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Introduction

The ‘Surgical Count’ entails accountability of items used during surgery
It is performed to ensure that sharps, swabs and instruments used within the sterile environment are not left unintentionally within any of a patient’s cavity.
Despite AORN’S recommended standard procedures for the surgical counting incorrect surgical counts still re-occur despite strictness in count performance among nurses

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Standardized counting procedure

The count should be performed on all procedures with a possibility of surgical materials retention.
Counting is done audibly, visually, concurrently, and methodically by the scrub and circulator nurse (AORN, 2021).
Counting starts from the operative site to the sterile trolleys then to the kick about bin.

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When should the surgical count be performed?

Before the procedure to establish a baseline
Before closure of a cavity within a cavity
Intraoperatively upon addition of items
Before wound or skin closure
When a counting discrepancy occurs
During relief of the scrub person or circulating nurse
At end of procedure when the surgical field is cleared

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What happens when a count discrepancy occurs?

When a discrepancy occurs;

It is verified verbally

Procedure is suspended

Visual search and wound exploration is performed

The incidence is reported

intraoperative radiographs obtained.

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Unresolved counts

Missing items are documented, and the search measure is done
The surgeon decides on further medical care if needed
The incidence occurrence is reported per organizations policy
A root-cause analysis performed (Fang et al., 2021) (AORN, 2021).

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Unintended retention of surgical items

Globally, its the most frequently reported sentinel event in the Joint Commission
An incomplete surgical count occurs when after a search and exploration of the wound, a counting discrepancy remains.

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Surgical Items

Before Imaging

After Imaging

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Consequences of RSI

Physical, emotional and monetary ramifications for patients.
Complications; sepsis, obstructions and perforations,
Extra medical costs due to repeat investigations, repeat surgical procedures,
Prolonged hospital stay and outcomes such as death
Malpractice liability costs and legal fees are possibilities as well (Steelman et al., 2018).

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Research highlight�Risk factors for RSIs

From an observational case control study by Fang et al, (2021)
Type of surgeries like emergencies and Prolonged cases
Additional surgical items on the operating field

Other Risk Factors For RSIs

Counting errors
Unexpected intraoperative events
Unplanned surgical change
Extended surgery time
Complexity of the surgery

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Other Risk Factors For RSIs

Emergency/urgent surgery
Higher volume of blood loss
Increased number of staff members involved in the surgical procedure and
The presence of only one scrub person and one circulator nurse (freitas et al., 2016).

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Research highlight�Mitigation to RSI

Implementation of a comprehensive safety policy
Use of technological adjuncts like sponge pocketing systems
Maintenance of vigilance in emergencies and prolonged cases
This was to reduce incorrect counts (Fang et al., 2021).

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Nurses’ role in implementation and update of surgical counts

Ensure surgical patient safety (WHO 2009)
Incorporated surgical count process in systems of health services
Perform a full and accurate count
Confirmation by radiology
Use of adjunct technology
Proper documentation on count sheets, whiteboards and patient’s records
(Freitas et al., 2016)

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Case scenarios

A 39-year-old man with endocarditis was admitted for septic shock. Imaging studies showed that he had a retained guide wire from the inferior vena cava to the left iliac and common femoral vein. The wire was removed as part of the initial interventional radiology plan, but epithelialization prevented the recovery of the right pulmonary artery segment.
Following an aortic valve replacement surgery, the sponge count was incorrect. A portable chest radiograph obtained was negative for RFBs. A follow-up portable chest radiograph report showed a curvilinear density overlying the right upper quadrant, of unclear cause; an abdominal radiograph was recommended.The sponge was found 1 year later after a CT scan obtained for nonspecific upper abdominal pain and the sponge was surgically removed.
A 68-year-old man underwent exploratory laparotomy, duodenostomy, and duodenal ulcer oversew for gastrointestinal bleeding. The intraoperative sponge count was incorrect, and a portable abdominal radiograph was obtained. No retained sponge was seen, but other intended radiopaque tubes and drains were noted.
A second portable abdominal radiograph was obtained 90 minutes later with the same clinical history. Clinical suspicion for a retained surgical sponge was high, but no retained foreign body was located. A portable abdominal radiograph obtained on1 postoperative day clearly showed a retained foreign body overlying the right side of the pelvis.

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REFERENCES

AORNs Recommended Practices for Sponge, Sharp, and Instrument Counts is Up for Review. Infection Control Today. (2021). Retrieved 29 September 2021, from https://www.infectioncontroltoday.com/view/aorns-recommended-practices-sponge-sharp-and-instrument-counts-review.
Fang, J., Yuan, X., Fan, L., Du, M., Sui, W., & Ma, W. et al. (2021). Risk factors for incorrect surgical count during surgery: An observational study. International Journal Of Nursing Practice, 27(4). https://doi.org/10.1111/ijn.12942
Freitas, P., Silveira, R., Clark, A., & Galvão, C. (2016). Surgical count process for prevention of retained surgical items: an integrative review. Journal Of Clinical Nursing, 25(13-14), 1835-1847. https://doi.org/10.1111/jocn.13216
Gomes, E., Galvão, M., Shimoda, G., de Oliveira, L., & de Araújo Püschel, V. (2020). Surgical counts in open abdominal and pelvic surgeries in a university hospital: a best practice implementation project. JBI Evidence Implementation, 19(1), 84-93. https://doi.org/10.1097/xeb.0000000000000253