HIGH- AND LOW-TECH Circulator Megan Dooman, RN, uses an electronic scanner to verify the sponge count and a hanging bag to organize sponges discarded from the sterile field.

A few years ago, we observed our surgical staff's closing count procedures. We compared them to our hospital's policy, and reviewed the literature for best practice recommendations. What we found was a wide disparity between what we did and what we should have been doing. That type of discovery won't surprise anyone who works in surgery. One of the big fault lines in closing counts is that it's an orderly, repetitive process that takes place in a rushed and often chaotic environment. Another complication: Counting practices can vary from room to room. We noticed different personnel organizing supplies and instruments in different ways and carrying out steps in different orders. These inconsistencies may have caused confusion with co-workers and possibly affected the accuracy of the counts.

Policy into practice
To improve your counting practices, start with a sound policy. You can't go wrong using AORN standards as a foundation. They recommend 2 people — the circulating nurse and a surgical tech — conduct a manual count concurrently, visibly and audibly.

Because the aim is to reduce variability and create a consistent process, carry out the steps in a prescribed order. A policy should outline which items you need to count — anything that could potentially be left in the body — and the manner and sequence in which you're to count them (such as, start at the field and move outward, sponges first).

The policy may even include specialty-specific counting guidelines, as different procedures may need, or not need, different preventive precautions. Is it necessary to count all instruments after an eye case, for example? Or, because a bladder cystoscopy is performed through the urethra, the likelihood of leaving unnoticed items behind seems pretty slim.

You want your policy to be thorough and routine, but not onerous. It should provide safety, but not make it such a burden that your staff eventually stops following it when you're not watching.

We found that counting bags are a valuable, low-tech way to keep track of sponges that have been discarded from the sterile field. As seen in the photo above, a single-use, see-through plastic, pocketed bag hangs from an IV pole, allowing a visual running tally of discarded sponges. These bags can add a lot of efficiency to counts if they're filled throughout surgery, and staff don't wait until the end of a procedure to bag the sponges.

Your counting policy shouldn't neglect instructions on what to do in the event that a closing count comes up short. If the item isn't found on the field, or on the floor, or in the trash, an all-points-bulletin usually involves a call to radiology and fluoroscopic imaging of the site. Radiology plays an important role in prevention response, so don't leave them out of the drafting or training of the policy. Through interactions with nurses, they can learn what a retained sponge or other object looks like on the screen.

While the majority of surgical instruments include radiopaque metal components and will readily show up on an X-ray, it's important to remember that smaller plastic pieces, like some parts of a laparoscopic stapler, might not. For visibility's sake, many surgical facilities now stock towels and lap sponges with tags, bar codes or chips that enable detection by imaging or scanning devices.

Another tip for seeing the unseen: When the radiology tech arrives in the OR, don't tell him what item is missing from the count. That'll limit what he's looking for. Just say, "We're missing something," and let him scan. I remember hearing about a situation at another facility in which a nurse reported a missing clamp at closing. The radiology tech's sweep didn't find a clamp. But it also didn't find the missing sponge beneath the patient's liver.

A word on technology
Recent years have seen the rising popularity of electronic sponge management systems (tinyurl.com/nbpx2cr). But the proper role of technology in counting should be verification only: an adjunct safeguard to confirm the accuracy of your manual sponge counts. When we set out to improve our process, we felt that even in light of the available technology, the human factor was important to keep. Admittedly, scanning the bar codes on sponges to count them into and out of the sterile field added another step, and admittedly staff's initial reaction was mixed. As they got used to it, though, they've been more accepting of this validation step. Keep in mind that in most instances of retained objects, the count was documented as correct.

Whenever quality improvement efforts introduce changes in practice, the reason carries a lot more weight than "we are required to do this." Soundly protecting your patients all comes down to process. We established a concise, clear and defined policy, educated our nursing staff and monitored compliance. And in the months following, we counted 34% fewer incorrect counts at closing.