Technology to Prevent Retained Items

Roughly 70% of retained surgical items are sponges, and roughly 80% of retained sponges occur with what staff believe is a correct count. No wonder OR managers are looking to technology to provide additional protections to the error-prone counting process that takes place in the clamor and chaos of the operating room.

A fatal case in point: In September 2017, a surgical team at Redding (Calif.) Mercy Medical Center left a sponge in a patient during bypass surgery to repair diseased blood vessels in his abdomen and groin. After surgery, the team did a sponge count and determined that all sponges had been retrieved. Ten days later, the patient died after suffering complications that included a cardiac-respiratory arrest. A postmortem abdominal X-ray revealed that a small sponge had been left in the patient's lower left abdomen, according to the California Department of Public Health.

An autopsy suggested that the man's death had been caused by several things, including peritonitis, or inflammation of the tissue lining the abdomen and covering abdominal organs, prompted by the sponge's prolonged presence in the patient's body.

It appears the hospital had followed its counting procedure, which states that "all sponges will be placed in the appropriate holders before the patient leaves the room. The physician must verify with the circulating RN that all holder pockets are filled and match the number on the dry-erase board."

The nurse and scrub technician who performed the counts in their usual manner told investigators that the pocketed sponge bag that was hung to place used sponges in had a partition that divided it down the middle. It had 2 slots on each side with 5 sections and could hold a total of 10 lap sponges, 1 sponge for each slot. She stated if the partition had become separated, 1 sponge could have covered 2 slots and looked like 2 sponges instead of 1.

In light of the incident, the nurse said they are now rolling the sponges so they fit the sponge holding bag better and making sure the ties for each sponge hang down. Each lap sponge has a blue tie approximately 7 inches long for the purpose of being visible when a patient is X-rayed. The X-ray-detectable marker is now placed where the team can see and count it (osmag.net/bEg4HP).

Is it any wonder that The Joint Commission estimates that current practices for counting sponges have a 10% to 15% error rate? We still practice audible and visible counts faithfully, and we use a whiteboard system to keep track of our counts. Sponge-detection technology can add an extra layer of protection against retained items. Here are some examples:

• The matrix label (barcoding). Electronic adjunct technology isn't used to replace the count, it used in addition to the count. One technology we're using now is called barcoding, but it doesn't actually look like a barcode. A barcode is made up of black and white lines. This technology uses a dot matrix label that looks like little boxes on each sponge.

You do your best to be vigilant in keeping track of your soft goods, but when humans are involved, that means there is always the possibility for errors to occur.

For each case, we scan every labeled sponge in, and at the end of the operation, we scan each sponge out using a tablet that can read the labels. The program uses each sponge's unique identifying number to track sponges counted in and out.

When you open a new pack of sponges, you do so on the back table, so the first pack is scanned in and then the surgical tech manually counts with the nurse, like you usually do. The scanning becomes like a second counter for you, one that keeps track of the sponges digitally. The technology keeps a digital record of the final sponge count.

• Radio frequency. With this option, all the sponges for the case have a small tag inside that is able to align with a radio frequency device. The detection device is usually a wand that can detect the tagged sponges if they are left in a patient or end up in the trash. The tag, a little bit smaller than a Tic Tac, is sewn into a little pocket on the sponge.

If we get to the end of the case and we're missing something, the radio frequency system can tell us if the sponge is somewhere in the patient. We then sterilely cover the "wand" and carefully scan over the wound, and if a tagged sponge has been left behind, the radio frequency device will detect it. A beep will go off on the machine, and you'll know there is still something left in the patient.

The wand doesn't tell you how many sponges there are — it can't count — it just tells you that there's a sponge in the patient's body somewhere.

You can also place a radio frequency detection mat under the patient on the OR table that connects to the same console as the wand. Instead of reading down — like the wand would if you were scanning the top of your patient — the mat reads upward. If there is a tagged sponge left inside your patient, you'll get an audible signal as you do with the wand.

The mat does not need a sterile covering because it remains beneath the sterile field. This allows for less interruption than the wand device because it is hands-free. The scrub person does not need to stop the flow of surgery to drape it and scan the patient. If you use the mat, you don't necessarily have to use the wand. They both perform the same procedure.

If the sponge isn't detected in the patient, you can then search the trash. Rather than digging through the trash with our hands and possibly contaminating the surgical field, we can wave the wand over the trash can, and if the beep goes off, then we can more closely examine the contents of the can.

• Combined approach. RFID — radio frequency identification — goes a step further by alerting you to the exact location, type and number of sponges in the surgical site. It's kind of like your car's E-ZPass. It can tell not only that a car went through the detector, but which car and who owns it.

Each sponge has its own unique RFID transmitter that can be detected by a wand device and scanned into and out of a program on a touch-screen tablet. The RFID sponge location system can not only tell you how many RFID sponges have been used and if any have been left behind, it will also tell you where they are. A digital read-out of the missing sponge(s) will appear on the screen of the tablet.

This system has both the capability to count the RFID sponges using a hand-held device and detect them using and RFID wand should you need to find the sponge inside the patient or somewhere else in the OR. OSM