instrument count records

stevierae · Jul 21, 2002

Hey Mike--

Where is West Point, CA? Do you guys need any travelers there?

shodobe · Jul 21, 2002

stevierae, West Point is a city of 600 people in the Gold Country of NorCal! Nearest hospital is in Jackson and is 70 beds. OR is run like a SDS, anesthesia doesn't want to work past 5pm. I work in SoCal at two 350 bed hospital. One does OH and heavy neuro, the other routine stuff.

PS, that 600 includes cows, dogs and goats. Mike

Jodie Nash · Aug 9, 2004

Hopefully you still have this email account and 3 years down the track you have heaps of info. I work in a theatre in Melbourne, Australia and we are reviewing the instrument count and would appreciate any information you have or direction you could give me.

Jodie Nash.

missmercy · Aug 9, 2004

PLEASE, PLEASE, PLEASE count -- then count again!!

My mother-in-law ( who is so supportive of my nursing career and the medical field in general:uhoh3: ) felt the need to place a newspaper article next to my plate at the dinner table just last night (we were invited for a family dinner) --

The article was all about some poor woman who went into OR for a long reduction who had died (7 years post-op) and donated her body to research -- hoping that we could learn more about COPD etc. -- When they went through the dissecting process, they found a large surgical towel rolled up behind her left lung. EEEWWW! The family is suing ( of course) -- saying that her quality of life was diminished by the fac that this towel was in there for so long. The disssection showed that her body was apparently attempting to wall it off -- HER surgeon doesn't feel that the towel would have any negative affect on the woman's health! WHAT!?!

So, as I said;

PLEASE, PLEASE, PLEASE count -- then count again!!

I wouldn't want any more articles to read. :uhoh3:

mcmike55 · Aug 9, 2004

I have been involved in this type of discussion before, and felt I took one for my hospital.

We have not done an instrument count in many years. None of the docs, new or old to us, have not demanded them.

In our defense, we are a small 3 room OR, we don't do neuro, open hearts, etc.

Our docs are very easy to get along with, and the techs do a great job watching what goes up comes back.

The techs have also taken it upon themselves to simplify our baskets, and our sterile processing people (in house) go to great lengths to make sure the baskets are packed properly, and check with us asap with problems.

Stevie and Shodobie, I'm sure you both have seen the studies saying that an instrument count alone does NOT guarantee somthing wasn't left.

I agree, that you do have to have policies in place to CYA. AORN has the bead on helping there. But we do no do counts either.

missmercy · Aug 10, 2004

After reading Mike's posts, I can see where the count could become a real pain in the keister!!! There must be some way to insure that goodies are not left behind prior to closing!!! SOme way to know that there aren't going to be surprizes!! I got to thinking -- of the 3 hearts I have watched -- the number of instraments on the tray readily to the doc were different with one doc than the other two ( that must be the mayo tray you were referring to?) That doc had a tech of sorts who was there for the express purpose of grabbing anything els the doc wanted instrament wise -- makes sense.

Any way I can get our docs who have the entire wal-mart stock at their fingertips to be sure they haven't let fun stuff in there when they are done instead of doing a count?! Could potentially save OODLES of time per case~!~

shodobe · Aug 12, 2004

The whole purpose of a count is not to save time but to assure patient safety. I don't think I could work an OR that doesn't count. I trust the people I work with, but still there is that potential for a mistake. I have seen it happen. There is a real weak defense to a jury with an excuse, we don't count because we trust each other. I don't think there is a jury in the country that would buy that for a second. Counting is a priority and should always be done no matter what. Policies aren't put into place just to CYA but as I said before, you are the patient advocate and you are there to protect the patient. Not counting is like selling tires and not putting air in them. Not counting is very,IMHO, unprofessional. Just my two cents worth. Mike

Also, MDs do not have an opinion weather counts are performed or not. They can moan and groan all they want, I still count. The department should have a policy inplace for counting and if not, can you spell, "liability"

stevierae · Aug 12, 2004

PLEASE, PLEASE, PLEASE count -- then count again!!
My mother-in-law ( who is so supportive of my nursing career and the medical field in general:uhoh3: ) felt the need to place a newspaper article next to my plate at the dinner table just last night (we were invited for a family dinner) --
The article was all about some poor woman who went into OR for a long reduction who had died (7 years post-op) and donated her body to research -- hoping that we could learn more about COPD etc. -- When they went through the dissecting process, they found a large surgical towel rolled up behind her left lung. EEEWWW! The family is suing ( of course) -- saying that her quality of life was diminished by the fac that this towel was in there for so long. The disssection showed that her body was apparently attempting to wall it off -- HER surgeon doesn't feel that the towel would have any negative affect on the woman's health! WHAT!?!
So, as I said;
PLEASE, PLEASE, PLEASE count -- then count again!!
I wouldn't want any more articles to read.

That woman was lucky to have lived 7 years given her disease process, and the family should be thanking the doc that gave her the additional 7 years--not suing him. If I were to be called as an expert witness in this case, I would say exactly that. If I recall the article correctly, this woman had lung cancer--the COPD was secondary to that; probably from years of cigarette smoking (which also caused the lung cancer.)

That is not to say that leaving a blue towel in was acceptable--but, 7 years ago, instrument counts were not routine everywhere, and blue towels--if used at all--were generally written on the count board like this: "Blue towel in peritoneum" (or chest, or wherever) and then, when the surgeon pulled the blue towel out for everyone to see, it was crossed off the count board. They are not X-ray detectable, so, even if they had done repeated X-rays over 7 years, it would never have shown up on X-ray. The circulating nurse should have written this on the count board. If anyone should be blamed, it should be the circulator--not the surgeon--blue towels need to be treated as any counted sponge would be counted, and removal of same verified and documented. But, again, in a med mal case, duty, breach of duty, damages and causation--ALLL 4---must be proven. In this case, I just don't see damages OR causation. She died of lung cancer and old age.

The body attempts to wall off ANY foreign body, no matter how small. Haven't you ever gotten a wooden sliver in your foot, been unable to extract it, and then later wound up with a foreign body granuloma--in other words, the sliver became encapsulated? People have bullets or shrapnel left in them all the time, rather than undergoing an unnecessary procedure to remove them--even a bullet in the lung may not be necessarily harmful.

Shodobe and I think differently on instrument counts--I think they are a royal, unnecessary pain in the a**. I have said this before--if the scrub would learn to put a minimum number of instruments, in pairs, up on his Mayo stand, put them back in his soak pan when they are no longer being used, replace them with what is needed prn, and end up, while closing, with only a suture scissors on the Mayo (the surgeons have the needle drivers, retractors and pick-ups) there would be no need to count instruments. It's only since newer scrubs have gotten into this routine of bringing practically their entire back tables up onto the Mayo, in no rational order and without gettign rid of them once they are no longer needed, that instrument counts became necessary--they were not willing, or able, to keep track of what was up on their Mayo at any given time, and that's when you started hearing about instruments left behind in body cavities.

I know where all my instruments are at any given time; I was trained that way--also, even on major cases, I rarely have more than 12 instruments up on my Mayo at any given time. I see people who have odd numbers--3, 5-- of every known variety and length of right angle ALONE up on their Mayo throughout the case--not to mention both long and short scissors, pick ups, etc.--and I just wonder where the heck they trained.

carcha · Aug 12, 2004

I am really amazed that so many of you either dont do an instrument count, or dont agree with it. I know like all of you that their a pain in the behind but my question is simply, why not do a count?. I have read a lot of subjective reasons on this thread but none that would make me review my practice. If your standing at the table anyway, your doing a sponge, suture ect ect count then why not do an instrument count. Are instruments left in the patient YES they sure are and the examples are out there for all to see. The latest is the lady in NY I believe who had a scissors left behind. The gentleman with a copper ret. left in his abdomen, the patient in the hospital I once worked in, though it was before my time when counts were not as rigid as today who had a roberts left behind. The risk manager told us of this case. So though you all may not have experienced it the fact is it happens so why not protect yourselves, the hospital, the patient and count the lot. It really dosent take up much time and yes I agree it dosent guanantee an item wont be left behind but ethically you will have tried to reduce that risk and thats all any of us can do. :

shodobe · Aug 13, 2004

stevierae, I agree they are a royal pain in the butt and I would rather not do them. Too many people put waaaay too much up on their mayo and this is the area where inst can be monitored. I have done enough types of cases to know what number of clamps and such to put on my mayo and I never vary from the number. I still put up the same amount of kellys that I put up 25 years ago for a hyster or open chole. The problem I see is usually the scrub doesn't keep an eye on everything they use and they don't take the time to find them to be able to say they are accounted for. When I go into break someone for lunch I usually start to reduce the number of inst on the mayo, because most of the stuff you won't use and I think they put them up for security. It would be nice to know that everything was perfect and you could trust everyone, but that isn't the case. I can say that there are people I trust explicit and others I don't trust as much. All of the surgeons that I work with always ask at the end of a case if the count was OK and I usually tell them if it wasn't they would be the first to know! Mike

stevierae · Aug 13, 2004

If your standing at the table anyway, your doing a sponge, suture ect ect count then why not do an instrument count.

Here's why: when one has time, at the beginning of the case and perhaps before the patient is even brought into the room, you can count at a slow, relaxed pace, and the instrument stes are very basic.

Then later, when all hell breaks loose and the aorta is inadverdently punctured, the scrub is doing his damndest to keep up and help keep the patient from bleeding to death, handing up vascular stitch after vascular stitch, trying to get the cell saver hooked up, trying to grab a vascular clamp or two as soon as somebody can get a vascular tray opened, and here's some inexperienced circulator, demanding that the scrub stop whatever he is doing and count towel clips--or suction tips--or each and every loose part on a Thompson retractor--or the damned Allis clamps --30 of them--that he hasn't used and WON'T use--or freakin' lap rings, which are in the major vascular tray but haven't been used since 1962--or 86 vascular clamps , (in ADDITION to the 32 bulldogs,) when all the surgeon plans to use is a single Craaford---and the surgeon thinks that the scrub isn't paying attention to the field, and, indeed, he isn't and he CAN'T, because of someone else's need to count everything as it is added to the field--and a LOT is added to the field, all at once.

Then when all is calm again and the poor scrub is trying to help close--and often all that is left are the surgeon and the scrub; the scrub is trying to retract, load suture, cut suture, irrigate and start counting sponges and needles--but he once again has to take his attention away from the field and count instruments--far more than he started the case with--and God forbid he can't find a metal Yankaur suction that was used--everything stops while he has to go through 3 or 4 soak pans and instrument trays until it is finally located--on the floor, with the cell saver tubing that fell off the field and got kicked underneath the Bovie when things were chaotic, 2 hours and 2 scrubs ago.

I really think that what is done at some hospitals should be implemented universally in lieu of instrument counts--every patient gets an abdominal X-ray before they leave for the PACU.

Oh, and if I was queen of the world, (LOL!!!) I would mandate that no scrub ever has more than 12 instruments up on the Mayo at any given time--and if those instruments were not in pairs, or in multiples of two, they'd go back to OR school and learn how to set up a Mayo tray in an efficient manner.

No, I've got a BETTER idea--they'd go to NAVY OR school and learn to set up a Mayo tray the Navy way--in an incredibly efficient manner.

You know, also, we hear about these cases of retained instruments and they make them sound so horrendous--yet, in most of the cases, the patients suffered no harm AT ALL. That's not to say it's OK to leave an instrument behind--but I don't think thse cases are as widespread as the media would like to have the public believe they are. In 30 years, I have never known of a retained instrument in any hospital in which I have worked, and that includes doing major trauma and bariatric cases. I really think the key is making the scrub more accountable for what he puts up on his Mayo--keeping it to a minimum, and not putting odd numbers of instruments up.

missmercy · Aug 13, 2004

Hey! shobedo and stevierae -- I hear ya!! I think that OR has become a very very complex and extremely volitile area these days!! Considering that many of the case that are considered routine now were not even dreamed of as recently as 25 years ago! Wouldn't it be great if there were bar codes, or chips or something that would enable the count to be accomplished through a quick techno scan or something?! I'll get right oninventing that!!

I guess what I think I am hearing is this: Yeah, counts are a great idea IF you have time, however, with back to back to bac OR cases, case that jump into the devils handbasket and set off for the hot place, and over zealous stocking of the mayo -- counts have become very timeconsuming, very counterproductive and frustrating! I agree that the cases of instruments getting left behind cannot be as frequent as the media would like us to think -- the government would have gotten involved or something if they were all that common. We could blame those random cases on aliens or something anyway ( just a thought). So, until we can develop either more frugal set ups, fool proof surgical procedures -- that won't get nasty, or we find some high tech way to monitor instrament use -- it just isn't practical to spend the time to do extensive and exhaustive counts .... sound right? Makes sense to me.

By the way shobedo -- I have a 20 pound mutt -- all cute and puppyish looking who is certain that she is a doberman:rolleyes: !! The quintesential guard dog!! She is finding it difficult to convince the rest of the dogs in the neighborhood of that though -- they all just think she's a sissy dog -- but we know that inside that little body -- somewhere -- is a "real dog!!" :chuckle