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Operating Room Procedure

Sponge, Needles & Instrument Count

Sponge count has been and still is one of the most important responsibilities of an operating room nurse. Association of Operating Room Nurses recognized this and laid a recommended practices regarding sponge, sharp and instrument count effective the 1st day of January 2000. According to the AORN Guidelines 2007, counts are performed to account for all items and lessen the potential for injury to the patient as a result if a retained foreign body. It further states that complete and accurate counting procedures help promote optimal perioperative patient outcomes and demonstrate the perioperative practitioners commitment to patient safety. The following are considered to be as counted items: Sponges (44, lap sponges, kittners or peanuts, cottonoids) Sharps Instruments

Usual Numbers of Pre-Packed Sponges: Lap Sponges = 5/package 4 x 4 sponges = 10/package Cottonoids = 10/package Peanuts or Kittners = 5/package Suture Boots = 10/package

Recommended Practices on Sponge Count 1. Sponges should be counted on all procedures in which the possibility exists that a sponge could be retained. 2. When to Count: 3. Before the procedure starts 4. Before the closure of a cavity within a cavity 5. Before wound closure begins 6. At the skin closure or end of procedure 7. At the time of permanent relief of either the scrub person or circulating nurse

8. The same goes with all the sharps and instruments, they should be counted in every procedure. Legal accountability for sponge counts during a surgery is a primary responsibility of the perioperative nurse. Performing counts creates a proactive injuryprevention strategy. These are some procedures which sponge count may not be necessary: 1. X-ray or fluoroscopy is taken as soon as before the wound is closed and the attending surgeon makes the determination that there are no more retained instruments in the surgical wound 2. Superficial procedures which the length of the wound is <10cm and the depth is <5cm, superficial skin procedure such as I&D, bur procedures 3. Gynecologic procedure with vaginal approach 4. Genito-urinal procedure: circumcision, vasectomy, TURP, brachytherapy 5. Closed procedures using a flexible or rigid camera or scope 6. Foot/hand surgery, perc punning, total joints with the exception of a total hip surgery 7. Life or limb-threatening situation 8. Initial sponge counts should be taken on all procedures. 9. Sponges should be separated, counted audibly, and concurrently viewed during the count procedure by two individuals, one of whom should be a registered nurse. 10. Perioperative personnel should not assume that the count on prepackaged sterilized sponges is accurate. Any package containing an incorrect number of sponges should be removed from the field, bagged, labeled, and isolated from the rest of the sponges in the operating room. 11. Sponge counts should be performed in the same sequence each time. The count should begin at the surgical site and the immediate surrounding area, proceed to the Mayo stand and back table, and finally to sponges that have been discarded from the field. 12. All sponges used during a surgical procedure should be x-ray detectable. Sponges should be left in their original configuration and should not be cut. 13. All counted sponges must remain within the operating room and/or sterile field during the procedure. Linen and waste containers should not be removed from the room until counts are completed and resolved. 14. Only non-x-ray-detectable sponges should be used as dressings. 15. Contaminated sponges should be handled and disposed of according to Occupational Safety and Health Administration (OSHA) guidelines, AORNs Recommended practices for environmental cleaning in the surgical practice setting, and institutional policies and procedures. 16. Counting of Sharps has the same guidelines save the following:

17. Suture needles should be counted according to the number marked on the outer package and verified by the scrub person and circulating nurse when the package is opened. 18. Linen or waste containers should not be removed from the operating room until all counts are completed and resolved and the patient has been taken from the room. 19. Used needles on the sterile field should be kept in a disposable, puncture-resistant needle container. Counting of Instruments also has the same set of guidelines except for the following: 1. Instrument sets should be standardized with the minimum types and numbers of instruments needed for the procedure. Instruments that are not routinely used on procedures should be deleted from sets. 2. Pre-printed count sheets that are identical to standardized sets should be used for documenting counts. 3. Pre-printed instrument count sheets expedite the counting process. 4. Members of the surgical team should account for disassembled or broken instruments in their entirety, including all parts of the instrument(s). 5. It is also important to that the sponge, sharp and instrument counts should be documented on the patients intraoperative record. The documentation should include: 1. 2. 3. 4. 5. 6. 7. Types of count and number of counts Names and titles of personnel performing the counts Results of surgical item counts Notification of the surgeon Instruments remaining with the patient or sponges intentionally retained as packing Actions taken if count discrepancies occur Rationale if counts are not performed or completed as dictated by policy

Memoirs: There was a time when a surgeon would love to throw things and had caused us a missing needle. The circulating nurse in-charge was very assertive and demanded the surgeon not to close the operative site unless the needle was found. The surgeon was pissed, but he really didnt care. He and the scrub nurse tried to look for it only to find it near the surgeons feet. That caused another scandal erupting in the operating room of the hospital. It is understandable for most nurses, especially the new graduates to be overwhelmed by the surgeon inside the operating room, the stress is present and you could see your

favourite surgeonat its worse. But remember, your primary duty is to your patient and his safety. Sponge count should be taken seriously by the operating room nurses, not only because it could cause them a revocation of their license, but for the safety of their patient who entrust his/her care into their capable hands.