Zooming in on Zero Retained Surgical Sponges

            The prevention of retained surgical sponges requires good communication among perioperative personnel and the consistent application of standardized processes of care. Review of individual cases, focused reviews and root cause analyses from multiple sources have revealed that operating rooms run into trouble in compliance with the “consistent application” and with the development of “standardized” processes of care applicable to all perioperative personnel. Most hospitals have a surgical count policy which directs behavior of the staff nurses and scrub technicians yet have no policies which direct behavior of surgeons, anesthesiologists and radiologists – other important perioperative personnel. Additionally the practices outlined within existing count policies are often not standardized and uniformly practiced throughout all the operating rooms even though they comply with the recommended practices of the AORN. It is often the case that everybody has "my" way of doing things but there is no standardized way. This state of affairs allows for much individual and service-specific variation. 

The most common retained surgical item that requires a second operation to remove, is a surgical cotton gauze sponge, used during the course of an operation to soak up body fluids or help maintain the surgical field. All surgical sponges used in the US contain a radiopaque marker which distinguishes them from cotton gauze dressings which don't contain markers and are used to cover the wound. The three main “stakeholders” in preventing retained sponges are surgeons, nurses and radiologists and communication between all three is a key element.  There should be an alliance between the surgeon - whose responsibility it is to remove all surgical items not intended to remain, and the surgical nurses - who are responsible for corroborating or refuting the surgeons assessment that everything has been removed. Preventing retention is a joint and shared responsibility.

To date, most OR’s have placed undue reliance on the surgical count to the exclusion of other actions to prevent unintentional retention. Error rates with current manual counting practices are ~10-15% and in over 80% of retained sponge cases the count has falsely been called "correct". That is the nurses counted the sponges but there were errors with the practice. These cases are the result of problems with current processes of care. In the 20% of cases where there has been a known "incorrect count", there are usually problems with poor communication or lack of knowledge. The surgeons have not obtained xrays or they have been misread or insufficient views have been taken. We suggest that we have been asking the wrong question at the end of the case: Instead of saying What's the count? - we should be asking Where are the sponges?  To answer this question, we have designed and studied a system we call “Sponge ACCOUNTing” which is a transparent, systemized, standardized, inexpensive, simple manual practice for accounting for surgical sponges. 

If there have been cases of retained sponges with your current OR manual practice and your organization is interested in working with their current investment in OR personnel without adding new technology, this Sponge ACCOUNTing system should be evaluated. If your organization is interested in looking at the new technological adjuncts to sponge counting, the three commercially available devices are briefly discussed below. The systems are not interchangeable and have their separate strengths and weaknesses. All have been on the market for less than 5 years and are continuously undergoing improvements and upgrades. If your organization has been unsuccessful with a reliable manual process and is willing to make the financial investment, these technological adjuncts should be evaluated. It turns out that there is not one best practice since all of these systems must be used in the local environment of each hospital. The cultures and level of complexity of hospitals are important determinants of which approach will be successful in RSI prevention. 

We have been successful in getting a number of hospitals to zero retained sponges for at least one year and are working with other hospitals to do the same to eliminate the problem of retained surgical sponges in all ORs, labor and delivery rooms and radiology suites….. any place that surgical sponges are used and an incision is made, which are the minimal conditions for the possibility that a sponge can be left in a patient. The goal is zero in 2010 which means that all members of the perioperative care team must work together to insure that no patient leaves the OR with a surgical sponge unknowingly left inside of them, no new mother goes home with a vaginal sponge inside of her and no radiologist misses a radiographic sponge on an xray.

The plastic hanging blue-backed sponge-holders are mounted in a rack on an IV pole. Each holder (not called a “counter” or a “bag” because the holder “holds” the sponges so they are easily seen by all) contains 5 pouches and each pouch has a thin center-divider which separates each pouch into 2 pockets. Circulating nurses place one sponge in each pocket as outlined. One sponge per pocket, 2 pockets per pouch and 5 pouches per holder means that each holder can accommodate 10 sponges. Each holder is always set up to hold 10 sponges be they laparotomy pads or raytex and different types of sponges are not mixed within one holder. Free sponges are always added to the field in groups of 10. Each rack can usually accommodate 10 sponge holders (5 on each side) which is 100 sponges!

 A wall-mounted dry erase board to record operative information and the IN counts should be easily visible in each room. This process should be standardized for use throughout all operating rooms on every case that uses sponges. The counts of the sponges as recorded on the dry erase board should be kept as a running total so it is transparent and easy for anyone to understand how many sponges are out at any time. 

The surgeon should perform a methodical wound exam (MWE) during the “pauze for the gauze” at the closing count to make a best effort to get the sponges out so the nurses can move them out of the kick buckets into the holders and account for them. There are guidelines for the MWE and other surgeon best practices. The practice of a “swish or sweep” is insufficient as sponges have been missed with this technique.

            The single most important element in the use of the hanging sponge-holders and the sponge ACCOUNTing system is to make sure that the final count is taken when ALL the sponges that have been opened during the case (used and unused) have been placed in the holders. There should be "no empty pockets". The surgeon and nurse can then visually verify during the “SHOW ME” step that all sponges have been accounted for and none remain in the patient. This final step of surgical sponge verification fits in well as part of the debriefing in the surgical checklist.

The key for OR culture change is comprehensive training, active learning and sustained followup. Practice change is difficult to accomplish and it takes far longer than most think. So far it has taken 3 years to get large facilities to zero retained sponges. We recommend ORs develop a comprehensive approach to training, apply internal and external auditing of practice and develop internal OR specific near-miss reporting systems with report out to OR patient safety or quality improvement committees to monitor compliance and take action when needed.