Who's responsible for surgical counts at your facility? The surgeon? The nurse conducting the count? Others in the room? This accountability question is the one we recently set out to answer. Many nurses may still have the impression that the surgeon is solely responsible for the outcome of the counts. But the legal climate surrounding retained foreign objects has changed over the last few years. The surgeon as "captain of the ship" doctrine is gone. The nurse conducting the count, as well as others in the room, are now just as accountable as the surgeon. We spent 5 months updating our surgical count policy. As you'll see in this recap of the keys to our success, the final product uses our EMR to promote patient safety and addresses surgical sponges placed as packing, as well as other challenges your surgical teams face every day.

1. Create a digital trail
When the OR staff suspects a retained foreign body, they order an X-ray. We worked with our IT and radiology departments to create a note in the patient's EMR that says that an X-ray has been ordered because the count was thought to be incorrect. This helps radiologists reading the patient's films to understand the patient's clinical history.

2. Make it easy
We knew that we had to design a new process sensitive to the staff's concerns. Many nurses were concerned that placing an electronic order for an X-ray was one more task for which the circulating nurse would be responsible. They felt it should be the physicians' responsibility. Placing an X-ray order when many other things needed to be done to complete a case would take too much time and distract from patient care delivery, they said. We decided that the surgeons could — and should — place the order if they weren't scrubbed. But if a surgeon was scrubbed, the nurse would place the order.

With a large staff, standardization is important. We developed a pre-established order in the electronic system specifically for an X-ray for a possible retained foreign body. The surgeon or nurse can place the order directly from our perioperative documentation system without having to close or minimize the documentation system. This is a big advantage and time saver for our staff.

The IT trainer also created bright yellow cards with instructions printed on them that attach to employees' hospital ID tags so that everyone has a quick and accessible reminder of how to place an X-ray order. This process has gone extremely well, with few errors or complaints from the circulating nurses who place the majority of the orders.

3. Read X-rays while patient's in the OR
We also worked with radiology to revamp our process for using X-rays to search for possible retained foreign bodies. Before, the film was taken and often read by the attending or a resident surgeon in the operating room. With a PACS system, an attending radiologist can quickly read a film through the network without changing locations. Now an attending radiologist reads the X-ray before the patient leaves the OR and reports to the attending surgeon over the phone. We rolled this process out 1 surgical service line at a time and then incorporated it as a practice standard.

4. C-arms are inadequate
We explored using C-arms to identify a possible retained foreign body in addition to using flat plate X-ray films. But the radiology department noted that it would be more difficult to archive a C-arm film and that it may keep patients in the OR longer. They were also concerned that the quality of the C-arm image wasn't as good as flat plate film. As you'll see later, we've slightly modified our C-arm stance, letting surgeons use them to search for missing instruments.

5. X-ray for needles of all sizes
Small needles (7mm or less) are often difficult to see on an X-ray image. Before, if a small needle broke or was missing, some surgeons would order an X-ray, while others wouldn't. Recognizing that film quality can be an issue, we standardized our policy so that any time a sharp is missing, regardless of the needle size, the patient should have an

X-ray. In ophthalmic cases, the surgeon can use a microscope when sharps are missing instead of ordering an X-ray to search for the missing needle.

6. Reconsider 4x4 sponges
In some services, we've stopped using radiopaque 4x4 sponges in an open abdomen or for packing because they can be hard to find when they've absorbed a lot of blood. Instead we use standard radiopaque pediatric laparotomy sponges. Before the procedure, the scrub cuts 1 end of the loop near the sponge so that it becomes a long blue string that's left hanging out of the surgical site.

7. X-ray in high-risk cases
In our literature review, we found that sometimes an X-ray is a good idea, regardless of the count's outcome. Our policy encourages surgeons to order an X-ray whenever there's a higher risk of having a retained foreign body, such as obese patients, lengthy procedures and procedures that involve multiple personnel changes or a permanent shift change.

8. Define counting requirements for kids
In procedures involving infants and small children, we modified our requirement for counting instruments. We reviewed policies from other hospitals and established 10kg or more as the required target for initiating instrument counts. Our chief of pediatric surgery was supportive of this target for instrument counts.

9. Address placed packing
There's a lot of debate surrounding sponge counts and intentionally placed packing with surgical sponges. If you can account for the sponges but you can't see them at the end of the procedure because they're in the patient, is the count correct? According to AORN and some healthcare providers, the count should be considered correct. But the sponges are not in front of you to be counted. After much debate, we created the rubric "incorrect packing placed" to describe this situation on the EMR and differentiate it from an incorrect count when you don't know where the missing sponges are.

10. Get staff input before you finalize
After several months of work on the revised policy, we presented a draft of the new surgical count policy to the OR staff. They were concerned about the anticipated surgeon response to the policy and how they should manage compliance with the new policy. They wanted reassurance from the managers and educators that the policy would be presented to the surgical leadership and would have its support. Staff also voiced concern about the new "packing placed" option.

11. Send it for final approval
With the policy nearing completion, we forwarded it to risk management for review. Overall, they were pleased with the policy and suggested only minor changes. We also sent it to the radiology department and the perioperative executive committee, a group of surgical chiefs, the director of business operations and the vice president for perioperative services. Once approved, the final policy was e-mailed to all staff and posted on our perioperative Web site on the hospital's intranet, where it's accessible along with all of our other policies.

12. Track your progress
Finally, we created a program to monitor surgical counts, with an electronic query to track count outcomes. We created a report in our surgical scheduling system that identifies cases in which a final count is missing when an initial count was documented or where an incorrect count is documented.

This monthly report verifies that counts are done in compliance with our policy. When an initial count is completed, a final count should also be completed or listed as not applicable. If a count is incorrect and not associated with packing placed, an X-ray should be ordered. And when an X-ray is ordered, the attending radiologist's name and title should be documented in the perioperative record along with the X-ray findings. Not surprisingly, we have spent a fair amount of time working with staff members to increase compliance with our revised policy. We also conduct short informational sessions on this topic at our weekly educational meetings.

Lastly, we know that policies and actual practice must be aligned. We're already reviewing our new policy to make changes. Our surgeons want to be able to use a C-arm to check for possible retained objects (other than sponges) if a C-arm has been used in the case, since it is likely already there when an instrument can't be accounted for. Our radiology department recently agreed to change our policy to reflect this practice.