5.5 Surgical Counts and Prevention of Retained Surgical Items

Surgical Counts and Prevention of Retained Surgical Items

Quick Answer: Surgical counts are legal, standardized perioperative safety procedures performed to prevent Retained Surgical Items (RSIs)—a Joint Commission Sentinel Event and CMS Never Event. Mandatory count intervals: 1) Initial baseline count (before incision), 2) Cavity within a cavity closure (e.g., uterus in C-section), 3) First closure count (peritoneum/deep fascia), 4) Final skin closure count, and 5) Relief staff handoff. Count order: 1) Operative field $\rightarrow$ 2) Mayo stand $\rightarrow$ 3) Back table $\rightarrow$ 4) Off-field kick buckets. Discrepancy algorithm: recount immediately, notify surgeon to halt closure, search wound and room, and obtain intraoperative X-ray before wound completion.

Preventing the unintended retention of foreign objects in surgical wounds is a primary professional and legal responsibility of the surgical technologist and circulating nurse. Retained items cause severe patient injury, sepsis, visceral perforation, secondary re-operations, and significant institutional liability.

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1. Regulatory Framework & Never Events

• Retained Foreign Objects (RFOs / RSIs): Classified as Never Events by the National Quality Forum (NQF) and Sentinel Events by The Joint Commission (TJC).
• CMS Non-Reimbursement: The Centers for Medicare & Medicaid Services (CMS) designates RSIs as a preventable hospital-acquired condition; hospitals receive zero reimbursement for secondary corrective surgical procedures or medical management resulting from retained foreign bodies.
• Standards of Practice: Governed jointly by the Association of periOperative Registered Nurses (AORN) Guidelines for Prevention of Retained Surgical Items and the Association of Surgical Technologists (AST) Standards of Practice for Surgical Counts.

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2. Countable Categories and Packaging Standards

                       SURGICAL COUNT CATEGORIES

  1. SPONGES                    2. SHARPS                  3. INSTRUMENTS
     - Laparotomy (Packs of 5)     - Scalpel blades           - Trays & modular sets
     - Raytec 4x4 (Packs of 10)    - Suture needles           - Retractor blades
     - Cottonoids (Packs of 10)    - Hypodermic needles       - Screws / wing nuts
     - Peanuts/Kittners (5)        - Electrocautery tips      - Bulldog clamps
     - Tonsil sponges (5)          - Vessel clips / bars      - Malleables

Sponge Classifications & Handling Rules

Absolute Sponge Safety Mandates

1. Radiopaque Verification: Every sponge on the sterile field must contain an X-ray-detectable element.
2. Never Alter Sponges: Sponges must NEVER be cut, torn, or trimmed with scissors.
3. Prohibition as Dressings: Radiopaque sponges must NEVER be used as postoperative wound dressings; radiopaque filaments on skin dressings can obscure diagnostic post-op X-rays.
4. Packaging Discrepancies: If a newly opened package contains an incorrect number of sponges (e.g., 9 Raytecs instead of 10), the CST must immediately hand the entire pack off to the circulator, who bags, seals, labels the pack as "INCORRECT (9)", and isolates it completely from the sterile field.

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3. Sharps, Instruments, and Miscellaneous Items

• Sharps: Scalpel blades, suture needles, hypodermic needles, electrocautery scratch pads, cautery active tips, safety pins, nerve stimulator needle probes, and vessel clip cartridges.
• Instruments: All assembled instrument trays, specialty add-on sets, and modular retractors (Balfour, Bookwalter). All loose pieces (screws, wing nuts, interchangeable blades, rubber clamp boots) must be counted individually.
• Miscellaneous Items: Vessel loops (red, blue, yellow, white), umbilical tapes, Fred anti-fog sponges, disposable bulldog clamps, vascular inserts, and suture booties.

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4. Surgical Count Timing and Intervals

                      MANDATORY COUNT INTERVALS

  1. INITIAL BASELINE COUNT ====> (Before skin incision; all field items)
  2. CAVITY WITHIN A CAVITY =====> (Uterus in C-section / Bladder closure)
  3. FIRST CLOSURE COUNT =======> (Peritoneal / Deep Fascia / Joint capsule)
  4. FINAL SKIN CLOSURE ========> (During subcutaneous and skin closure)
  5. STAFF RELIEF HANDOFF ======> (Whenever CST or RN permanently relieved)

1. Initial Baseline Count: Performed by the CST and Circulating Nurse prior to the skin incision. Establishes the baseline inventory of all sponges, sharps, and instruments.
2. Cavity within a Cavity Closure: Performed whenever a hollow organ or closed compartment inside a major cavity is closed (e.g., closing the hysterotomy incision in a Cesarean delivery, bladder closure, cardiac chamber repair).
3. First Closing Count (Peritoneal / Deep Fascia): Performed as soon as the surgeon begins wound closure of the primary cavity (peritoneum, deep muscle fascia, pleura, joint capsule).
4. Final Skin Closure Count: Performed during subcutaneous tissue or subcuticular/skin closure.
5. Personnel Relief Count: Performed whenever either the scrub person or circulating nurse is permanently relieved during the procedure.

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5. Dual Concurrent Counting Mechanics and Zone Sequence

Counting must be performed simultaneously, audibly, and visually by both the CST and the Circulating Nurse. Sponges must be separated and counted individually into distinct stacks.

                     SURGICAL COUNT ZONE SEQUENCE

  [ 1. OPERATIVE FIELD ]  ---> (Wound, cavity, retractors, sponges in use)
           |
           v
  [ 2. MAYO STAND ]       ---> (Active working instruments, sharps, sponges)
           |
           v
  [ 3. BACK TABLE ]       ---> (Reserve instruments, un-opened packs, basins)
           |
           v
  [ 4. OFF-FIELD ]        ---> (Kick buckets, clear plastic sponge counter bags)

• Bagged Sponge Counter Bags: Used sponges are placed in clear plastic hanging organizer pockets (5- or 10-slot capacity) to allow immediate, continuous visual validation.
• Room Confinement: No linen hampers, trash bags, or kick buckets may be removed from the OR suite until the procedure is finished, final counts are declared correct, and the patient has been transported out of the room.

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6. Incorrect / Discrepant Count Resolution Algorithm

When a count discrepancy occurs, the surgical team must immediately execute the standardized emergency resolution protocol:

                  INCORRECT COUNT RESOLUTION ALGORITHM
                  
                     [ COUNT DISCREPANCY DETECTED ]
                                   |
                                   v
         [ STEP 1: Immediate Recount with Circulating Nurse ]
                                   |
                                   v
         [ STEP 2: Notify Operating Surgeon; HALT Wound Closure ]
                                   |
                                   v
         +-------------------------+-------------------------+
         |                                                   |
 [ STEP 3: Sterile Field Search ]            [ STEP 4: Room Search (RN) ]
 - CST searches Mayo stand, back table,      - RN searches kick buckets, trash,
   basin sets, under sterile drapes            linen hampers, under OR table
         |                                                   |
         +-------------------------+-------------------------+
                                   |
                                   v
              [ STEP 5: Surgeon Systematically Explores Wound ]
              (Inspects anatomical gutters, subphrenic space, pelvis)
                                   |
                                   v
               [ Item Still Missing? ===> YES ]
                                   |
                                   v
            [ STEP 6: Order Immediate Intraoperative X-Ray ]
            (Portable X-ray/Fluoroscopy of entire operative field)
                                   |
                                   v
            [ STEP 7: Radiologist & Surgeon Review Radiograph ]
                                   |
                                   v
            [ STEP 8: Document in EHR & File Incident Report ]

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7. Technology-Assisted Counting Systems

• Radiofrequency Identification (RFID): Sponges embedded with miniature radiofrequency chips detected via a handheld wand or mattress sensor plate.
• Barcode / Data Matrix Scanning: Each sponge pack is scanned into an electronic database upon opening and scanned out upon disposal.
• Clinical Mandate: Technological adjuncts supplement but NEVER replace the manual, two-person audible and visual count.