Retained Surgical Sponges Process Improvement for Patient Safety

1. Retained Surgical SpongesProcess Improvement forPatient Safety Leon G. Josephs, MD,FACS Chief of Surgery St. Vincent Hospital Worcester, MA

2. 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

3. 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

4. Goals of Process ImprovementNo SRE • No RFB • No wrong site • No wrong side • No wrong patient

5. 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

6. Retained SpongesImpetus for Improvement • Counts aren’t perfect-80% “correct” • X-rays aren’t perfect • SRE • Nonpayment events

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

8. Retained SpongesRisk Factors Risk Factor • Emergency surgery • Unexpected change • High BMI Multivariate analysis Risk Ratio • 8.8 • 4.1 • 1.1 Gawande, NEJM, 2003

9. Retained Sponges • 69% of all RFBs • 7% had >1 • 54% in abdomen • 22% in vagina • 7% in thorax Gawande, 2003, NEJM

10. Retained SpongesChallenges to Improvement • Infrequent event “never happened to me” • Surgeons dislike change • Skeptics among nursing and physicians • Cost

11. Goals of Process Improvement • Zero Retained Sponges • Reduce Anesthesia Time • Reduce Risk to Nursing “sponge search” • Eliminate X-ray • Improve OR efficiency • Liability

12. Process Changes • Revise Counts-AORN standards • Educate nursing and MD staff • Define High Risk Patients for RS Emergency Major change in procedure BMI>30 Multiple sites/cavity

13. 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

14. Retained SpongesDetection Methods • Wound exam • Counts • X-ray • RF • RFID • Bar coded

15. 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

16. Retained SpongesDetection Study • All high risk patients • Counts • X-ray • RF Surgical Detection System Wanding

17. Detection StudyWhy RF ? • Easy to Use • Fast and Accurate • Not cost prohibitive • Good experience at HUP

18. RF Protocol • PROCEDURE/PROTOCOL: • Items needed • R.F. sponges • R.F. console • R.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.

19. 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” LED’s illuminated green in a clockwise sequence. • After a successful wand check, the wand ready LED will illuminate green.

20. 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” 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

21. 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.

22. 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.

24. 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

25. Retained SpongeDetection Study Results

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

27. 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

29. 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