New OR Nurse -Instrument Count Question

[heythere15]

Hi fellow OR nurses!

I am new to the OR (and a new grad RN... eek!)

I have a question about instrument counting at the end of a case. A case I was in yesterday had 4 trays open and instruments were everywhere ranging from the field, mayo stands, the back table, and floor. When I was counting with my tech, how do I know that the same instrument isn't accidentally counted twice.? Especially since instruments are still being passed to the surgeon while counting. I just don't want to accidentally count an instrument twice and call the counts correct when actually something is left in the patient.

Any advice?

Also, I have not learned to scrub...so if there are any tips or tricks that the techs use to keep track of which instruments came from which tray, I'd appreciate it!

Thanks!

[Rose_Queen, BSN, MSN, RN]

Counts should follow a sequence in that items are counted from the field out. It would start with the instruments in the surgeon's hands, then the mayo stand, then the instrument table, then anything that is off the sterile field. Anything that is not actively being used or set up to be used next shouldn't be scattered around- the scrub should have it back on the instrument table with the rest of the instruments not in use.

Even with cardiac surgeries where we have a lot of instruments out of a lot of trays, we are able to keep track of what's already been counted- if it's in the surgeon's hands when it was counted, it is laid on the patient's legs and stays there until the count is finished. If it's handed up to the surgeon and hasn't yet been counted, it's counted as it's handed up. Several of our PAs and surgeons are also self-sufficient- if we're in the middle of a count, they'll take what they need next off the mayo stand where the scrub has it waiting for them, and it's usually already counted by the time they're taking it.

As for knowing what instruments are in which pan, reach out to your sterile processing department- they may be able to print out lists of what's in each pan that you can keep for reference. Beyond that, it's just something you learn with experience.

[FurBabyMom, MSN, RN]

I have to agree with Rose Queen about the method to counting. My coworkers and I also separate what has already been counted from what hasn't been counted. The suggestion about familiarizing yourself with count sheets / tray contents is a good one.

How does your facility handle instrument counts - is it off a printed sheet, is it written down? I'm genuinely curious. For us, each tray is sent up from sterile processing with a "count" sheet. We're supposed to count off that sheet at the beginning and the of the case (writing down at the beginning that tray contents match what should have been in the tray, checking it at the end). Some of our staff had a practice of counting the trays from memory, which made it difficult for those less familiar with trays to relieve during cases in progress (we had the sheet from CPD, or maybe not as they often, at the time, were discarded, but it was a mess).

Due to the service I work on and the nature of our procedures, most of the time I do not have to count instruments. That said, I've done enough cases where I have had to count instruments that I know the contents of about 5-10 trays without looking at the sheet. I know the contents of nearly all of the trays on our service line and we don't have to count instruments often (we're rarely entering the abdominal or chest cavity). I don't know, I try to work out of one tray as much as possible. Virtually every tray we have has suture scissors, and either metz or tenotomy scissors (maybe even both), so I use the scissors out of whatever tray is my "primary" and closest whenever possible. Same goes for needle drivers - in most cases a needle driver is a needle driver (though there are times finer or smaller drivers are needed, or castros are needed). I take only what I need from my other trays. If that's a specific vascular clamp, or extra long instruments, then I know where each one came from. I put things back with the correct tray until needed again. I learned this practice when I was on orientation and learning to scrub. My coworkers teaching me - nurses and scrub techs taught me that it is generally easier to keep track of things if you keep things mostly orderly (whenever possible). That is in general the practice of most of the nurses and techs who scrub in our facility.

My other suggestion is maybe talking to the person scrubbing to see what they do to keep things from being counted twice? Maybe a conversation might provide valuable insight?

[Rose_Queen, BSN, MSN, RN]

How does your facility handle instrument counts - is it off a printed sheet, is it written down?

We have a printed sheet with names of instruments but no numbers. We count what's on the field- if we have more than one tray, they are combined and counted together. So, let's say we're doing a laparotomy. We have our basic instrument tray that is used on almost every surgery plus a laparotomy tray that includes longer instruments and bowel clamps. The "stringer" from the basic tray are on the table, then the instruments from the laparotomy tray are added in so that all like instruments are together- the 9" kelly clamps in the laparotomy tray are placed next to the 6" kelly clamps that are in the basic tray and all are counted as kellys. We've found many times that SPD miscounts when assembling the trays, and we no longer include count sheets inside the tray as everything is computerized.