Surgical Counts

Counts are performed for

two main reasons:

 To ensure that the patient is not

injured as a result of a retained
foreign body

 To account for those items used

during a case
Items to be counted:
 Sponges

 Sharps

 Instruments

 Miscellaneous items that are small enough

to be retained
Sponges are defined as:
 Laparotomy sponges
 Raytecs (4x4’s and 4x8’s)
 Cottonoids and neuro-patties
 Dissectors such as kittners, peanuts, etc.
 Deaver covers and clamp covers
 Umbilical tape
 Tonsil and cylindrical sponges
 Radiopaque surgical towels
Sharps are defined as:

 Suture needles
 Scalpel blades
 Hypodermic needles
 Electrosurgical needles and blades
 Safety pins and dura hooks
 Razor blades and weck blades
Instrument Counts
 ALL INSTRUMENTS used on the
procedure are to be included in counts,
including all pieces of the instruments
(screws, wingnuts, suction tips, etc.)
Adding instruments
during the case:
 When a new set of instrument is
introduced, even for only one or two
items to be removed and used, the set
is to be counted in its entirety before
the instruments are removed. The
introduced set will then be included as
part of all counts during the
procedure.
Miscellaneous counted
items:
 Vessel loops
 Suture boots
 Rubber shods
 Cautery scraper pad (scratch pad)
 Trocar sealing caps
 Bulldog clamps
 Irrigating tips
 Any item small enough to be retained
Who performs counts?

 The circulating nurse and the

scrub nurse count together and out
loud, quietly, while visualizing each
item.
When to perform sharps
and sponge counts:
1. Before an incision is made

2. Before closure of a cavity within a cavity

2. As wound closure begins

2. At skin closure or end of procedure

2. At the time of permanent relief of either the

scrub person or the circulating nurse
No initial count…

 Counts not completed prior to skin

incision will be counted as incorrect.
An inventory count will be completed
at the end of the case.
Additional counts are
required when:
 Multiple teams will be working in the same site
(e.g. pelvic exoneration). Sponge counts will be
completed at the conclusion of each procedure.

 Multiple sites, multiple teams (e.g.

mastectomy/tram flap).

 Multiple site case where more than one

individual procedure is completed, therefore
counts are completed separately.
How are sponges
counted?
 When counting initially and when adding sponges during a case:

- break the tape

- separate sponges,
visualizing each sponge
Countable Items that are
Packaged Incorrectly
 If an incorrect number of sponges or
sharps is in a package, the scrub nurse
hands it off to the circulator, who bags
it and labels it as incorrect. A new
package is then given to the scrub
nurse. The incorrectly-packaged
item(s) are NOT added to the count
sheet!
Intraoperative Precautions

 NEVER cut sponges

or towels!

 Counted items are not

removed from the
room until final counts
are complete and
correct

 No trash is removed
until final counts are
complete and correct
Off-field sponges
 When counting “off-
field” sponges, lay them
on an impervious sheet
in the number that they
were originally packaged
to facilitate visualization
by scrub and circulator

-OR-
 Use the sponge bag
counting device
Incorrect Counts
 Whenever a count comes out incorrect for a non-
emergent case:

- inform the surgeons, call the attending if he/she

has left the room

- recount all items; open all bags of sponges and

recount

- search the trash, linen, and floor

- request additional help if necessary

 When counts remain
unresolved:
 An x-ray must be done
before the patient leaves the
room. The
x-ray must:
– Include the entire
operative site
– Be read by the attending
surgeon before patient
leaves the OR
– Circulating RN calls ED
Reading Room at phone
number # 343-7185 or
pages # 835-1239 for
Stat Read by an
Attending Radiologist.
Documentation of
Incorrect Count
 VPIMS Patient tracker
 “Counts” screen

 Count Worksheet

 Occurrence Report (VERITAS)

 Resultsof x-ray
 Reader of x-ray
Intentionally Retained
Sponges
 For cases with excessive bleeding (e.g. trauma) in which the
surgeon determines that for the benefit of the patient sponges
must be left in the patient, the count is considered incorrect.

– The surgical attending confirms the number and location

of intentionally-retained sponges when possible with the scrub
person and circulating nurse

– The circulator documents in the intraoperative record the

number of intentionally retained sponges per the surgical
attending

– An x-ray is not required for this initial procedure

– An x-ray is required for patients returning to the OR for final

removal of intentionally-retained sponges
 Time Out

 Each patient will be assessed by the

surgical team for risk factors that lead
to a potential of retained foreign body

If an x-ray is needed, plan accordingly

to avoid delays!
Identified Risk Factors
 An operation was performed on an emergency
basis (e.g. Level I Trauma)

 An operation involved a major unexpected change

in procedure (e.g. endovascular converted to open)

 More than one surgical team is involved or one

team performing different procedures
simultaneously

 Permanent change of nursing staff during the

procedure (e.g. change of shift relief)
Requires an X-Ray
 If one or more risk factors for retained
foreign body are identified and the surgical
wound is able to be closed, an
intraoperative x-ray must be taken and read
by the attending surgeon, with final reading
by a radiologist

 Attending will document the findings of the

x-ray in his/her operative note
Trauma, Packed Wounds
 ALL LEVEL I TRAUMA CASES where the
surgical wound or abdomen is closed
primarily will require a mandatory x-ray

 The attending trauma surgeon will be

responsible for the initial reading with a final
reading by an attending radiologist
Damage Control
 When the patient undergoes a “damage
control” procedure and the surgical wound
is deliberately packed and left open, the
count will be considered incorrect

 This is to be documented in VPIMS and in

the surgeon’s operative report

 An x-ray is NOT required during the initial

portion of the damage control procedure
Requesting an X-Ray
1. Radiology technologist will be notified in
advance by the OR Charge Nurse or
designee of all boarded Level I cases
2. Radiology technologist is paged when
portable image is required
3. If more than one body cavity is entered,
images of both are necessary
4. X-ray order(s) specifies the possible
foreign body type
Requesting an X-ray
5. Digital image(s) are developed and sent to
PACS
6. Surgeons review image on OR PACS
workstations
7. Circulating nurse calls ED reading room at
phone number 343-7185 or pages 835-
1239 for stat read by an attending
radiologist
8. Final report is signed before patient
discharge