Retained Surgical Sponges Process Improvement for Patient Safety

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Retained Surgical SpongesProcess Improvement
forPatient Safety

• Leon G. Josephs, MD,FACS
• Chief of Surgery
• St. Vincent Hospital
• Worcester, MA

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Retained Surgical Sponges

• Define the scope of the problem
• Discuss impetus for improvement
• Discuss the process improvement challenges
• Review St Vincent data
• Outcomes and summary

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Retained SpongesScope

• 1/1000-1500 abdominal cases
• 1500 cases per year in US
• 67 require reoperation
• Medical-legal cost to hospital is 150,000
• Stawicki, Scientist, 2008

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Goals of Process ImprovementNo SRE

• No RFB
• No wrong site
• No wrong side
• No wrong patient

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Impetus for ImprovementRetained Sponge

• January 2007 named Chief of Surgery
• Early on, two Retained Sponge cases
• One acute, one delayed
• 10/07 Dr. Gibbs ACS Clinical Congress
• Focus on why it occurs via RCA
• Process Improvement

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Retained SpongesImpetus for Improvement

• Counts arent perfect-80 correct
• X-rays arent perfect
• SRE
• Nonpayment events

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Retained SpongesWhy

• Unmarked towels
• Poor quality x-rays
• Poor nursing standards
• Poor wound exam
• Poor communication
• 80 have normal counts
• Gibbs,Current ProbsSurg, 2007

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Retained SpongesRisk Factors

• Risk Factor
• Emergency surgery
• Unexpected change
• High BMI
• Multivariate analysis

• Risk Ratio
• 8.8
• 4.1
• 1.1
• Gawande, NEJM, 2003

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Retained Sponges

• 69 of all RFBs
• 7 had gt1
• 54 in abdomen
• 22 in vagina
• 7 in thorax
• Gawande, 2003, NEJM

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Retained SpongesChallenges to Improvement

• Infrequent event never happened to me
• Surgeons dislike change
• Skeptics among nursing and physicians
• Cost

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Goals of Process Improvement

• Zero Retained Sponges
• Reduce Anesthesia Time
• Reduce Risk to Nursing sponge search
• Eliminate X-ray
• Improve OR efficiency
• Liability

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Process Changes

• Revise Counts-AORN standards
• Educate nursing and MD staff
• Define High Risk Patients for RS
• Emergency
• Major change in procedure
• BMIgt30
• Multiple sites/cavity

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MD and Staff Education

• On line presentation with post test
• Hands on demonstrations with equipment and wands
  in all applicable areas OR, OB and Cath Lab

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Retained SpongesDetection Methods

• Wound exam
• Counts
• X-ray
• RF
• RFID
• Bar coded

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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

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Retained SpongesDetection Study

• All high risk patients
• Counts
• X-ray
• RF Surgical Detection System Wanding

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Detection StudyWhy RF ?

• Easy to Use
• Fast and Accurate
• Not cost prohibitive
• Good experience at HUP

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RF Protocol

• PROCEDURE/PROTOCOL
• Items needed
• R.F. sponges
• R.F. console
• R.F. Sterile wand
• Place console within 4 feet of the patients
  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.

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RF Protocol

• When 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 LEDs
  illuminated green in a clockwise sequence.
• After a successful wand check, the wand ready LED
  will illuminate green.

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RF Protocol

• The 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 LEDs 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

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RF Scan Procedure

• Position 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.

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RF Scan Procedure

• Start 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.

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Retained SpongesStudy Design

• Measured time to get x-ray and reading
• Measured time to prepare and use RF Detection
• Reviewed cost and effectiveness
• 180 consecutive high risk patients

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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
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Retained SpongeDetection

• No retained sponges
• RF decreases anesthesia time by approximately
  thirty minutes
• High satisfaction with surgeons and nurses

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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

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Retained Sponges

• Improved patient safety
• MD and Nursing staff satisfaction
• Improved OR and hospital efficiency
• RF is an adjunct to good nursing practice and
  wound exam by surgeon
• RF is safer, faster and more cost effective
  compared to X-ray for retained sponges
• Considering use of RF instruments

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