Counting instruments is still the best policy
Perioperative nurses share cost-effective tips
When it comes to accounting for instruments used in a surgical procedure, to count or not to count?’ may not be the question, perioperative experts warn.
"If it’s a procedure in which a major body cavity is opened or the depth or location of wound is such that an instrument could be left in the patient, what you should be asking yourself is Do I want to be safe or sorry?’" argues Linda Groah, RN, president of the Association of Operating Room Nurses (AORN) in Denver. "What’s a minute or two extra in the OR compared to just one case of costly litigation?"
The bottom line, Groah explains, is that nurses have a responsibility to ensure that patients receive safe care. Her adamant response came after Hospital Peer Review visited a recent on-line forum where perioperative nurses discussed the widely varying counting policies and procedures among their facilities. (See resource box for server address.)
While one participant said her health care system had discontinued instrument counts, another said counting was done at the surgeons’ discretion. Both cited concerns about the staff’s labor costs and operating room expense. But the majority in the discussion group insisted counts help maintain quality of patient care and inventory control as well as decrease liability.
Yet hospitals can’t ignore the realities of cost-containment and managed care pressures, they conceded. The key, says Groah, is to develop an efficient approach to instrument counting. Here’s how:
1. Develop procedure-specific policies.
"On the one hand, an idealistic policy and procedure manual could require that every instrument for every procedure be counted. But that is neither cost-effective or necessary," says Cynthia Spry, RN, MSN, CNOR, regional clinical advisor for Advanced Sterilization Products, the Johnson and Johnson division in New York City that manufactures the Sterrad sterilizer. Spry is also past president of AORN.
For example, in laparoscopic surgeries the instrument is far larger than the incision, thus making counting unnecessary. "Or take a cataract procedure," Spry says. "There’s no way an instrument is going to get lost in an eye."
But you’ll still want to consider the implications of counting for inventory control, adds Kathy Francis, RN, CNOR, BSN, staff nurse, St. Vincent’s Medical Center of Richmond in Staten Island, NY.
"Whenever possible, I count on all cases because I want to know we haven’t thrown any clamps out with the drapes," she explains. "Back when we used reusable drapes, every month or so we would get a box of instruments back from the laundry."
That’s why each hospital, she says, must carefully examine its case load to determine what types of surgeries are performed and what inventory control methods are available.
"Your instrument-counting policy must reflect what works best for you," Spry says. "Make it very precise, so nurses know when to count, how to count, and when not to count."
For a starting point, consider AORN’s Recommended Practice Guideline, which says instruments should be counted on all procedures in which the likelihood exists that an instrument could be retained," says Mary O’Neale, RN, MN, CNOR, perioperative nursing specialist for AORN.
The guideline advises that instruments should be counted:
• before the procedure to establish a baseline;
• during the procedure if additional instruments are added to the sterile field;
• before wound closure;
• at the time of the permanent relief of a scrub person and/or circulating nurse.
2. Standardize instrument sets.
Once you determine which procedures are to be counted, reduce the number and types of instruments, O’Neale says. "Delete from sets those instruments that are not routinely used. If you need them, open, count, and add at the time of the procedure," she says.
Streamlining and standardizing instrument sets improve the ease and efficiency of counting instruments as well as providing inventory control and cost containment.
"Because our instrument crates are standardized, we know exactly what’s supposed to be in them so it saves time," says Francis.
However, Francis doesn’t take the contents for granted. "We cannot be certain the set is complete unless we open and count what’s in it," she says.
3. Create a pre-printed form for each standard set.
After standardizing, it’s then easy to itemize the contents of each set. Note on a form which instruments may need to be added if the procedure converts to an open incision.
"Having a pre-printed sheet for each major procedure helps ensure accuracy and efficiency and prevents unnecessary delays," O’Neale says.
The circulating nurse needs only to check off the number of instruments opened for that specific procedure. If the surgeon requests additional instruments, they can be counted, added to the set separately, and noted on the form, she adds.
For example, at Northshore Surgery Center, a freestanding facility in Milwaukee, the list is enclosed in the sterile, standardized set, says Natalie Hubbard, RN, staff nurse and clinical coordinator for laparoscopy and obstetrics/gynecology.
"We do a quick double-check, then we count the instruments again at closing," she says. "They are also counted again when they are sent to decontamination and again when they are reassembled."
4. Count in the same sequence.
"Another efficiency tip is to begin at the surgical site and the immediate surrounding area and proceed to the Mayo stand and back table, ending with instruments that have been removed from the field," O’Neale says.
Unlike counting sponges, you may decide not to have two nurses counting instruments during or at the end of the procedure. "The scrub nurse can hand off to the circulating nurse, who then counts the instruments," Groah says.
5. Prepare for the unexpected.
No policy manual will substitute for good judgment, however.
For example, in the on-line group, one person suggested that in order to expedite the counting procedure as well as save money, additional instruments for conversion to an open incision could be opened and draped on a back table. If the set wasn’t needed in that procedure, then it could be saved for the next one.
"This is absolutely not acceptable," Groah says. "You could be inviting cross-contamination."
She suggests placing the set unopened of course on a cart outside the room. "Then if you need it, you can wheel it in. Yes, the surgeon will have to give you an extra minute to count it, but it’s better than running the risk of cross-contamination."
(The Internet address for the on-line forum for perioperative nurses is [email protected]. PERIOP is an electronic forum for Perioperative/OR/Theatre Nurses WorldWide. This mailing list is open to nurses and other health professionals interested in the care of patients immediately before, during, and after surgical and interventional procedures.)
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