Standardizing Sponge Accounting: A Process That Works

Inconsistent sponge accounting practices are a common occurrence in many ORs. Also common are retained surgical items, which continue to top The Joint Commission’s list of top reported sentinel events.

Determined to reduce this risk, Beth McCarthy, MSN, RNC-EFM, perinatal and perioperative educator at Lourdes Health System in Camden, N.J., and a multidisciplinary team instituted major changes to standardize the process for sponge counting.

“Prior to the change everyone had a different way of counting sponges and there was also no consistent approach for communicating the count as a complete team— counting is not just a nurse and physician issue,” McCarthy stresses.

The Process

Five changes for sponge accounting practices were implemented as part of the new process.

1. Changing the Sponge Count from Five to Ten Units

   Before McCarthy’s colleagues implemented the change, sponges were counted in units of five. Based on the Sponge ACCOUNTing System practices recommended by Dr. Verna Gibbs, founder of No Thing Left Behind, teams switched to keeping a running total of sponges counted off as units of 10.

   “We’ve found sponges are easier to view and count in units of 10,” McCarthy shares. Used sponges are documented on a white board in every OR and labor and delivery setting with a running total noted in 10s for all sponges on the field.




2. Replacing Clear Sponge Bags with Blue-Backed Bags

   This replacement was made to allow accounted sponges to be more visible when hanging in the bag for all to see.




3. Making Bloody Sponges More Visible

   The red lining usually used in the kick-bucket has been replaced with a clear liner, which McCarthy says makes a significant difference in improved visibility for bloodied sponges that were difficult to distinguish in the red liner.




4. Requiring the Physician to Verify the Count

   At end of a procedure, the physician is asked to stop and verify the count verbally. For example, a surgeon may say, “We have 50 sponges here, this is our running total and everything is accounted for.” This verbalization must occur before the surgeon can leave the room and the circulating nurse is encouraged to remind the entire team that this collective sponge accounting must be verbalized, McCarthy notes.




5. Rethinking What It Means To Account For Sponges

   In line with Dr. Gibbs approach, signage is placed in every OR and labor and delivery setting asking, “Where are the sponges?” McCarthy says this approach is a big change from thinking and asking, “What is the count.”

   “This conceptual framework of thinking about directional location of the count, versus only as a number has proven an effective approach to get all team members thinking differently about sponge accounting.”

   To support this new process a comprehensive policy for sponge and surgical item accounting was shaped based on Dr. Gibbs’ recommended approach, as well as recommendations in AORN’s Guideline for Preventing Retained Surgical Items.

Maintaining Standardization

McCarthy says working to make the new sponge accounting process more hardwired has taken dedication and reinforcement. “You have to change the culture on something like this, it starts with leadership and I think when staff understand the rationale behind the change they are more apt to buy into it.”

She incorporates case studies in simulation training for sponge accounting as part of required annual staff learning, which helps remind teams how serious an RSI can be for the patient, team members and for the facility caused by increased costs and the stigma of allowing a preventable patient injury.

While miscounts are much less common than prior to process change, teams document any miscounts (in which the count was corrected before the patient incision is closed) and these data are shared with facility- and system-level administration. No RSIs have occurred since the approach was implemented.

“Standardizing accounting practices are very much a matter of habit that can take a while to build,” McCarthy notes. “We have noticed that once standardization was implemented, we were more able to notice when a count went awry so we could resolve the issue quickly.”

Watch a video of the Sponge Accounting System in practice.

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AORN Journal CNE Articles

Back to Basics: Counting Soft Surgical Goods (.8 CHs)

Guideline Implementation: Prevention of Retained Surgical Items (1.7 CHs)

Clinical Issues- July 2016 (1.1 CHs)

Webinars

Guideline for Prevention of Retained Surgical Items (1 CH)

Guideline Update: Prevention of Retained Surgical Items (1.25 CHs)