Nursing ppt by myassignmenthelp.net

Surgical Counting

Counting for all accountable items throughout the operative procedure(s) includes :-

1) Before the procedure to establish a baseline (#Initial Count)

2) Prior to closure of a cavity within a cavity (#Additional Count)

3) Before wound closure begins (#First Count)

4) At skin closure or at the end of the operative procedure(s) (# Final Count)

5) At the relief of the scrub person (# Relief Count)

Purpose of Surgical

Counting To ensure all items used during surgical

procedure are removed

Reduce the risk of injury (ACORN,

2006)

Gold standard to manage this risk

(Gibbs, 2003)

Responsibility of peri-operative RN in

charge of the case

Major items required to be

counted

Absorbent Items Sharps

Vascular ItemsDisposable Retraction

Instruments

Major countable Items

Sentinel Event

Unexpected Occurrence

• Death

• Physical Injury

• Psychological Injury

Loss of Limb

• Loss of function

• Risk thereof

• Immediate investigation required

Focus on RSI

• Retained surgical instrument

HOSPITAL AUTHORITY (HS)

Statutory Body under Hospital Authority

Ordinance

Manage Hong Kong’s Public Hospitals

Accountable to Hong Kong Special

administrative

Region Government

Contribute to fulfillment of Hong Kong SAR

Government’s policy

HA Sentinel Events (SEs)

4 5 4 6 7 60

2

4

6

8

10

12

14

16

18

20

2007/08 2008/09 2009/10 2010/11 2011/12 2012/13

RSIs in Other Departments

RSIs in Operating Theatre (32 cases) 40%

80 cases

37%

Site of RSIs

AbdomenExtreme

Tonsillar bed

Eye

Thoracic

Oesophagus

Other

11

http://www.ha.org.hk/riskalert

63%

Type of RSIsTiny dislodged

fragment or broken

part

Raytec gauze &Abdominal pad

Malleableretractors

68%

Contributing factor of RSIs

Quality

(Integrity)

Quantity(Counting)

40%

RSIs in

Open Surgery

Open Abdominal

Surgery

Open Other Surgery

67%

RSIs in Minimally Invasive Surgery

Laparoscopic

Surgery

Endoscopic Surgery

67%

Raytec gauze or

abdominal pad

Malleable retractors

100%

Tiny disloged

fragment or broken

part

Complications due to RSI

Perforation of bowel

Sepsis

Loss of Limb or function

Death

2008

Gyn. Lap. surgery

Plastic insulated sheath of a lap. forceps

Abdomen

HA Risk Alert, Issue 4 (2008)

A segment of plastic insulated sheath of a

laparoscopic instrument was retained inside

patient

16

Contributing Factors

Difficult specimen retrieval

• Peeling off a piece of instrument coating

Improper integrity of instruments

• No proper checking of instruments before the end of operation

Recommendations

Non Insulated metal

• Instrument can be used with non insulated metal outer tube for specimen retrieval

Ensure integrity of instrument

• Instruments should be checked for their integrity before the end of operation

An oval shaped metallic clamp button

from stapler was retained in patient’s

abdomen

20

2008

Lap. resection of rectum

Metallic clamp button from the stapler

Abdomen

HA Risk Alert, Issue 7 (2008)

Grasping forceps was left in abdomen of

patient

22

2009

Metal plate inside the lumen of the forceps

Abdomen

A metallic covering defect at the end of the

70 degree telescope was found

24

A fragment of the end of telescope

Details

Contributing Factors:

Difficulty in detecting

defect of delicate

instruments.

Low awareness of

staff on checking

instruments integrity.

Recommendations:

Use LED H and

Magnifier for

facilitating checking

and inspection of

instrument integrity

To document details

of scopes sued in

surgical operations.

Causative factors to RSIs

26

Cause-effect diagram

RSIs Lap. surgery

Organization Method/Process Instrument

Work Environment PatientStaff Communication

Scrub person-Distraction bysurgeon-lack of awarenesson integrity of Instruments

-Plenty ofinstruments forcounting-Spare parts/screwseasily dislodged

-Longoperation time-Obesity

Scrub person- surgeon:No confirmation of correct counting before closure Scrub person-circulating nurse:No consistent sequencein counting

Low compliance on SAG standardsof checkingthe instruments’integrity whenclosure of wound

No structured policies to reducethe risk of RSI

-Hasty environment- Inadequate time forchecking the integrity of instruments whenclosure of cavity & wound

The swab and instrument count is essential and plays key role in enhancing surgical patient’s safety (Woodhead and Fudge, 2010).

Greenberg (2008) concluded that one in eight surgical cases involves an intra-operative discrepancy

Instruments can be retained during laparoscopic procedures, therefore, initial instrument counts should be performed (AfPP 2007, AORN 2010, ACORN 2006, SAG 2010, AST 2006)

First P:

Practical utilization of laparoscopic instruments

30

Revised

G104-01

General & Team

B

Lap. Surgery

Revised

G104-02

Team D & U

Lap.

Surgery

↓47%↓ 3% ↓17%

Created

G104-03

Team A

Lap.

Surgery

Second P:

Practical utilization of laparoscopic

instruments

31

Supplementary laparoscopic instrument

Screws

Screw x 2

Screw x 1

Screw x 2

Metal Ball (左右) x 2

鍋釘(左右) x

2

螺絲帽 x

1

Third P:

Partition of Used & Unused

laparoscopic instruments

32

Separating

Additional instrument tray

Fourth P:

“Partial Count” in Laparoscopic surgeryInitial counts 1st

Closing count 2nd

Closing count

3rd

Closing count

Before sending to CSSD

Relief count

AfPP (2007) UK / NursesAORN (2010) USA / NursesACORN (2006) Australia/ NursesACS (2005) USA / SurgeonsSAG (2010) HK / NursesAST (2006) USA / Technologists

Before the procedure

Before closure of a cavity within a cavity

Before wound closure begins

At skin closure or end of procedure

At the time of permanent relief of either the scrub person or circulator

Laparoscopic surgery After all trocars removed(Closure of peritoneum, muscle layer, and fascia

en masse in laparoscopic surgery)

Absorbent items Yes Yes Yes

Sharps & Other miscellaneous items

Yes Yes Yes

Basic instruments

Yes No Yes Yes

Laparoscopicinstruments

ALL Laparoscopic instrument

Used Laparoscopic instrument



Counted &a visual

inspection for completeness

A visual inspection for completeness Counted & a visual

inspection for completeness

Counted & a visual inspection for completeness

33

Prescriptive nature of procedure

Lack of clarity what constitutes an

‘accountable’ item

Failure to consider current technologies

and use of plastics and other X-ray

detectable items (Hamlin, 2005)

Pilot study

Phase 1

15 Elective Laparoscopic

Colorectal Surgery

5

patients excluded

2 patient convented to open

surgery

3 patients' scrub persons were not

trained

10

patients included

Phase 2

5 Elective Laparoscopic

Urological Surgery

4

patients included

1

patients excluded

1 patient convented to open

surgery

37

38

Full count

231 236

326

200

180

240

330

350

250

360

0

50

100

150

200

250

300

350

400

1 2 3 4 5 6 7 8 9 10

Time (Seconds)

Full count: 4’30”

39

Partial count

200

180

195

109

171

103

122

103

187180

65

234

183

90

0

50

100

150

200

250

1 2 3 4 5 6 7 8 9 10 11 12 13 14

Time (Seconds)

Partial count: 2’32”

40

Full count – Partial count

4’30”

2’32”

0

50

100

150

200

250

300

Full Count (N=10) Partial Count (N=14)

Time (Seconds)

Efficiency: ↑44%

41

Number of Used Lap. instruments

2’44”

1’18”

0

20

40

60

80

100

120

140

160

180

More than 12 (n=12) Fewer than or equal to 12 (n=2)

Time (Seconds)

Efficiency: ↑52%

42

Experience of “Partial Count”

2’52”

1’59”

0

20

40

60

80

100

120

140

160

180

200

Inexperienced (n=9) Experienced (n=4)

Time (seconds)

Efficiency: ↑30%

43

Instruments -- Experience

5’06”

3’38”3’12”

1’30”

2’17”

1’5”

0

50

100

150

200

250

300

350

More than 12 Fewer than or equal to 12

Full Count (Inexperience, n=10)

Partial Count (Inexperience, n=9)

Partial Count (Experience, n=4)

Efficiency: ↑70%Efficiency: ↑55%

44

Effectiveness Efficiency

Communication Safety

Evaluation

Effectiveness

45

0%

20%

40%

60%

80%

100%

120%

Surgeons

Nurses

Q1.This modified checking procedure can enhance counting strategy development.

Rating: 95% 5% Strongly Agree90% Agree5% Disagree

0%

10%

20%

30%

40%

50%

60%

70%

80%

Surgeons

Nurses

Q2.This checking method is appropriate to apply in our OT situation.

Rating: 81%10% Strongly Agree71% Agree19% Disagree

0%

20%

40%

60%

80%

100%

120%

Surgeons

Nurses

Q3.The counting procedures are in precise and effective way.

Rating: 100%5% Strongly Agree95% Agree

RR: 95% (N=21, Doctors, n=7, Nurses,

n=14)

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Efficiency

0%

10%

20%

30%

40%

50%

60%

70%

80%

Surgeons

Nurses

Q4.Nurse and surgeons are familiar with the counting sequence: Head-Neck-Body-Tail-(complete).


0%

10%

20%

30%

40%

50%

60%

70%

80%

Surgeons

Nurses

Q5.You believe that the turnaround OT time will not be delayed.


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Surgeons

Nurses

Q6.This is an efficient and safe counting procedure.

Rating: 100%14% Strongly Agree86% Agree

Efficiency: ↑55% ＞12, ↑70% ≦ 12

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Communication

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Surgeons

Nurses

Q7.You have got the basic information introduction of Retained Surgical Items (RSIs).


0%

10%

20%

30%

40%

50%

60%

Surgeons

Nurses

Q8.(Nurse) - You have got surgeons' collaboration and understanding.

Rating: 64%7% Nurse Strongly Agree57% Nurse Agree29% Disagree7% Strongly Disagree

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Surgeons

Nurses

Q9.Surgeon shown compliance on "Pause for Counting"


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Reducing of RSIs

Q10.It would reduce the Risk of RSIs at a lowest rate.


0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Strongly Agree Agree Disagree Strongly Disagree

Surgeons

Nurses

49

Implication

Future Development

Standard Operating Procedure

(SOP)

Guideline for all laparoscopic procedures

Guidelines for Specialty Nursing

Services (Perioperative

Care)

50

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