Leon G. Josephs, MD,FACSChief of Surgery

St. Vincent HospitalWorcester, MA

Retained Surgical SpongesDefine the scope of the problemDiscuss impetus for improvementDiscuss the process improvement

challengesReview St Vincent dataOutcomes and summary

Retained SpongesScope

1/1000-1500 abdominal cases1500 cases per year in US67% require reoperationMedical-legal cost to hospital is

~$150,000

Stawicki, Scientist, 2008

Goals of Process ImprovementNo SRE

No RFBNo wrong siteNo wrong sideNo wrong patient

Impetus for ImprovementRetained Sponge

January 2007 named Chief of SurgeryEarly on, two Retained Sponge casesOne acute, one delayed10/07 Dr. Gibbs ACS Clinical

CongressFocus on why it occurs via RCAProcess Improvement

Retained SpongesImpetus for Improvement

Counts aren’t perfect-80% “correct”X-rays aren’t perfect SRENonpayment events

Retained SpongesWhy

Unmarked towelsPoor quality x-raysPoor nursing standardsPoor wound examPoor communication80% have normal counts

Gibbs,Current ProbsSurg, 2007

Retained SpongesRisk Factors

Risk FactorEmergency surgeryUnexpected changeHigh BMI

Multivariate analysis

Risk Ratio8.84.11.1

Gawande, NEJM, 2003

Retained Sponges69% of all RFBs7% had >154% in abdomen 22% in vagina7% in thorax

Gawande, 2003, NEJM

Retained SpongesChallenges to Improvement

Infrequent event “never happened to me”

Surgeons dislike changeSkeptics among nursing and

physiciansCost

Goals of Process ImprovementZero Retained SpongesReduce Anesthesia TimeReduce Risk to Nursing “sponge

search”Eliminate X-rayImprove OR efficiencyLiability

Process ChangesRevise Counts-AORN standardsEducate nursing and MD staffDefine High Risk Patients for RS

EmergencyMajor change in procedureBMI>30Multiple sites/cavity

MD and Staff Education On line presentation with post testHands on demonstrations with

equipment and wands in all applicable areas – OR, OB and Cath Lab

Retained SpongesDetection Methods

Wound examCountsX-rayRFRFIDBar coded

Retained Sponge Detection Study•St Vincent Hospital•300 beds•17 ORs and four OB rooms•16,000 operations annually•Teaching hospital•Modern, state of the art facility

Retained SpongesDetection Study

All high risk patientsCountsX-rayRF Surgical Detection System

Wanding

Detection StudyWhy RF ?

Easy to UseFast and AccurateNot cost prohibitiveGood experience at HUP

RF ProtocolPROCEDURE/PROTOCOL: Items needed

R.F. spongesR.F. consoleR.F. Sterile wand

Place console within 4 feet of the patient’s chest, just outside the sterile field.

Connect supplied power cord to back of console.Set the power switch in back of the console to “ON”. Do not

disconnect power or turn off the power switch until the scanning is completed.

When the power is on, the console will conduct a self-check.

RF ProtocolWhen the system ready LED light is illuminated, the

wand can be connected.Dispense the wand unto the sterile field and have the

scrub person remove it from the wrappings.Pass the silver connector end of the wand off the field to

the circulator and then the circulator will connect to the R.F. console.

The scrub will then hold the wand up in the air to allow the wand to do a self –check. Indication of scanning will automatically be indicated by the circular array of “Scan” LED’s illuminated green in a clockwise sequence.

After a successful wand check, the wand ready LED will illuminate green.

RF ProtocolThe wand will be tested by scanning a R.F. sponge

that is on the back table (not on or in the patient). A solid tone and “Scan” LED’s and “Detect” will illuminate yellow.

After a successful wand test, scanning of the patient can proceed.

If a tag is not detected after completing scanning pattern or if scanning must be stopped, press the “Start-Stop” button. Press the “Start-Stop” button to reinitiate scanning.

Console will time out after 4 minutes; to reinitiate scanning press “Start-Stop” button

RF Scan ProcedurePosition wand as close as possible to the body at

the neckline.With wand remaining parallel to body, move

wand distally to the knees, reverse direction back up to the right shoulder.

Start the lateral scan down the right side to the knees and then up to the left shoulder

Scan lateral from the left shoulder and back to the knees.

Do this at a rate of 3 seconds per pass.

RF Scan ProcedureStart the horizontal scan by placing the

wand lateral on the left shoulder and across chest to the right shoulder.

Across the body to the left hip, then across pelvic area to right hip.

Proceed across the legs to the left knee and then across the lower legs to the right knee.

Proceed then across the whole body to the left shoulder.

Retained SpongesStudy Design

Measured time to get x-ray and reading

Measured time to prepare and use RF Detection

Reviewed cost and effectiveness180 consecutive high risk patients

Retained SpongeDetection Study Results

Patient-11/7-6/08

Call xray(min)

Result(min)

Total(min)

Wand(min)

BMI

1-30 15.6 18.2 33.8 1.8 37.1

31-60 11.6 14.1 25.7 1.4 36.6

61-90 10.4 16.3 26.7 1.2 35.1

91-120 10.4 14 24.4 1.2 35.8

121-150 11.5 14.8 26.3 1.1 36.4

151-180 13.8 15.3 29.1 12 36

Retained SpongeDetection

No retained spongesRF decreases anesthesia time by

approximately thirty minutesHigh satisfaction with surgeons and

nurses

Retained SpongesDetection Cost Analysis

Reading, tech, film, OR time= $206/case

RF with single use and sponge cost of 30 sponges =$55/case

Margin is $150,000/1000 cases

Retained SpongesImproved patient safetyMD and Nursing staff satisfactionImproved OR and hospital efficiencyRF is an adjunct to good nursing practice

and wound exam by surgeonRF is safer, faster and more cost effective

compared to X-ray for retained spongesConsidering use of RF instruments