Relief Count Disagreement--Please Help

[Emily Suzanne]

The situation:

As the relief RN, I came into the operating room at 1500. The case was a port placement and a nephrectomy. The supplies, instruments, etc, were opened and had already been counted by the previous team, but the case had not yet begun. Patient was in the room and asleep.

I was relieving three nurses (two of which were orientees) and one scrub tech. (Yes---a lot of cooks in the kitchen) The scrub nurse had scrubbed out before her relief arrived. The relief scrub nurse scrubbed in and I got report. At this time, the nurses I was relieving asked (reluctantly) if I wanted to do a relief count. I understand that it's 3 o'clock and everyone wants to go home, but I said yes, under the assumption that a relief count was policy--even in this sitation where the case hadn't quite started yet. The scrub nurse was pulling up to the field as this decision was made.

We ended up having to wait for an appropriate time for the scrub nurse to count in the middle of the procedure. Turns out that the original count was off. It took about 15 minutes for everything to be sorted and the nurses/tech I was relieving were unhappy (to say the least).

Originally I thought that I needed a relief count, but now I am second guessing myself. I guess because they had already done an initial count, I figured that we needed a relief count. It was an odd situation. If they hadn't counted, I could have done an intial count with the relief scrub nurse, but the case was so close to starting.

Thoughts? What would you have done in that situation?

[Rose_Queen, BSN, MSN, RN]

Verify the policy. My facility's policy states that there must be a count at any point of permanent relief, whether both circulator and scrub or only one. We also have a 30 minute overlap. Therefore, it is much easier for the current staff to continue doing what they were doing and the relief staff to be doing the count. Yes, there are times it can get a bit iffy with sponges, especially if several are in the incision, but we get it done. One reason why the scrub person should not break before relief is scrubbed in and ready to take over.

However, we also work to facilitate ways to avoid having to do relief counts. If it is that close to change of shift, we work at getting relief staff in ahead of time if they are from mid-shift (11a-7p) so that the later staff can do the initial count. The same goes for those of us on my cardiac team- if a case is going to be running at end of shift, we do our best to assign the call team to that case, partly so they are extra hands in the morning and partly to avoid the relief count.

[Emily Suzanne]

Thank you so much for your reply.

Our policy (or any policy that I can find) states what to be done in my specific situation. The case hadn't yet started, but everything had already been counted. The timing was just so weird. The case was minutes from starting. I don't know what the right thing is here. Should I have nixed their initial count and done our own inital count, or was I right in doing a relief count...or would either one be acceptable?

[FurBabyMom, MSN, RN]

Our policy is that if you are relieving someone who has already counted, and it is permanent (not lunch/break/etc), you count. Whether or not the procedure has started. Our policy says that anyone can ask to count and their coworkers have to go along with it. One person from the team (scrub or circulator) has to have participated in the initial or relief count. We are not allowed to leave the room until we've completed counting to the best of the ability at that time (sometimes we can't count things like patties, and that gets documented that everything else is correct but we omitted XYZ and why).

I guess my question would be - if people are scheduled to get off at 1500 and the procedure isn't starting imminently, why not try to wait for relief staff to count? Sometimes we're getting ready to start another case and someone gets relieved "off the list". We have a "go home early" list where folks who'd like to leave early can sign up and if staffing allows the charges send those folks home before mandating others (the charge nurse will relieve 0700-1500 staff then start on the list).

[WhoDatWhoDare, BSN, RN]

Thank you so much for your reply.

Our policy (or any policy that I can find) states what to be done in my specific situation. The case hadn't yet started, but everything had already been counted. The timing was just so weird. The case was minutes from starting. I don't know what the right thing is here. Should I have nixed their initial count and done our own inital count, or was I right in doing a relief count...or would either one be acceptable?

Well, in my facility our policy states that counts are done at specific instances AND whenever someone asks for a count, whether REQUIRED or not. The relief count is one of those specific instances and our policy doesn't have any verbiage regarding whether there was a surgical start or not.

You mention that one option was to just discard that initial count and do your own initial count. I pose to you the following question: What if the original was correct and your "new" initial count was inadvertently inaccurate? My opinion is that it couldn't hurt to have the extra count to ensure everything was correct and continued to be so.

I get that there might be some unfortunate delay with the outgoing staff getting out on time, but in THIS instance, based on what I'm understanding in your original post, it's a good thing you did this count since it appeared there was a discrepancy that needed to be corrected before the outgoing staff left... imagine how much worse/difficult it would have been to figure out what was wrong without the help of the people who setup/counted it still there had you not done this relief count in the first place.

Regardless, there was a difference of counts and this should be used as a teaching moment. Why was there a difference of counts? What can be done to prevent this in the future? Could there have been patient harm if not discovered? Etc...

Good luck,

-WhoDatWhoDare

[Emily Suzanne]

Thank you all for the responses. I thought that what I did was the right thing. The nurse that I relieved felt otherwise--- and expressed her disapproval to management, but I'm in very good standing with the manager so nothing came of it. She is a younger nurse and I think she was trying to assert herself, but it definitley made me think and second guess myself. And I'm still not certain why she was (is) so upset.

This was all a learning experience. But I like the policy that states if someone wants to count...you count!

If anyone else out there has any similiar experiences or advice, please contribute!

[springchick1, ADN, RN]

Our policy is that if you are relieving someone who has already counted, and it is permanent (not lunch/break/etc), you count.

We don't get scrubbed out for breaks but our policy is that you count when ever you are relieved, lunch or permanent And if it's lunch relief, you count when you come back. What happens if Needles get open while thr lunch relief is scrubbed in and then a needle is lost. It's too risky not to count whenever there is a change of staff.

[Rose_Queen, BSN, MSN, RN]

We don't get scrubbed out for breaks but our policy is that you count when ever you are relieved, lunch or permanent And if it's lunch relief, you count when you come back. What happens if Needles get open while thr lunch relief is scrubbed in and then a needle is lost. It's too risky not to count whenever there is a change of staff.

We do count our needles at every relief in cardiac, but an expectation of doing an entire count when nobody is leaving the department? Unrealistic.