Webinar SURGICAL OBJECT SURVEILLANCE

Kyung Jun, RN, MSN, CNOR

January 22, 2014

• Please vote for best title regarding

preventing retained surgical item

– “SOS”: Surgical Object Surveillances?

– “What Goes In Must Come Out”?

– “Seek and Sweep”?

– FOFO: Free of Foreign Object?

TITLE

• Share our journey of what has worked and

what has not…

• Provide opportunity to network with other

hospitals on this issue

• Allow time for feedback and questions

OBJECTIVES

• 950 beds

• Teaching hospital with both faculty and

private physicians

• Over 43 operating rooms on 8 separate

locations

• Over 30,000 surgeries per year

OUR JOURNEY

Increased Risk

Emergency surgeries

Unplanned changes in procedure (e.g. intraoperative hemorrhage, code blue)

Increased body-mass index

Multiple surgical specialties

Multiple nursing staff hand-offs

Intervention Anticipate cases with high probability of RFO

Call out packed items and write on the board

Surgeon to surgeon report

RN to RN report using SBAR

Sweep or Peep (visual/manual inspection of site) prior to closure

X-ray

For incorrect count or missing item

Inform radiologist: item in question, operative area, drains, and lines

Radiologist must speak to the Surgeon to convey the result

Do not close skin until x-ray is negative

Surgery end time is defined as “last stitch in”

Adapted from Gawande, Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2009; 35 (3): 229-35

EARLY ON

• In 2008, had a peak in RSI

• Initiated RFO Oversight Committee

• Importance of Oversight Committee

– Multidiscipline

– Physician & nurse involvement

– PI facilitator keep project on tract

– Aimed to achieve goal within 12-18 months

HISTORY

CONCLUSIONS/RECOMMENDATIONS ACTION PLAN/FOLLOW-UP

Standardize the White Board

List all countable items

RFO Squad: TOC for 3 months

Eliminate confusion over Xray criteria

by changing requirements for xray to 1)

incorrect count 2) inability to count 3)

when member of the team requests it 4)

bring back patients with packed laps

“Check Out Process” pause, MD/RN/ST

account for all items, methodical

wound exploration

Separate out all instruments used from

fascia to skin closure and reconcile at

end

Complete standardizing White Board

Present “Check Out Process to RFO

Oversight Committee

Involve MD/RN committee and UPC on

Check Out process

Finalize decisions on instrument count

protocol

Continue RFO Class

PERFORMANCE MEASURE: NEVER 27 EVENTS- RFO

COMMITEE/OWNER: OPERATING ROOM

0

1

2#

o

f R

FO

s

Sep-08 Oct-08 Nov-08 Dec-08 Jan-09 Feb-09

Never 27

Events

(RFO)Target 0

PERFORMANCE MEASURE: NEVER 27 EVENTS- RFO

COMMITEE/OWNER: OPERATING ROOM

RFO

Oversight

CTE

OR RFO CTE

TASK FORCE STRUCTURE

Clinical Improvement Committee

RFO Taskforce Oversight Committee

(Meets Monthly)

RFO Prevention in

the O.R.

Team Leaders:

OB, MD,

Surgery, MD,

OR, RN

RFO Prevention in

other Procedural

Areas

Team Leaders:

ED, MD

Medicine, MD

Med-Surg. Adm., RN

New Technology to

Prevent RFO

Team Leaders:

Surgery, MD

Clinical Engineering

Education &

Communication

Team Leaders:

OB, MD

Nursing Adm. PhD

Nursing Ed.

RFO Integration Team

Zero RFOs in the Operating Room

Team Leaders:

• OB, MD

• OR, RN

• Surgery, MD

Team Members:

• Nursing OR, RN

• Nursing adm., RN

• Nursing OB, RN

• Nursing OR, RN

• Surgery, MD

• Trauma, MD

• Ortho Surgery, MD

• Surgery, MD

• ID MD, MD

• Surgery, MD

Team Charge

- Review & analyze the effectiveness of the current CSMC RFO prevention process

in the OR

- Critical evaluation of the current count practice along with distracting factors

- Highlight prevention gaps and offer recommendations

- Test recommendations and implement improvements

PI Facilitator:

Team Members:

• Medicine, MD

• OBGYN, MD

• Surgery, MD

• OBGYN, MD

• Nursing OR, RN

• OBGYN, MD

• OBGYN, MD

• Surgery, MD

• 12 questions to test staff, surgeons, and

anesthesiologists knowledge about the count

process, when to take an x-ray and to get input

on what we need to change

• Survey sent to OR nurses, techs, surgeons,

OBGYN, anesthesiologists, interventionalists

SURVEY

• Most valuable questions asked were:

• What distractions interfere with the count? Rank 1-5 with

1 being the most distracting

– Multitasking

– Music

– Computer entry

– Too many people in the room

– other

• If you had one suggestion to reduce the risk of retained

foreign objects in the OR, what would it be?

SURVEY

Documentation Standardization

Whiteboard Standardization in the Operating Room

• Larger whiteboards installed

• First test: magnet standardization, magnets finalized on May 18

• Other considerations: add permanent lines, add permanent item locations

• Next steps: collect feedback from the staff and follow-up on best practices

from the Patient Room Whiteboard Standardization Project

BEFORE AFTER

Angiocath Cottonoid fred Iodoform gauze

Penrose drain Safety pins Sternal wires Umbilical tapes

Cottonballs House Mayfield pins Q-tips

shoestring Bulldog reels CiP

Fish hooks Pacing wires Rubber band Alcohol wipes

ENT gauze Hypo needles Stapler

cartridge

Vessel loop

Mayfield pins Suction tips Suture boots Weck cell

Shoe strings Throat packs shods Vag packs

Bovie scratch Instrument

caps

Peanuts seprafilm

Surgical Items

• In-service for every one

• Small groups

• “RFO Prevention Month” in October

• Audits

EDUCATION

• Survey the room: remove labels, remove opened sutures, clear whiteboard, check kick bucket and sharps container

• Count instruments/ sponges/ needles BEFORE pt enters

• Use standardized board (needles, micro-needle) no exception

PRIOR TO SURGERY

• Count from surgical field (pick up laps, open

them), mayo stand, back table, to sponge

counter bag

• Circulating RN calls out items to be counted

• Pick up laps, open them, insert into bag

with radiopaque string visible

• Create distraction free environment during

counts- stop the music, etc..

COUNTING PROCESS

• Keep tally of needles and sponges throughout case

• NO ST and RN should break at the same time

• Only primary circulator gives countable item

• Use Sponge counter bags (5 laps with blue tag showing, 10 raytecs)

DURING SURGERY

• Must use for every case (no exception)

• Show blue radiopaque tags

• 5 laps; 10 raytecs

• “show me” Pass off all sponges and raytecs

to fill the sponge counter bags

• See it; touch it; open it; feel it

SPONGE COUNTER BAGS

“Show

Me” from

Dr Verna

Gibbs

• X-ray criteria

– Incorrect count

– After removal of packed sponges

– Inability to count for any reason

– When a member of surgical team requests it

X-RAY

• Avoid cutting cottonoids, tapes, and sponges

• Tapes, cottonoids are cut, all portions must be accounted for

• When cutting gauze, vag pack and molding cotton or others, have a count of 5’s

• Put this on the board

• When packing (throat, abdomen, chest, vagina) put this on the board

• Other methods (clamp on your gown)

PACKED ITEMS

• Count done by RN & ST for open cavity and

vaginal cases

• RN/ST count BEFORE the patient enters

room: nurse with protocol reads, ST counts

• Instrument count should be included in

the FINAL count

• Most commonly left item: sponge, needle,

clamps, retractors, malleable

INSTRUMENTS

• Surgeons busy operating

• Accounting was sole nursing responsibility

• Must have joint accountability through Check Out

– Methodical Wound Exam

– Count uninterrupted

– Closing suture

JOINT ACCOUNTABILITY

Defining Methodical Wound Examination

A methodical wound examination is necessary to prevent RFO

Minimum requirements for a methodical wound exam:

Space to be closed must be carefully examined

Special focus should be given to closure of a cavity within a cavity

(heart, major vessel, stomach, bladder, uterus, vagina)

Strive to see & touch – reliance on one element of sensory

perception is insufficient

Look and feel in the recesses of the wound and examine under

fatty protuberances and soft-tissues appendages

If the surgeon is informed of a missing object, while the OR staff

are looking for the surgical item, the surgeon should stop closing &

repeat the methodical wound exam

We need your help to define the methodical wound exam in your

discipline

Goal: define methodical wound exam for each discipline

Defining Methodical Wound Examination

Goal: define methodical wound exam for each discipline

Samples Abdomen and Pelvis

Definition should not be complicated. Definition must be easy to remember while in the OR.

Defining Methodical Wound Examination

Goal: define methodical wound exam for each discipline

Samples Mediastinum or Thorax

Definition should not be complicated. Definition must be easy to remember while in the OR.

PAUSE for the Check Out !

Process Start: Surgeon announces he / she is ready to close

Surgeon Nurse & Scrub Tech

• Perform methodical wound

examination

• Verbally attest to

completion of wound exam

• Close wound

• Perform sponge and sharps

accounting

• Verbally attest to completion of

sponge and sharps accounting

• Perform instrument accounting

Process End: Nurse documents completion of the Check Out process

• X-ray must be taken if broken inside patient

• Chain of command

• Midas: name of item, manufacturer, catalog

number, lot number, contact person for

company

BROKEN INSTRUMENTS

RFO X-ray Test of Change

X-Ray

Requested in

OR

Contact

Radiology

X-Ray

Performed Image Read

Results

Communicated

When Should

x-ray be called?

Incorrect count

Inability to count

Significant deviation

from planned

surgery

When any team

member has a

concern

Before final wound

closure for wounds

previously

intentionally left

open or packed

Exception: patient is

in extremis

Steps:

Call Imaging at 3-3825

Communicate the

following information:

Steps:

X-ray the patient

X-ray a sample of the

missing item

Technologist will not

leave the OR until

image results are

available

Perform additional

views as needed

Steps:

Image must be read

by a staff radiologist

Nurse will bring up

image in the OR

Attending Surgeon to

remain in the OR and

view the electronic

image

Radiology extension

3 - XXXX

Steps:

Attending Surgeon

and Staff Radiologist

to speak directly while

simultaneously

viewing the image

Discuss image results

and next steps

1. Patient location: floor

and room #

2. Attending Surgeon

3. OR phone #

4. Missing item, be

specific

5. Area of the body to

image, general

location of the RFO

6. Items that will show

up on the image that

should be in the

patient (drains,

pacemaker, clips,

etc)

RFO X-ray Process

• Criteria

• Inability to count for any reason

• When an item is unaccounted for

• After packed item is removed

• When anyone requests it

X-RAY

Technology Evaluation (2010)

Counts High Tech Option Status

Instruments X-ray • time consuming, dollar impact, not always a reliable

method of detection

Sponges Wand (RF Surgical) • Pilot to begin Jun 2

• 20 wands to be tested on 3 OR, 5 OR, 6OR

• Meeting on May 21st to determine needed supplies

Barcode (Surgicount) • Focus groups did not endorse this product

Wand + Bucket

(Clearcount)

• Question as to whether they can handle our size

Needles • No high-tech option available

Surgical Safety Checklist

Sign In Time Out Check out

Before induction of anesthesia Before skin incision Before wound closure

Patient has confirmed:

Site Marked / Not Applicable

Anesthesia Safety Checklist Completed

Pulse Oximeter on Patient & Functioning

No

Yes

No

Yes, and equipment / assistance available

No

Yes, and adequate intravenous access

and fluids planned

• Identity • Site • Procedure • Consent

Does Patient Have:

Known Allergy?

Difficult Airway / Aspiration Risk?

Risk of > 500ML Blood Loss?

Confirm all team members have

introduced themselves by name and role

Surgeon, Anesthesia Professional, and

Nurse Verbally Confirm:

• Patient • Site • Procedure

Anticipated Critical Events

Surgeon reviews: what are the critical or

unexpected steps, operative duration,

anticipated blood loss?

Anesthesiologist reviews: are there any

patient-specific concerns?

Nursing Team reviews: has sterility

(including indicator results) been

confirmed? Are there equipment issues or

any concerns?

Has antibiotic prophylaxis been given

within the last 60 minutes?

Yes

Not Applicable

Is essential imaging displayed?

Yes

Not Applicable

Name of the procedure recorded

Sponge and sharp counts are correct

How the specimen is labeled (including

patient name)

Whether there are any equipment

problems to be addressed

Surgeon, Anesthesiologist, and Nurse

review the key concerns for recovery and

management of this patient

Surgeon performs methodical wound exam

Visual inspection of sponge tree

Nurse verbally attests to completion of

sponge and sharp accounting

Surgeon begins wound closure

Sign out

Do you have a specific concerns to note

prior to the procedure?

Surgeon verbally attests to completion of

methodical wound exam

Nurse and Scrub Tech perform sponge

and sharp accounting

Nurse and Scrub Tech perform instrument

accounting

Instrument counts are correct

Nurse verbally

confirms:

Not Applicable (spine, hip case)

Yes

RFO PREVENTION AUDIT

Date: Date: Date

Unit/Rm: Unit/Rm: Unit/Rm

Physician : Physician: Physician:

Circulating RN Circulating RN Observed

MRN: MRN: MRN:

Audit #1 Audit #2 Audit #3

YES NO N/A COMMENTS YES NO N/A COMMENTS YES NO N/A COMMENTS

1. survey room: check sharp

container, pharm bin, kick

bucket, clear board, remove all

labels

3. keep sponge counter bags

up

4. The Check Out

Addressed the following:

a. Pause by all

b. Count by RN and ST

c. Methodical Wound

Exploration by MD

d. Attestation of count status by

RN

e. Attestation of MWE by MD

5. Include instrument count at

final count for open cavity and

vaginal case

6. Protocol sheet used for

instrument count

7. "Show Me"- fill all spaces in

sponge counter bags and show

MD

• Process of looking at “other” retained

items (guide-wires,

• Always audit everything

– Sponge counter bags

– Methodical Wound Exam

• Study trends of near misses

– When are we doing x-rays

– Hand offs

WHERE ARE WE NOW

DAYS WITHOUT

RETAINED SPONGE

797