This Week's Discussion: "Correct Counts in the OR vs. a Countdown to Disaster"

I believe, being a good and competent operating room nurse is almost as difficult as being a good mother. Some people don't like to hear an analogy made between a mother and a nurse but I feel there is a connection and that this connection is very pertinent.

Yes, the job description is somewhat different but in essence the job description is more alike than different! Just like a "good mother" a good operating room registered nurse circulator, the nurse that coordinates a patient's entire surgical case for the entire length of the case, has to be "everywhere" i.e. sees all, and is expected to do all! Most importantly, just as it is one of the roles of motherhood to protect her child / children, this is the main role of the operating room circulator i.e. to keep her / his patient safe. To Do No Harm!!! Legally and ethically, a nurse is bound by state laws to Do No Harm! A nurse is also bound by state law to make sure that no one else does any harm to her / his patient especially IF that nurse delegates "authority" to unlicensed staff.

It is often forgotten that one can delegate authority but one really cannot delegate responsibility.

Much goes on in an operating room setting in order to "DO NO HARM" to a patient. No one really wants to "harm" their patient, well almost no one. There are cases of deliberate harm to patients. BUT I'll try to stay on topic i.e. COUNTS, correct, and incorrect counts and examples of issues occurring in the operating room which contribute to incorrect counts or the lack or absence of proper count.

First, the manager of any operating room or surgical center or area where "invasive"  procedures on patients are being performed has to be an operating room Registered Nurse! The burden of responsibility is on them! The RN in charge has to know national OR standards and adhere to national recommendations as well as be a strong leader not affected by cronyism. The RN in charge is one of the patient's first line of defense!

Secondly, and very importantly, the operating room circulator has to be a Registered Nurse who is with her / his patient during the entire length of the case, not delegating "circulating" duties to unlicensed or to other non RN staff and not circulating between other OR rooms / cases. This operating room RN is also one of the patient's first line of defense! The RN's duty is to make sure that "all" hospital policies, and guidelines as well as national standards and mandates are also followed on ALL cases! The OR manager cannot be everywhere so that is why it is important to have one OR registered nurse circulator in each OR room i.e. case!

One of every eight OR cases has an incorrect count!  Personally, I think this number is quite higher, and is under reported!  It can also be that many patients are walking around with "suture needles" inside them. Hmm, that twinge, hmm, often needles cannot be picked up (seen) on x-ray nor can sponges be seen because the sponge (or lap pad or towel) is "hiding" behind a bone or because the patient is very obese and the rays just don't penetrate through all the tissue or because the actual view taken during x-raying was not the proper view.

Serious injuries can occur to the patient causing massive infections just from the "rotting" of a sponge left behind! Hmm, a surgical instrument wiggling and giggling inside one's body would not feel too good let alone the potential for a perforation / erosion by the retained surgical instrument.

So, counting for a surgical case can be complicated BUT it is imperative that COUNTS are done with two people i.e., the operating room RN circulator and the scrub person! It is imperative that COUNTS are performed according to national standards, most importantly, it is IMPERATIVE that no one argues whether or not a count should or should not be done!  JUST DO IT!

Counting involves counting instruments (metal instruments show up on x-rays), radio-opaque sponges, radio-opaque lap sponges, radio-opaque towels, and hundreds of other items which are not radio opaque, raney clamps, weck cells, cotton balls, etc. etc..

I have noted as a circulator on cases where "staff" would hide a sponge or lap between their belly and the OR table, why did they do this? Oh, just to see if the counts were being counted correctly.

 

I have noted as a circulator on cases where "staff" have thrown a rolled up sponge clear across the room.  Hmm, it gets pretty messy crawling on the floor looking for the lost sponge!

 

I learned a lesson early in my career, when I and a scrub staff counted the final count too early.  The incision was about one inch from being closed when we did a final count.  Well, a sponge was pushed into the one inch opening! Thank goodness it was noticed that a sponge was missing before the patient left for the recovery room.

Judge for yourself the following scenarios on the issue of counts.  It is very easy to see why it is paramount for the operating room RN circulator to be overseeing "what is and what is not!"

Examples of count issues.  No wonder there are incorrect counts!

• Counting some items but not counting other items.
• Not counting final "separate" counts when doing "bilateral" sites.
• Too many relief staff on cases.
• A relief count not being performed at the change of any staffing.
• Lack of counts on cases where "nothing can be lost in that small incision."
• Pre-printed counts sheets that are "incorrect."  If there is an extra instrument on a set and that "extra" instrument is not written on the pre-printed sheet, then how does the RN and Scrub person know to count it or even to look for it?
• The use of non-radio-opaque items such as towels, etc.  If these items were not counted in the first place, then they will probably not be counted at all.
• The use of non-radio towels etc. to "temporarily" pack a surgical incision which at the moment cannot be closed by the surgeon due to swelling of the intestines or the need for a wash out of the wound on another day.
• Counts being performed by only the Scrub person.  It has to be done by two persons.
• The lack of proper amounts of counts.  Especially not counting when a major cavity is entered.  Hmm, when a woman has a vaginal hysterectomy performed a major cavity is entered! There is still a debate as to whether or not to count instruments, on a vaginal hysterectomy!
• Standards adhered to in one unit of the hospital but not in some of the other units.
• The lack of pre-counting on "Band-aid" surgeries, i.e. "nothing can get lost" or
  were not going to open up the belly."  Famous last words!
• Small suture needles not being counted because "they are too small to cause the patient any problems if one gets lost."
• Plain sponges (used during prepping) getting mixed up with the radio-opaque sponges and getting mistaken for a radio-opaque sponge.  Hmm, that radio opaque sponge might be in the patient!
• Separating "counted" items from "non-counted" items with a towel.  "Oh, I won’t use any of the non-counted items."
• Too much taking, loud music or laughter.  The room should be quiet during counts.
• Bluetooth.  The surgeon’s phone rings but before the RN can answer it, it flips over to the surgeon’s earpiece.
• Hostile environments are not conducive to getting a correct count.
• The OR chart states that the "count" is correct but it is not.  It can happen if there were 11 sponges in a sponge pack and the staff only "looked" for 10.
• Hmmm, a needle etc. is missing.  Wow, it was found, but what if it was from a previous case? Not all OR rooms are cleaned properly.
• As far as new technology, bar coding and the chip (RFID), and all other things made by man are imperfect, I think, and will eventually break down. Also, there is a learning curve for all staff as well as the issues of dead batteries and broken equipment.

Perhaps if all "count sheets" were mandated to be placed on a patient'’s chart as well as be signed by "all staff" involved in the counts, there might be fewer mistakes.

Ask any mortician about the "stuff" they have found in deceased bodies!

So as one can see, the counting methodology in the Operating Room is far from perfect. I purport, again, that it is the OR RN Circulator who is the "mother" advocate of each patient.

Blessings to all,
Helen French RN,BSN