The Count Revisited

VPNG Strategies for SuccessCathy Dean Clinical Support & Development Nurse Alfred HospitalLatrobe Perioperative Course Coordinator

Objective:Elimination of the RSI

Session outline Identify strategies to improve count practices and

eliminate RSIs and to explore ways that current count practices can be further improved

An overview of current count practices Discuss current available studies on counts and RSI Identify future directions in using research to prevent

RSIs Improved team communication as a tool in RSI

prevention Technological adjuncts and their role in preventing RSIs Data collection as a tool to identify trends and

emerging patterns in RSIs Using research findings on trends and patterns to

inform practice Toward the future

Current count practices ACORN standards: detail the minimum standards

for management of accountable items Standardized system designed to reduce risk of

RSI ACORN standards; Local guidelines and

State/Territory policies and guidelines Apply to all members of the surgical team Scrub & Scouts have the primary responsibility

for the management of the count procedure but the surgeon has a significant role.

Count practices Well established formalised process Core responsibility of the perioperative nurse Consumables are counted but ACORN do provide

leeway on individual facility requirements in the counting of some items.

ACORN standards do require all instruments are counted and reconciled against the tray lists

Variations in what is counted Variations in process documentation Individual hospital guidelines on the counting of

instruments and instrument trays

Counting of all Instruments

So how do RSIs occur? Multiple cases Multiple teams Poor team communication – respect and

action; unknown to each other Fatigue Lack of handover process Rushed or incomplete count practices New equipment and procedures Unfamiliar with procedure or instrument sets

Literature Case reports clinical series & opinions Little quantative research insight into RSI risk

factors to date What contributes to the RSI risk profile ? Identification of clinically important

differences not agreed on within the literature.

Surgeon perspective and circular in nature. Limited findings or recommendations that

inform practice

Questions asked Body mass index Emergency procedures Blood loss Nursing staff change over After hours Lack of counts or no counts ….what has been extracted? ….a surgical trainee in the OR ??

The Perioperative Nurse How do we prevent RSIs?Asking the questionsCollecting the data

Data Understanding the issues through data Risk Watch – Victoria Global risk watch : data Transparent reporting Agreed terminology In form our practice in a clear way that

can be linked into our everyday practice.

Communication RSIs are rare events …never events Team communication Human factors Surgical safety checklist & time out Achieving the level playing field with

equal and respectful communication

Risk watch 2004-2014 Retained curette laparoscopic surgery Disposable verres needle sheath A retained pack in a laparotomy case Raytec gauze hip replacement Retained pack – vaginally Artery forceps Measuring pins Fractured guide wires

Preventing RSIs Good systems; good communication High functioning teams training

programs in communication Formal Human factors training Standardised practices Data informing practice quickly and

effectively Adoption of adjunct technologies that

seamlessly achieve high confidence levels in reconciling the count.

Technological adjuncts Reducing the incidence of RSIs Query an added layer of complexity

RFI for RSIs Packs & Raytec Disposable trocars and sheaths Instrumentation Reliable detectors for all items Enjoying confidence that no thing is left

behind

Safety Programs National Safety Standards Board to ward approach Strategies based on emerging trends Inform practice Adopt strategies quickly

Complex Surgery complex counts Complex environment

Communication Complex environment Knowing the team Pause & introduction WHO – white board Understand the plan All team members understanding the

count To hear and to act

Getting it Right together

Strategies for success Realising the RSI as a never event? Teaching communication Ongoing communication support within the

interdisciplinary team Board to ward Equal and respectful Data to inform practice and practice change Adjunct technological aids to enhance

safety and eliminates RSIs

References ACORN standards 2014-2015 Australian Institute of Health and welfare Canberra, Sentinel events in

Australian public hospitals 2004-05. July 2007. Boyd, C., & Lottenberg, L., (2015) Preventing Retained Surgical Sponges:

clinical and Economic Considerations. General Surgery News (2015) . http://

www.globalpatientsafetyalerts.com/English/ContributingOrganizations/Pages/default.aspx

Copeland, A., Retained surgical sponge (gossypimboma) and other retained surgical items: Prevention and Management. www.uptodate.com (2015)

Feldman, D., Prevention of Retained Surgical Items ., Mount Sinai Journal of Medicine (2011) 78: 865-871.

Hariharan, D., & Lobo, D., Retained surgical sponges, needles and instruments. Ann R Coll Surg Engl (2013) 95: 87-92.

Hicks, C., Rosen, M., Hobson, D., Ko, C., & Wick, E., Improving safety and Quality of Care With Enhanced Teamwork Through Operating Room Briefings, JAMA Surg (2014) 149 (8): 863-868.

Ivory, K., Listen, hear, act: challenging medicine’s culture of bad behaviour. MJA. (2015) 202 (11)

McDonald, I., Human Behavior behind most surgical errors (2015) http://www.fiecehealthcare.com/story/johns-hopkins-mayo-clinic-causes-surgical-errors-never-events/2015-06-09

Mehtsun, W., Ibrahim, A., Diener-West, M., Pronovost, P., & Makary, M., Surgical Never Events in the United States. Surgery (2013) volume 153 (4).

Moffatt-Bruce, S., Cook, C., Stienberg, S., & Stawicki, S., Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system., Journal of Surgical Research 190 (2014) 429-436

References cont. Orosco, R., Talamini, J., Chang, D., & Talamini, M. Surgical Malpractice in the

United States. J Am Coll Surg (2012) 215: 480-488. Pennsylvania Patient Safety Advisory, Beyond the Count: Preventing

retention of Foreign Objects. Vol 6 No 2 June 2009. http://health.vic.gov.au/clinrisk/sentinel/index.htm : Risk Watch News

letters Rupp, C. et.al. Effectiveness of a Radiofrequency Detection System as an

Adjunct to Manual Handling Protocols for Tracking Surgical Sponges: A Prospective Trial of 2,285 Patients. J Am Coll Surg (2012;215:524-533

State Government Victoria, Department of Health, Supporting patient safety Sentinel event program Annual report 2011-12 and 2012-13.

Stawicki, S., et.al., Natural history of retained surgical items support the need for team training, early recognition, and prompt retrieval. The American Journal of Surgery (2014) 208, 65-72.

Stawicki, S., et.al. Retained Surgical Items: A Problem Yet to be Solved. J Am Coll Surg (2013) 15-22.

Steelman, V., Graling, P., & Perkhounkova, Y., Priority Patient Safety Issues Identified by Perioperative Nurses. AORN Journal (2013) Vol 97 No 4.

The Joint Commission Sentinel Event Alert, Preventing unintended retained foreign objects. Issue 51 October 17, 2013.

Williams, T., Tung, D., Steelman, V., Chang, P., & Szekendi, M., Retained Surgical Sponges: Findings from Incident Reports and a Cost-Benefit Analysis of Radiofrequency Technology. J Am Coll Surg (2014) 219:354-364.