Instrument Counts

[mcmike55]

At the "suggestion'" of our insurance carrier,,,,our hospital is planning to

re-institute instrument counts.

Ok, I know, we should have always been doing them.....let's not go there!!

Moving on....my question.

Any helpful suggestions to getting this started again??

Over the years, several of our baskets have, in my opinion, gotten out of hand. My suggestion is to thin them back down, taking the "extras" and making up new baskets. That way, we only count what we, 9 out of 10 times, will use.

We already have basic trays, Heinz (for big cases) Misc tray, Minor and Small instruments. We then add trays if needed for specific cases such as Uro or TAH's.

I'm also concerned about the surgeons. We will likely add maybe 10 mins or so onto each case. I'm not sure how they will handle this!

My thought is that they just will have to learn to live with it. I also suspect that we will get better and quicker at it.

If I remember, our old policy said that we don't need to do instrument counts on small cases like carpal tunnels or cystos for example.

But in those days, we didn't do laparoscopic cases.

How do you all handle like lap chole's, etc??

Mike

[Marie_LPN, RN, LPN, RN]

We only count instruments on cases where the peritoneum is entered. We count sharps and sponges on everything, even myringotomies

BUT we only count on lapro cases if the case is posted "laproscopic, possible."

For example "Total lady partsl Hysterectomy, possible abdominal." Or "Laproscopic Cholecystectomy, possible open."

We also count insturments if the surgeon requests it (to avoid the xraying at the end of the case).

If the surgeon doesn't like the count, remind them of pt. safety. They'll just have to get over it.

[grimmy, RN]

i agree with marie. its about pt safety, but you can also remind them that instruments left inside the body are a quick trip to litigation for everyone in the room. we count for any possible body cavity incision (as marie mentioned), and we count smalls for everything, even neuro and eyes. our docs are used to it, and we don't make a big deal. we do have a few that grumble when the scrub is busy counting during closing, but our scrubs are good at making sure all closing suture is lined up and ready to go while counting. if they complain, take them to lorne blackbourne's book "surgical recall," chapter 1, page 7 (all our medical students carry it) where it says:

"never argue with the scrub nurses-they are always right. they are the self-less warriors of the operating suite's sterile field, and arguing with one will only make matters worse."

'nuff said.

[carcha]

Your idea for setting up your counts again sounds great. I'm sure you'll iron out any wrinkles. I couldent agree with you about the extended time counting. May I ask what does your scrub do while the surgeons are closing the wounds now?. The count should take up no more time then no count. I would suggest that you all discuss when you will do your counts following the surgery to make sure your all on the same page, especially the junior nurses who may never have counted before. I find that a lot of nurses do their final count far far too early when its possible for a foreign object to be retained I also feel you should drum into your junior what to do when the first count is incorrect, ie do not keep handing over sutures in the hope the missing sponge is found. I dont mean to preach but these simple incidents have almost been the down fall of at least 5 of my colleagues over the years, good luck from us in london and happy counting!

[kimballina]

I agree that you should modify your trays as best as you can to make them more efficient and easier to count. At my hospital, in Sydney, Australia, we have always checked our trays and have to sign paperwork to say checks have been done pre and post op (by both scrub and scout doing the count).This count is done for all procedures no exceptions!!!!. It is part of our Australian heath department policy.It really does not take that long,and trust me the surgeons get use to it (they did complain a little bit in the beginning).They now rely on it!!I suppose it has been made easier by the fact that the surgeons have to wait for us as it is protocol for all checks to be done prior to commencement of any incision.

Yes it is difficult for junior and new staff but they also see it as a great way of learning their instruments!!

Our operating time has not seemed to have slowed down.For instance a typical day: 2x hernias, 3x lap choles, 2x liver resections, 3x ERCPs .We stop operating at 6pm,start at 8am.

We here do not x-ray every patient after an op, that is considered as a unneeded exposure to radiation,so the instument check is a wonderful reassurance that nothing has been left in the patient.Of course if there is any discrepency or doubt about totals a x-ray is done before the patient leaves the room.

Hope this helps.

Kimballina

[mcmike55]

Thank you all for your responses!! I knew I could "count" on you!

To respond to a couple of things that came up.

Our techs are usually busy during closure holding retractors, etc, acting as first assistants. It's not unusual for us to do say a hemi-colectomy or lap chole with only the surgeon and tech.

I may have built in a little too much time I guess, but I would like to start on the high side and work back.

The other day, we had a scrub tech teacher from a local college come in and talk to everyone about keeping our count technique all the same, it did help.

Also, a couple of the techs are working with the docs and sterile processing on cutting down trays. Over the years we have just gotten too much stuff on some of them.

The RN's, are working with the docs on the paper work side, revising our policy's to make this work.

We have not yet started our counting,,yet,,,some preliminary stuff to get in place first.

Kim,,,,,thanks for your input. I guess it just shows how "old fashion" I am. I just find it soooo coool that two nurses, one in Ohio, and another in Australia can talk and share view points. I LOVE IT.

Thanks again. Mike

[grimmy, RN]

we have not yet started our counting,,yet,,,some preliminary stuff to get in place first.

kim,,,,,thanks for your input. i guess it just shows how "old fashion" i am. i just find it soooo coool that two nurses, one in ohio, and another in australia can talk and share view points. i love it.

thanks again. mike

speaking of australian nurses, we have a travel nurse from australia, and she has mentioned the back tables they have with multiple levels and "side pans" that attach to the back table. well, i want one! maybe we have them in the us, but i haven't seen one - i've been sheltered - and maybe they cost more. she also laid out her stringers backwards, that is, with the business ends of the clamps facing the back of the table. this was so that the circ, who would be at the back of the table, could easily see the clamps during a count. i love meeting nurses from different places because of the different ways to do things. i learn a lot!

[mcmike55]

Grimmy,,,I agree, I would like to see an attachment for the back table. Might come in handy at times. Sort of like attaching a Thompson, but to the back table instead of the OR table I guess.

We have always pointed the working end of the instruments away from the field. In my limted scrub experience, it was easier to ID the instrument, the grab the handle when it was closest to me. It is easier for the circulator too.

Our basic string goes needle drivers, scissors, hemostats, kelly's, kochers, then to allis and babcocks, ending with sponge sticks.

Most of the techs, put them drivers to their left, but a few went right to left.

I always liked left to right. Most of my work was done on the left side of the back table. Again, in my limited scrub experience. When the docs walked in and see me, there question usually is, "who called off" or something along the lines of "are we that desprite" :chuckle

I love it though!! Mike

[grimmy, RN]

grimmy,,,i agree, i would like to see an attachment for the back table. might come in handy at times. sort of like attaching a thompson, but to the back table instead of the or table i guess.

we have always pointed the working end of the instruments away from the field. in my limted scrub experience, it was easier to id the instrument, the grab the handle when it was closest to me. it is easier for the circulator too.

our basic string goes needle drivers, scissors, hemostats, kelly's, kochers, then to allis and babcocks, ending with sponge sticks.

most of the techs, put them drivers to their left, but a few went right to left.

i always liked left to right. most of my work was done on the left side of the back table. again, in my limited scrub experience. when the docs walked in and see me, there question usually is, "who called off" or something along the lines of "are we that desprite" :chuckle

i love it though!! mike

our stringers change depending on the pan, but most begin with scissors, drivers, and work on down to sponge sticks and cv clamps. we had to go to additional pans when it was just too darn heavy to lift the rib instruments. we rarely use doyens and fenestrated chest retractors, but they're in there (and weigh a ton). i'd never thought to put the stringer "backwards," and i wonder if i'd be able to see them from the field...regardless, i don't necessarily want to change my habit, since it works well for me, and as a team we have to agree on setup changes. we scrub each other out for lunch and shift changes, and having a standard setup facilitates the relief process.

i think what i'd love about the whole backtable add-on or shelf system would just be places to stash the stuff i don't use everytime, but when you need it, you need it sorts of stuff...like specimen containers or telfa, the marker, dressings i want to stay clean, etc. i do have stash places now, but they're not necessarily easy to access. and, especially for those 2 or 3 part cases, like esophagectomies, and mediastinoscopy/lobectomies, my extra mayo is stacked to the roof!