count sheet

[MsHB]

I have noticed that a few of my fellow nurses will sign the count sheet before the final count is completed. They will sign it after the initial count. This doesn't seem right to me, as I always thought that you shouldn't pre-sign anything, and that you don't sign the count sheet until the final count is completed!

What will often happen is that a nurse will pre-sign for the count, get called away, and not even be there for the final count, even though they signed for it. When I asked them why, it is usually "no particular reason" or "in case I forget to do it later"

Does anyone have any ideas, comments? Or is it just me?

Ta

Ms HB

[carcha]

Although I dont profess to know much I DO believe that counting instruments has got to be better for all concerned then not counting them. Why in this day and age of lawsuits would anyone believe that a count is un necessary?. Do all hospitals have policies?, and if so if a count is part of the policy and not performed both scrub and circulator should find themselves in a lot of trouble because its due to laziness or massive egos that they have not done a five minute count. I do believe the post that states a count cannot guarantee an item cant be left behind, I believe the only way to guarantee that would be to x-ray every patient prior to closing, ..... twice....., so protect yourselves, do a count, thats my thought for the day!

[TMnurse]

I worked at a medium size community hopsital (6 ORs) where we did instruments counts. It was no problem to do a closing count x2 of everything and instruments. I now work at a University/teaching hospital with 4x the number of ORs. More over, it seems that all the cases we do are major stuff (no lap choles) and we open 3-5 trays for nearly everything. We cannot effectively do closing counts. For a while, we tried but the docs are usually closed and ready to move the patient out of the room and we're only on our 2nd or 3rd tray. We have tried but are limited to only large/obese patients to do instruments counts. Does anyone have a second RN scrub in to help do a count while the other scrub nurse helps close? It seems to me that would be the only way we could effectively do closing counts. Any ideas?

[MsHB]

I worked at a medium size community hopsital (6 ORs) where we did instruments counts. It was no problem to do a closing count x2 of everything and instruments. I now work at a University/teaching hospital with 4x the number of ORs. More over, it seems that all the cases we do are major stuff (no lap choles) and we open 3-5 trays for nearly everything. We cannot effectively do closing counts. For a while, we tried but the docs are usually closed and ready to move the patient out of the room and we're only on our 2nd or 3rd tray. We have tried but are limited to only large/obese patients to do instruments counts. Does anyone have a second RN scrub in to help do a count while the other scrub nurse helps close? It seems to me that would be the only way we could effectively do closing counts. Any ideas?

So would that mean that the second RN is scrubbed for the entire case?

[orrnlori, RN]

I worked at a medium size community hopsital (6 ORs) where we did instruments counts. It was no problem to do a closing count x2 of everything and instruments. I now work at a University/teaching hospital with 4x the number of ORs. More over, it seems that all the cases we do are major stuff (no lap choles) and we open 3-5 trays for nearly everything. We cannot effectively do closing counts. For a while, we tried but the docs are usually closed and ready to move the patient out of the room and we're only on our 2nd or 3rd tray. We have tried but are limited to only large/obese patients to do instruments counts. Does anyone have a second RN scrub in to help do a count while the other scrub nurse helps close? It seems to me that would be the only way we could effectively do closing counts. Any ideas?

Yes, I work in a large teaching hospital that's also a level one trauma center. We also many times have large, as in absolutely huge, patients. During traumas with multiple services involved it's impossible to do smooth counts because we can have 5 or 6 pans easy opened and being used, along with all the other things that go on during a big bloody surgery. It's a real problem

[suzanne4, RN]

Any of my trauma cases, where we do not get a chance to do a proper count............we always just do an x-ray before moving the patient off of the table. That is all that you can do.

But on other cases where you have 5 or 6 pans open, you are not usually using everything from each pan, I try to keep only the pan or two where I am using everything in it, then the other trays on a separate table when possible, and only count what I have taken from them, keeping them covered with a sterile towel, so no one takes from them. It makes the counting much easier. Usually, you are just taking a retractor from another tray or something like that. And it is much easier to count just the few things that you have added to your set.

Of course, with a big trauma, only x-ray can be your friend. We get one before we move the patient off of the table, as well as have it read by a radiologist before moving the patient.

Hope that this helps................. :balloons:

[carcha]

Suzanne4, I have seen this type of count in another place I have worked in and do not agree with it. The circulator has got to take the word of the scrub that she/he only took one instrument out of the tray, and what happens if someone takes over from you and takes your word so on and so on and you've made a mistake. As far as I'm concerned the only proper count is a complete count nothing less and I've refused to do a partial count with the scrub. Would it stand up in a court of law,is it policy and acceptable practice in your hospital, if not why put yourself at risk?. Are you telling the surgeon after each count that " the sponge, needle, and instrument count is correct" or do you say "the sponge, needle and partial instrument count is correct".

My other concern is the post about the amount of instruments hindering the count. I would have thought that if anything because you are using so many instruments is precisely why you must protect your patient and do a count. As for the surgeons having closed before you can do the count, well they only finish closing if scrub nurses continue handing over sutures before they have completed what every or nurse be they the most junior of the most senior, knows is legally and ethically correct, a full sponge needle, and instrument count. I'm not preaching, sorry, but I've seen what happens to a scrub nurse when an instrument is left behind. Protect yourselves.

[MsHB]

Suzanne4, I have seen this type of count in another place I have worked in and do not agree with it. The circulator has got to take the word of the scrub that she/he only took one instrument out of the tray, and what happens if someone takes over from you and takes your word so on and so on and you've made a mistake. As far as I'm concerned the only proper count is a complete count nothing less and I've refused to do a partial count with the scrub. Would it stand up in a court of law,is it policy and acceptable practice in your hospital, if not why put yourself at risk?. Are you telling the surgeon after each count that " the sponge, needle, and instrument count is correct" or do you say "the sponge, needle and partial instrument count is correct".

My other concern is the post about the amount of instruments hindering the count. I would have thought that if anything because you are using so many instruments is precisely why you must protect your patient and do a count. As for the surgeons having closed before you can do the count, well they only finish closing if scrub nurses continue handing over sutures before they have completed what every or nurse be they the most junior of the most senior, knows is legally and ethically correct, a full sponge needle, and instrument count. I'm not preaching, sorry, but I've seen what happens to a scrub nurse when an instrument is left behind. Protect yourselves.

I agree carcha, a full count must be done. Not only for the patient's sake but also for our own.

I know I have limited experience, but in our OR we do two counts for all major cases, (counting every instrument - regardless of whether we use it or not), and the surgeons always want to know if everything is correct before they close.

Do surgeons in other hospitals out there really close up the patient and not care if everything is accounted for?:uhoh21:

[orrnlori, RN]

Yes. Especially if the patient is unstable. They will go for the xray before they will wait for the counts.

[suzanne4, RN]

You can be counting off the other trays as you go along, just as we do in heart cases. This is my preferred way of doing the counts anyhow. You are not using instruments from each tray thru to the end of the case, at least not normally. And if you are, then perhaps some of your trays need to be redone. I had that happen at a hospital that I went to work at, they were opening seven trays for a small case each time. It was much more efficient to just create a new case for that particular service.

[carcha]

Orrnlori, I dont understand your point. I like u have I'm sure ,taken part in some horrific trauma cases, and some elective cases which have gone very wrong. Those cases if so unstable are kept intubated anyway and sent to the unit. I have never, never, never not completed a FULL count nor has my count in any way delayed the surgeons, anaesthetist or delayed the patient in any capacity. There is no excuse for any scrub nurse not performing a full count as she is legally and ethically obliged to do. To put the blame on the medical personnel is just not acceptable. We are professional, responsible, and accountable practitioners. No excuses. As you can tell I feel strongly about this one.

[orrnlori, RN]

Two weeks ago we had an MVA crash through the OR, shattered pelvis, open head, liver and spleen lacs, both femurs fractured. The surgeons refused to wait while we finished the counts, they packed her and they wanted her in angio because they couldn't find all the bleeds. I'm not BLAMING the surgeons, however, it is THEIR CALL TO MAKE! They pulled the patient out of the OR to go to angio. We finished our counts, but the patient was rolling out the door as we did. The surgeons' position is that saving the patient trumps OR policy every time. What do expect the nurses at my hospital do, throw themselves in front of the doors and tell them they can't make this call? I'm not talking about the chole that goes south here. I consider myself a professional, responsible and accountable too, but ultimately it's the doctor's call where I work. I trust their many many years of medical training to make those decisions.

[Audreyfay]

When I worked in the OR, there was one plastic surgeon who DID NOT WANT any counts done. Therefore, he took complete responsibility for the "no count" status. There was one time I was circulating for one of his cases and he ended up nicking an artery. All of a sudden there was a huge incision and sponges packed everywhere. Since he said no counts in the beginning, there was still no counts in the end. However, the scrub nurse was still responsible for making sure the instrument sets were brought back complete. I recall going through the laundry many times, searching for towel clips!

Regarding narcotics, I was the nazi. I couldn't stand it when people didn't sign out their narcotics. A little trick I picked up was to always count what was left and signed out as I was signing out mine. It saved me more than once! Can't be careful enough. Never sign before counting. That can otherwise be called signing your license away. Mine is too important!