High-Tech Sponge Detection

Years ago, Valerie Y. Marsh, BSN, MSN, DNP, CNOR, was sure a sponge had been left inside a patient. "The surgeon swore it wasn't in there, and he wasn't going to reopen the incision to find out," recalls Ms. Marsh, a clinical assistant professor at University of Michigan School of Nursing in Ann Arbor. "I said, 'Listen, it's got to be in there. It's no place else. Can we at least get an X-ray?' So we did, and sure enough, it was there."

Nowadays in University of Michigan's ORs, it's not necessary for nurses to request that surgeons X-ray in this case. They can immediately determine if a sponge is unaccounted for by using high-tech sponge detection systems that leverage the use of special sponges containing either barcodes or radiofrequency (RF) tags to confirm an accurate count, every time.

Both barcode and RF technologies are very good and reliable, but they do have differences, according to Robert M. Cima, MD, a colon and rectal surgeon who is a professor of surgery at Mayo Clinic in Rochester, Minn. He characterizes the barcode system his institution uses as more of an accounting or inventory system, where sponges are scanned in and out to confirm the count, while RF systems employ a wand or mattress topper that can detect sponges left inside the patient or accidentally tossed in the trash.

"The barcode device truly is an accounting of sponges," says Dr. Cima. "It tells you how many sponges you opened, and how many you removed from the field."

The RF detection approach, meanwhile, centers on a small RFID chip on each sponge. "It gives you that same accounting capability, but it also gives you the capability to detect where a sponge might be," says Dr. Cima. "You have a wand, and if you're in close proximity to the sponge, it'll tell you it's there."

"When you look at the literature, the most common reason sponges are retained is because of the counting problem."
Robert M. Cima, MD

Mayo Clinic adopted the barcode technology years ago. "When you look at the literature, the most common reason sponges are retained is because of the counting problem," says Dr. Cima. "When a miscount is identified, sponges are often located once the surgical team is aware they're missing."

That's where Dr. Cima sees the true benefit of the barcode technology. "Staff place sponges under the scanner, see them register on the machine and monitor the counter," he says. "It's pretty straightforward to know sponges have been counted."

Dr. Marsh says it's not just important that OR teams use this technology, but also that they use it carefully and correctly. "As long as it's used right, it's 100% effective," she explains. "If you take shortcuts — if you don't individually scan out all the sponges, — that's when you get into trouble," she says. Once that message got through, Dr. Marsh's OR teams embraced the sponge-tracking technology.

Today, an internship program Dr. Marsh developed for nurses new to the OR includes ample education on the barcode-scanning system. "We go through the counting process as a circulator and then as a scrub person, so by the time they actually get into the OR on their own, they're well-versed on the machine," she says.

Kathleen Langerman, BSN, RN, CNOR, MSN, evening charge nurse at Novant Health Huntersville (N.C.) Medical Center, reported a low initial utilization rate — less than 5% — of her facility's RF-based sponge detection machine. "It was abysmal," she says. "Surgical professionals don't like to be told 'you gotta.' They have to be shown 'you gotta.'"

Learning about the substantial clinical and financial cost involved with re-surgery due to retained objects hammered home the message for her staffers. "It was upwards of $60,000," says Ms. Langerman. "And nobody wants to be the nurse responsible for that." She also got her staff to buy in to using the technology by telling them adoption of the tech would eventually be tied to bonus criteria.

Ms. Langerman even created an educational program for her coworkers, including surgeons, on proper use of the sponge detection system. "The main barrier was that OR staffers were confident in their manual counts, and thought they didn't need the extra step," she says. "But counts can be incorrect, and we all know this."

To help increase use of the technology, Ms. Langerman added use of the machines to preference cards linked to the health system's electronic health record. She says positivity was another key aspect of securing compliance. Brag Boards in every department lauded those who used the system. "In staff meetings, I wouldn't call people out specifically unless they were 100% compliant."

Ms. Langerman also had one-on-one meetings with staff members who weren't compliant with the technology and put signs on OR doors and stickers on OR monitors that asked staffers, "Have you wanded?"

The surgical team eventually came around. "It took us about four months to get compliance above 90%," says Ms. Langerman.

Education and reeducation are key to success with this technology, says Ms. Langerman. "Be aware of barriers you might face," she says. "Mostly, it's consistency, and managing the expectation that this has to happen, because no one wants to be that nurse who left something behind."

Proponents of sponge counting and detection systems stress they're not meant to be replacements for manual counts, but rather to provide confirmation and reassurance that the manual count was correct. "You perform the surgery, and prior to close, you count, and then you wand the patient, because counts can be incorrect," says Ms. Langerman, who reports the wand can find sponges at least 18 inches deep.

How often does the wand find a sponge? "The percentage of retained objects is very low," she says. "We haven't found anything within a patient. However, if I've done a final count and I can't find a sponge and know it's not in the patient, I've wanded trash looking for sponges."

Dr. Marsh agrees her institution's barcode-based system isn't a replacement for manual counts. "We made it a tool," she explains. "The process is the same, except now it's computer technology that's recording the information. The reason we need the technology is because we're human, and we make mistakes."

In addition to peace of mind, however, the technology also provides a record that goes beyond paper charting.

Dr. Marsh says this can be crucial in a case where, for example, a surgery took place at your facility and then a sponge is retained when the patient undergoes another procedure somewhere else. "If they come back to us and say, 'You left the sponge from the original surgery,' we can pull that case's record and say, 'No, we closed our count out before the patient left the room,'" she says. "All we had before was our paper chart that said, 'We counted together, and the count was correct.'"

Dr. Cima notes another attractive byproduct of the technology: It removes a frequent bone of contention. "The biggest issue has always been when the nurse says the sponge count is off, and the surgeon says, 'Well, it's your responsibility, count again,'" he says. Now the nurse says, 'The machine says we're off by one,' and once they say that, the surgeon's got to look for the sponge." OSM