure is started. Personnel in the scrub role should be scrubbed, set-up and ready to count prior to the patient being brought back to the Operating Room.

6) First Count: Counting of sponges, sharps, instruments and miscellaneous items at the beginning of closure of a body cavity or the entire opening.

7) Second Count: Counting of sponges, sharps, instruments and miscellaneous items at the skin closure.

8) Hollow Organ Count: Counting of sponges, sharps, instruments and miscellaneous items before closure of a hollow organ or cavity within a cavity (Uterus, Bladder, Aorta, etc.).

9) X-ray detectable – means the item contains radiopaque indicators.

10) Minimally invasive surgery – includes laparoscopy and other procedures that involve small incisions and endoscopic instrumentation performed in the OR.

PROCEDURE: 1) A registered nurse will participate in ALL counts.

2) It will be a dual responsibility of the scrub and the circulator to initiate the counts at the times designated herein and to observe each item as it is counted. The scrub will have theresponsibility of asking for the closing counts when it is the appropriate time.

3) All counted items will be audibly counted and concurrently viewed by two individuals – one ofwhom will be an RN. The counts will be recorded on the count sheet and the count board.

4) Any item added by a relief circulator will be initialed on the count sheet and count board.

5) After the initial count, linen and trash will remain in the room until the procedure is complete andthe patient is transferred from the operating room.

6) The count board will not be erased and the count sheet will not be discarded until the patient leaves the operating room.

7) Items will be counted on the field first, then mayo stand, then back table and finally items off thesterile field; Proximal to distal from the wound.

8) Scrub personnel will touch each item as it is counted.

9) Sponges, sharps and miscellaneous items will be counted a minimum of 3 times per case:• on ALL procedures before the incision is made - REQUIRED• upon closure of a hollow organ (uterus, bladder, aorta) – IF APPLICABLE• at first tissue layer closure or before closure - REQUIRED • at final tissue layer closure - REQUIRED • at time of permanent relief – IF APPLICABLE; should be documented in the Operative Notes.

10) Separate closing counts will be taken when a bilateral or multiple procedure(s) is performed and will be documented in the operative notes in the intraoperative record.

11) Additional counts will be performed at the discretion of any team member. There must be twosequential correct counts of each item counted for the final counts to be considered correct.

12) Counted items will not be removed from the room during the procedure. Exception: any packageof needles, sponges, etc., noted to have an incorrect number when first counting the pack, (i.e., 9 raytec vs 10) will be removed from the room immediately and not added to the count.

SHARPS & MISCELLANEOUS ITEMS:1) All suture packs will be counted by the scrub and circulator at the initial count or whenadded to the sterile field; the proper number of needles will be verified when opening the pack.

2) Empty suture packages will NOT be saved or used to rectify a discrepancy in a closing needle count. The actual number of needles may not be the same as the number of empty packages.

3) Used double armed needles will be placed on the needle mat in pairs.

4) Sharps that are passed or dropped off the sterile field will be retrieved by the circulating nurse in a safe manner, the item will be shown to the scrub person, and it will be isolated from the sterile field to be included in the final count.

5) Suture needles that are passed or dropped off the sterile field will be secured between 2 pieces of clear tape and attached to the count board and will be included in the final count.

6) The scrub person should be able to account for all sharps on the sterile field; sharps should always

be confined and contained.

7) In the case of missing needles – needles smaller than 17mm (RB-1) may not consistently be visible on x-ray. An occurrence report will be written; the count will be declared incorrect; documentation in the operative notes will state that the x-ray was deferred due to the missing needles size of 17mm or smaller. If other items are missing as well, then an X-ray will be taken.

SPONGES:1) Sponges bound in packaging will be left contained until both the circulator and scrub areready to begin counting the items.

2) Each sponge will be completely separated while counting.

3) Sponges should be left in their original configuration and should not be cut or altered. Altering a sponge invalidates subsequent counts and increases the risk of a portion being retained in the wound.

4) Cottonoids will be separated and counted by 10’s.

5) Kittner/peanuts will be returned to the original holder for counting.

6) Tonsil sponges will be separated and counted by 5’s.

7) Counted sponges will not be used to carry specimens to pathology (i.e. fresh specimens, frozen sections).

8) Counted sponges will not be used by anesthesia for any reason.

9) Counted sponges will not be used for dressing sponges.

a) Dressing sponges will not be placed on the back table until the wound is closed and the final count is completed and resolved.

10) If a vaginal pack is placed at the end of surgery the circulating nurse will place a gray armband imprinted with “retained item” on the patient’s arm. The number of vaginal packs will be written on the armband.

11) In the event that the patient’s condition requires that sponges are intentionally used as packing and

the patient leaves the OR with the packing in place, the number and type of sponges retained should be documented in the intraoperative record and in an occurrence report. The count should be documented as incorrect.a) A gray armband imprinted with “retained item” will be placed on the patient’s arm. The circulating nurse will write on the armband the number and type of sponge retained. b) When the patient returns to surgery and the packed sponges are removed, the number and types should be reconciled with the number and types removed. The number and types should be noted in the current patient’s record. The removed sponges should be isolated and not included in the counts for the subsequent procedure.c) A two-view (lateral and flat plate - anteroposterior) X-ray should be taken after the subsequent procedure of the surgical site before the patient is transferred from the operating room.d) If the sponges are removed in an area other than the OR, the number and type removed should be noted on the patient’s record, and an X-ray taken to verify all retained sponges have been removed.

SPONGE COUNTER BAG GUIDELINES: 1) Sponge counter bag systems will be used to separate used sponges and will facilitate visualization for counting.2) All sponges will be “opened” prior to their placement in the sponge counter bags.3) Sponges will not be mixed in the bags – 1 bag for raytec, 1 for lap sponges, 1 for baby laps.4) 10 raytec sponges may be placed in each bag – 2 in each of five divided pockets, total of 10 per bag.5) For lap sponges, gently separate the seal between each pocket. Place 1 sponge per pocket, total of 5 per bag.6) Baby lap sponges may be placed in each bag – 2 in each of five divided pockets, total of 10 per bag.7) For counts – when more than one bag is hanging, bags placed in the front need to be removed from the hooks and completely visualized by the staff involved in counting. Bags should be rolled, after being counted, and kept with other counted items. ALL bags should remain in the operating room until the counts are completed and resolved.

INSTRUMENTS / RETRACTORS:1) Instrument counts should be completed BEFORE the incision is made, preferably before the patient is brought into the operating room.

2) Instruments, including retractors, will be counted initially on all procedures in which the likelihood exists that an instrument could be retained - in which a major body cavity is opened or the depth or location of the wound is such that an instrument could be left in the patient; procedures requiring the opening / closure of a cavity such as the abdominal, retroperitoneal, or thoracic cavity;

includes minimally invasive procedures. a) Procedures which an initial instrument count should be completed (in addition to the sponge, sharp, and miscellaneous item count) include, but are not limited to – herniorrhaphies, vaginal hysterectomies, mini-laparatomy, marshall-marchetti, thoracotomy, appendectomy, cholecystecomy, post-partum tubal ligations, C-sections, any laparoscopic procedures including laparoscopic assisted procedures, etc. b) On laparoscopic procedures the stringer, knife handles, forceps and retractors are to be counted initially (all instrumentation except the laparoscopic instruments). If the procedure remains a scope the later instrument counts may be aborted.c) Laparoscopic assisted procedures require counts of all the instrumentation except laparoscopic instruments. This includes initial and first counts. d) On laparoscopic assisted vaginal hysterectomy cases the instruments will be divided into stringer#1 and peel pack #1 for the upper procedure, and stringer #2 and peel pack #2 for the lower procedure, and counted separately on two tables. The counting process will include initial and first count on the lower procedure, but on the upper procedure the first count may be aborted if the abdominal cavity is not opened.

3) Instrument counts may be aborted after the initial count if the procedure does not involve entrance into a major cavity or if the likelihood does not exist that an instrument could be retained.a) The final instrument count should not be considered complete until those instruments used in closing the wound (retractors, needle holders, scissors, etc.) are removed from the wound and returned to the scrub person.4) An instrument count is not required on spinal procedures that are done with an anterior and/or posterior approach or open heart procedures. A C-arm sweep at the end of the procedure is required to verify the absence of foreign bodies and is to be read, before the patient leaves the OR, by the surgeon. If the surgeon has any questions or problems when reading the C-arm sweep the X-Ray technologist can transfer the image to the radiology department and it can be read by a radiologist. Documentation of the results of the X-Ray and who read it is to be entered on the intraoperative record.

5) Procedure for counting specific retractors:1. Balfour:2. O’Connor & O’Sullivan (O&O):3. Kirschner:4. Omni5. Bookwalter

6) Instrument counts should be performed:• Before the procedure or incision is made – REQUIRED• Upon closure of a hollow organ (uterus, bladder, aorta) – IF APPLICABLE• At first tissue layer closure or before closure - REQUIRED• At the time of permanent relief of the scrub person and / or circulating nurse – if feasible; should be documented in operative notes in the intraoperative record.

7) Instruments disassembled during a procedure will be counted as separate parts and will bedocumented on the count sheet (suction tips, wing nuts, blades, sheaths, etc.). Rationale: Removableinstrument parts can be purposefully removed or become loose and fall into the wound or onto or off the sterile field.

8) Instruments added to or removed from the field will be noted on the instrument count sheet/board.

9) Instruments removed or inadvertently dropped from the sterile field will be retrieved by the circulating nurse, shown to the scrub person and placed on a blue towel or wrap, on a prep table or the floor within the OR room, within sight of both the scrub person and the circulator and will be included in the final count. Instruments removed from the field must remain in the operating room for the duration of the case.a) At the end of the case, dropped or removed instruments will be retrieved by the scrub person and will be placed with the other instruments on the back table, prior to being taken to Decontam.

10) When additional instruments are added to the field, they are counted when added and recorded as part of the count documentation. When instruments are added to the field partially from a set, the entire set needs to be counted and added to the count documentation. Sets must be removed from the pan or wrap and checked for sterility & this eliminates the confusion of what was and is not counted – ALL items should be counted.a) Additional instruments added to the count will be documented in the “added” column of the count sheet. They are differentiated as separate from the original count.

11) Instrument set recipes will be standardized with the count sheet. Instruments will be strung in Central Sterile in the order they appear on the recipe sheet.

EMERGENCY / CASE CONVERSION:1) Instrument counts will be performed if possible in an life-and-death-emergency procedure; omissions of instrument counts due to emergencies require informing the surgeon and taking an X-ray with two views (lateral and flat plate - anteroposterior) of the surgical site before the patientis transferred from the operating room.

2) All procedures which the originally scheduled procedure is converted or changed after the patient is brought into the OR room, require an X-ray with two views (lateral and flat plate –anteroposterior) of the surgical site. The X-ray results will be communicated to the surgeon, staffand will be documented in the intraoperative record. The physician reading the X-ray will also bedocumented in the intraoperative record. Radiology will be notified that the reason for theX-ray i.e. for a retained item.

BROKEN ITEMS1) Any broken item (i.e., needle or instrument) will be accounted for in its entirety and will be \available in the room for subsequent counts. All parts should be saved and given to the ORManager or AVP. The item will be sent to Risk Management, along with an occurrence report. AnX-ray with two views (lateral and flat plate) of the surgical site should be taken. If the broken itemis smaller than 17mm (the size of an RB-1 needle) then the X-ray is up to the surgeons discretion. Items smaller than 17mm may not be consistently visable on X-ray.

ORGAN PROCUREMENT PROCEDURES:1) Counts for organ procurement procedures: Sponges, sharps, instruments and miscellaneous items will be counted as per this policy. Counted items could be at risk for being retained and sent with the donated organ(s), retained in the donor, or left in the OR.

DOCUMENTATION:1) Documentation of counts will include:a) Types of counts and number of countsb) Names and title of personnel performing the counts

c) Results of surgical item countsd) Notification of the surgeone) Instruments or sponges intentionally remaining with the patientf) Actions taken if a discrepancy occursg) Outcomes of actions taken

2) The circulating nurse will announce the results of the closure counts to the surgical team, specifically to the surgeon.

COUNT DISCREPANCY:1) When a discrepancy in the count(s) is identified, the surgical team is responsible for carrying outsteps to locate the missing item. Procedural steps include:

a) Notify the surgeon and surgical teamb) Procedure suspended, if patient’s condition permits.c) Manual inspection of the operative site.d) Visual inspection of the area surrounding the surgical field, including the floor, kick buckets, and linen and trash receptaclese) An X-ray will be taken and read before the patient leaves the operative room.Two views from a different angle are required to determine an absence of foreign body.f) The Physician reading the X-ray and the results of the X-ray will be documented in the intraoperative nursing record.g) If the surgeon deems the patient too unstable for x-ray, the x-ray should be taken at the next level of care (ICU), as soon as possibleh) All measures taken and outcomes will be documented on the patient’s intraoperative record. i) An occurrence report will be submitted in Meditech.

REFERENCES:

1) 2007 AORN Recommended Practices and Guidelines.