EAST CHESHIRE NHS TRUST CLINICAL PRACTICE “THE COUNT”

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					EAST CHESHIRE NHS TRUST

Division of Surgery and Anaesthetic Specialities

        Principles of Safe Practice in the
        Perioperative Environment

      CLINICAL PRACTICE
         “THE COUNT”

  (Departmental Clinical Policy/Procedures)




                    Implementation date: October 04
                    Review date: July 2011
                    Compiled by Sr. A. Dooley & Sr. D Smith
Policy Title:                   The ‘Count’ – Perioperative Clinical Practice 2009 V2

Executive Summary:
                                To ensure all staff undertake safety checks of countable items during operative
                                procedures and that such counts are documented correctly. This will prevent foreign
                                body retention and subsequent injury to the patient. It will outline what to do if
                                discrepencies in the count occur.




Supersedes:
                                Version 1 October 2007
Description of                  Removal of use of Koerner forms.
Amendment(s):                   05/05/09 inclusion of throat pack insertion and removal
This policy will impact on:

Clinical practice, Patient Safety, Vicarious Liability


Financial Implications:

Nil

Policy Area:                 Clinical Practice – operating   Document Reference:
                             Theatre
Version Number:              2                               Effective Date:                July 2007
Issued By:                                                   Review Date:                   July 2011
Author:                      Sr A Dooley Theatre Sister      Impact Assessment Date:

                                               APPROVAL RECORD

                                         Committees / Group                             Date
Consultation:                            Management
                                         TCC
                                         Specialist Advice (if required)                October 2004
                                         National Association of Theatre
                                         Nurses
                                         Other (please specify)
Approved by Director:                    Clinical Risk Management Group                 October 2004
Received for information:                CRMG, Trust Board                              October 2004




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      PRINCIPLES OF SAFE PRACTICE IN THE
     PERIOPERATIVE ENVIRONMENT CLINICAL
                  PRACTICE

THE COUNT: (Swabs, Instruments & Needles)

1.        Introduction
The aim of this protocol is to inform and provide guidance on good practice to all
staff involved in invasive procedures.

The overriding principle of the count is that all swabs, instruments and sharps must be
accounted for, at all times during an invasive procedure, to prevent foreign body
retention and subsequent injury to the patient.

N.A.T.N. (1988), highlights that “ before closure of a cavity, a complete check should
be performed. The person performing the procedure has ultimate responsibility for
ensuring that all swabs and packs are removed prior to wound closure”. It is
important to note that, this, the following associations and authorities also endorse
guidance.

•    NHS: The National Health Service Litigation Authority: C.N.S.T.

•    Association of Operating Department Practitioners

•    British Anaesthetic & Recovery Nurses Association

•    Medical Protection Society

Although as identified it is the responsibility of the user to return all items, it is also
recognised by N.A.T.N. as ‘custom and practice’ that the scrub person implements the
checking procedure in order to be able to state categorically that all items have been
returned. All the afore mentioned does not however, remove the professional
responsibility from each member of the theatre team.

The process of the count must be audible to those counting and be conducted by two
members of staff, one of whom MUST be an appropriately trained member of the
perioperative team.

A count must be undertaken for all procedures in which the likelihood exists that
swabs, instruments and/or sharps could be retained.

Countable items are defined in appendix 1:

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Theatre checklist for Operative Procedures: Countable Items
2.       Packaging

a        All swabs, including Pledgets, neuro patties and packs, that are used during
         invasive procedures must have an X-ray detectable marker fixed securely
         across the width of the swab, so that if a swab is retained in a body cavity it
         can be detected radiographically.

b.       All swabs and packs must be packed in bundles of five (5) and be of a uniform
         size and weight. Any packages containing fewer or more than fives should be
         removed from, the procedure area immediately. Checks should be made based
         on multiples of five. Swabs are the same size and weight so that they may be
         weighed to estimate blood loss. They are packed and counted in bundles of
         five to aid uniformity of count and avoid wastage.

3.       Responsibility for counts

a.       Each count must be undertaken by two staff members, it is essential that one
         of the staff members undertaking the count is a appropriately trained, qualified
         perioperative practitioner or holds a Certificate of dental surgery assistants
         (i.e. not a learner or support staff). The staff involved in the counting
         procedure must be able to recognise and identify the equipment in use.

b.       It is recognised that, ‘the same two perioperative personnel should perform all
         the counts that are done during the surgical procedure’. (NATN 1998)

         •    Should it be necessary to replace either person during the procedure, a
              complete count should be performed, recorded and signed by the
              incoming and outgoing practitioners.

         •    Should it be necessary to replace either person temporarily during the
             procedure, a complete count should be performed, recorded and signed by
             the incoming and outgoing practitioners.


         •    Should it be necessary to replace either person temporarily during the
             procedure, the relieving practitioner should follow the standard procedure
             detailed in (3a), note and sign any additions on the intraoperative
             record/care plan.

         •    The name of the replacement or relieving practitioner must be
             documented on the intraoperative record/care plan.

c.       Items, which are to remain in the patient by intention (e.g. pacing wires,
         drains, and catheters), must be documented in the intraoperative record/care
         plan. When a countable item is deliberately left in a patient, this must be


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         recorded in the patients case notes and intraoperative record. Its removal must
         also be recorded.



d.       An example of a countable item which may be left in a wound intentionally is
         when an abdominal cavity is packed with large raytec swabs to aid
         haemostasis for a limited period e.g. 24-28 hours. All items remain within the
         operating theatre until the procedure has been completed and all counts have
         been performed. (See appendix 1) and are correct.

e.       Any swabs that are used as surface dressings must not be X-ray detectable.
         Swabs that are to be used for this purpose must not be opened until the skin
         has been closed. They must not be X-ray detectable, as it must be
         demonstrated that all X-ray detectable swabs have been removed from the
         patient postoperately.

4.       Checking Procedure

a.       A count should be performed of all countable items, (as defined in appendix1),
         for all surgical procedures and recorded immediately. This record should be
         retained in the patient’s notes. (NATN; 1998 P81)

b.       Provision should be made in the theatre for a dry wipe count board, which is
         pre-printed and states all relevant items used. This board should be
         permanently fixed to the operating theatre wall and be positioned at a height
         for facilitates access and visibility during the procedure.

c.       The initial count must be performed immediately prior to the commencement
         of the surgery (see appendix 1) by the qualified scrub person and the
         circulating practitioner.

         Any items added during the procedure, must be counted and recorded.
         Adherence to departmental policy for the accounting of surgical instruments
         that are used during the procedure must be strictly adhered (see appendix 1).

         At all times throughout the surgical procedure the scrub practitioners must be
         aware of the location of all instrumentation. Neatness in approach should be
         encouraged to ensure that, only instrumentation that is deemed necessary is in
         use at any given time.

f.       If any item i.e. blade, needle or instrument breaks during use, the scrub
         practitioner should ensure that all the pieces have been returned and are
         accounted for. If any part of a blade or needle is not accounted for the
         procedure detailed in Section 6 (Count discrepancy should be followed). Any
         equipment or instrumentation found to have been damaged will compromise
         patient safety and therefore must be removed immediately from the sterile
         field and labelled for repair, in regards surgical instruments this would also be
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         documented on the HSDU instrument Tray checklist. It may be necessary
         dependant upon the fault to inform the supplies department, the manufacturer
         and/or Department of Health (DOH) if an obvious fault is found with
         equipment. If appropriate the DOH will issue a ‘Hazard Warning’ or ‘Safety
         Bulletin’.

g.       A count should be initiated by the scrub person and performed at the
         commencement of the closure of any cavity /or /organ and the final count at
         the commencement of skin closure (see appendix 1). Surgical instrumentation
         and items with screws and /or removable parts should also be included in the
         count. The surgical team must allow time for these counts to be undertaken
         without undue pressure.

h.       On completion of the final count a verbal statement must be made by the scrub
         practitioner to the effect that; all equipment is accounted for and verbal
         acknowledgement should be received from the surgeon in order to alleviate
         any misunderstanding. (See appendix 1). The acknowledgement that the count
         is correct should be witnessed by the circulating person and the scrub person.

i.       At the end of the surgical procedure the scrub practitioner in conjunction with
         the circulating person must record that satisfactory checks have been
         undertaken (see appendix 1) and recorded on the Patient Notification Form
         Signature Sheet.

5.       Checking Techniques

a.       Both the scrub practitioner an the circulating person must count aloud and
         items should be completely separated from each other during the checking
         procedure.

b.       The integrity of the X-ray detectable markers in the swabs, etc must be
         checked during the count.

c.       At the initial count, and when added during the procedure swabs etc should be
         counted into separate groups of five. These should not be added to those
         already counted until the verification of the number contained in the packet.
         The additions should be in multiples of five (see appendix 1).

d.       In the event of an incorrect number of swabs etc (i.e. not five) the entire
         packet must be removed from the sterile field.

e.       If any interruption occurs during the counting procedure, the count must be
         recommenced.

f.       Items should not be cut or altered unless specifically intended for the purpose.
         If alterations to any item are requested by the surgeon performing the
         procedure, this must be documented and included in the count.


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6.       Count Discrepancy

a.       If any discrepancy in the count is identified the surgeon must be informed
         immediately and a thorough search implemented at once.

b.       If a thorough search does not locate the item, an X-ray must be taken before
         the patient leaves the operating theatre.

c.       Missing micro items (for example: needles which cannot be detected on
         X-ray) should be performed at the discretion of the surgeon.

d.       All missing items must be documented. The discrepancy and subsequent
         action must be reported to the Senior Manager on the shift, and a record must
         be made regarding the incident. The trust formal incident reporting procedure
         must be initiated and followed.

e.       If at the end of this procedure the item is still not accounted for and cannot be
         detected on X-ray the surgeon will decide if they need to re-open the patient to
         search for the item.




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        EAST CHESHIRE NHS TRUST THEATRE
                       SERVICES
          Macclesfield District General Hospital

             THEATRE CHECKLIST FOR OPERATIVE
                       PROCEDURES
               COUNTABLE ITEMS : APPENDIX 1

Countable items are defined as;

•   X-ray detectable gauze

•   Pledgets

•   Needles

•   Surgical Instruments

•   Slings

•   Tapes

•   Bulldogs

•   Kaltostat (Calcium Sodium Alginate)

•   Blades

•   Hypodermic needles

•   Neuro patties

•   Diathermy blades

•   Suture reels

•   Cotton wool balls / buds

•   Scratch pads




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N.B. Items that are not identified within the above list, but at any time loose contact
with the user/operator for any period of time must be treated as a countable item, as
defined within the procedure.




THE PROCEDUURE

1.       Commencement of a surgical procedure the scrub practitioner in conjunction
         with a suitable trained circulating person (as identified in the protocol) should
         perform a check of all countable items.

2.       The check of countable items (other than surgical instrumentation) must be
         counted by the scrub practitioner in conjunction with the circulating person.
         The count is then recorded immediately on the ‘count board’ situated on the
         wall of each operating theatre by the circulating person as follows:

                    Patients Number Date:

                    4x4=

                    4x6=

                    9x9=

                    12 x 12 =

                    18 x 18 =

                    Sloops =

                    Pledgets =

                    Cotton Rolls or Balls =

                    Sutures =

                    Blades =

                    Suture reels =

3.       Before commencement of surgery the instrument tray should be checked with
         the tray list by the scrub person and the circulating practitioner. The record of
         surgical instruments, used must be documented on the Instrument Tray check
         list, this includes the date, theatre, scrub person and patients number. All


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         supplementary instrument packets should be retained and the instruments
         returned to H.S.D.U. in their packets.




4.       During the surgical procedure any countable items (other than surgical
         instrumentation) accepted by the scrub practitioner into the sterile field must
         be counted in conjunction with, and recorded by the circulating person. As
         follows:

         •          e.g. 4 x 4 =5+5+5

         •          e.g. Pledgets = 10

         •          e.g. Sutures = 1+2

5.       During the surgical procedure used swabs will be discarded by the scrub
         person into a bowl out of the sterile field. The swabs are collected by the
         circulating person and placed in swab bags, one swab to each pocket (the bags
         hold 10 swabs).


6.       At the commencement of the closure of any cavity or organ the scrub
         practitioner in conjunction with the circulating person, must perform a count
         of all countable items as follows:

         Swabs/ Needles/ Sling/ Tapes/ Pledgets/ Bulldogs: etc.

         The above must be counted by the scrub practitioner in conjunction with the
         circulating person to ensure that the quantity of the items still remaining in the
         sterile field and external to the field, correlates exactly with the quantity
         recorded on the ‘count board’.

         A full swab count must consist of the scrub practitioner, in conjunction
         with the circulating person, accounting for swabs in multiples of five.

Surgical Instrumentation:

The above must be counted by the scrub practitioner in conjunction with the
circulating person to ensure that the quantity of all surgical instrumentation still
remaining in the sterile field correlates exactly with surgical instrumentation listed
one each individual HSDU Instrument Tray checklist.

In addition all supplementary surgical instrumentation still remaining in the sterile
field must be counted by the scrub practitioner in conjunction with the circulating
person, the count should correlate to the instrument packets.

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The outcome of the counts must be verbally relayed to the operating surgeon and must
be verbally acknowledged by the operating surgeon. This is recognised as the first
count, and the surgical team must allow time for this count to be undertaken without
undue pressure.

7.       The final count must be carried out at the commencement of skin closure and
         should be repeated in the same manner as the first count, and relayed to the
         surgeon again:

8.       If at any stage of the process there is a discrepancy in the counting process all
         theatre personnel must adhere to the guidance in Section 6
         (Count Discrepancy) of the protocol.

On completion of the procedure the following documentation must be fully
completed, accurately and legibly by the identified personnel: and signed by the scrub
practitioner and circulating person.

•    HSDU Instrument Check List.

•    Theatre Patient Notification Form Signature Sheet




Throat Packs:

A throat pack may be inserted by the anaesthetist or surgeon to;
   • Absorb material created by surgery in the mouth.
   • Prevent fluid or material entering the oesophagus or the lung
   • Prevent escape of gases around the endotracheal tube
   • Stabilise artificial airways.

The decision to use a throat pack should be justified by the anaesthetist or surgeon for
each patient as appropriate. This person assumes responsibility for ensuring the
appropriate safety checks are carried out and that the pack is removed after surgery.

The throat pack must be inserted in such a way as to leave the white indicator ribbon
visible outside the patient’s mouth. It may also be taped to the side of the face or the
artificial airway.

The throat pack insertion and removal must be undertaken with a two person check.
On removal of the throat pack the person removing the pack will verbally ask for a
witness to the event. The insertion and removal must be documented and signed for in
the Theatre Notification Form by one nurse / ODP or Anaesthetist who witnesses its
insertion and removal.


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REFERENCES

National Association of Theatre Nurses, 1998: Safeguards for Invasive Procedures:
The Management of Risks. Harrogate. NATN. 7-8.

National Association of Theatre Nurses 1998: The Count. Principles of Safe in The
Perioperative Environment: Harrogate: NATN. 79.




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BIBLIOGRAPHY

ACORN, 1998: Counting of Accountable Items. Standards, Recommended Practices
and Guidelines. Denver, AORN Inc.

Bynom S,1998: Reflections – a lost swab. British Journal of Theatre Nursing. 8 (5)
15-18.

Fish J, 1992: An alternative to swab racks. Nursing Standard. 7(3) 55-56.

Fulbrook S, 1995: Duty of Care. British Journal of Theatre Nursing. 5 (5) 18-19.

Lamb A, (1992): The Swab Rack – an outdated ritual. British Journal of Theatre
Nursing. 2 (2) 14-17.

Langlow A, (1992): Relying on the count. The Australian Nurse Journal. 21 (11)
31-32.

Langlow A, (1992): More on Foreign Bodies. The Australian Nurses Journal. 22 (1)
30 –31.

MDA, 1998: Reporting adverse incidents relating to medical devices.

NATN, 1998: Universal Precautions and Infection Control in the Perioperative
Setting. Harrogate. NATN.

NATN, 1998: Infection Control, Principles of Safe Practice in the perioperative
Environment. Harrogate. NATN

NATN, 1998: Universal Precautions.        Principles of Safe Practice in the
Perioperative Environment. Harrogate NATN.

NATN, 1998: Use and Handling of Instruments, Principles of Safe Practice int the
Perioperative Environment. Harrogate. NATN.

Olsen C, 1995: Sutures, Needles, and Instruments. In: Meeker MH 1995, Alexander’s
Care of the patient in Surgery. 10th Ed. St Louis, Mosby.

Taylor M, Campbell C, 1998: Surgical Practise In: Clarke P, Jones J. (Eds) Brigdens:
Operating Department Practise. Edinburgh. Churchill Livengstone.

Tingl J, 1997: Legal problems in the operating theatre: learning from mistakes.
British Journal of Nursing. 6 (15) 889-891.


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UKCC, 1992: Code or Professional Conduct. 3rd Ed. London UKCC.




LOCAL POLICY

The main areas for consideration are:

1.       Education & Training

2.       Packaging

3.       Responsibility for counts

4.       Checking Procedures

5.       Counting Techniques

6.       Count Discrepancy

1.       Education & Training

a.       It is recommended that, where a Trust runs a perioperative course the post
         basic nursing student/trainee OPD, or any newly appointed staff should have
         supernumerary status until they have been deemed (assessed) competent for
         this skill.

b.       An introduction to the local policy must be included in all staffs orientation
         programme.




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           Appendix –Equality and Human Rights Policy Screening Tool

Policy Title: Clinical Practice. The Count Policy                              Directorate: Surgical Business Unit

Name of person/s auditing / authoring policy: Sr A Dooley, Sr J Hatton


Policy Content:

•     For each of the following check whether the policy under consideration is sensitive to people of a different age,
      ethnicity, gender, disability, religion or belief, and sexual orientation?

•     The checklist below will help you to identify any strengths and weaknesses of the policy and to check whether it is
      compliant with equality legislation.

1. Check for DIRECT discrimination against any minority group of PATIENTS:
                                                                                             Action
Question: Does the policy contain any statements which may
                                                                    Response                required       Resource
disadvantage people from the following groups?
                                                                                                          implication
                                                                      Yes        No       Yes      No        Yes            No
1.0     Age?                                                                     √
1.1     Gender (Male, Female and Transsexual)?                                    √
1.2     Learning Difficulties / Disability or Cognitive                           √
        Impairment?
1.3     Mental Health Need?                                                       √
1.4     Sensory Impairment?                                                       √
1.5     Physical Disability?                                                      √
1.6     Race or Ethnicity?                                                        √
1.7     Religious Belief?                                                         √
1.8     Sexual Orientation?                                                       √
2. Check for DIRECT discrimination against any minority group relating to EMPLOYEES:
                                                                               Action
Question: Does the policy contain any statements which may
                                                                    Response  required                     Resource
disadvantage employees or potential employees from any of
the following groups?                                                                                     implication
                                                                      Yes        No       Yes      No        Yes            No
2.0     Age?                                                                     √
2.1     Gender (Male, Female and Transsexual)?                                    √
2.2     Learning Difficulties / Disability or Cognitive                           √
        Impairment?
2.3     Mental Health Need?                                                       √
2.4     Sensory Impairment?                                                       √
2.5     Physical Disability?                                                      √
2.6     Race or Ethnicity?                                                        √
2.7     Religious Belief?                                                         √
2.8     Sexual Orientation?                                                       √
TOTAL NUMBER OF ITEMS ANSWERED ‘YES’ INDICATING DIRECT DISCRIMINATION = 0


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 3. Check for INDIRECT discrimination against any minority group of PATIENTS:
                                                                                    Action
 Question: Does the policy contain any conditions or
                                                                  Response         required    Resource
 requirements which are applied equally to everyone, but
 disadvantage particular people because they cannot comply                                    implication
 due to:
                                                                       Yes   No   Yes    No    Yes        No
 3.0   Age?                                                                  √
 3.1   Gender (Male, Female and Transsexual)?                                √
 3.2   Learning Difficulties / Disability or Cognitive                       √
       Impairment?
 3.3   Mental Health Need?                                                   √
 3.4   Sensory Impairment?                                                   √
 3.5   Physical Disability?                                                  √
 3.6   Race or Ethnicity?                                                    √
 3.7   Religious, Spiritual belief (including other belief)?                 √
 3.8   Sexual Orientation?                                                   √
 4. Check for INDIRECT discrimination against any minority group relating to EMPLOYEES:
                                                                                    Action
 Question: Does the policy contain any statements which may
                                                                  Response         required    Resource
 disadvantage employees or potential employees from any of
 the following groups?                                                                        implication
                                                                       Yes   No   Yes    No    Yes        No
 4.0   Age?                                                                  √
 4.1   Gender (Male, Female and Transsexual)?                                √
 4.2   Learning Difficulties / Disability or Cognitive                       √
       Impairment?
 4.3   Mental Health Need?                                                   √
 4.4   Sensory Impairment?                                                   √
 4.5   Physical Disability?                                                  √
 4.6   Race or Ethnicity?                                                    √
 4.7   Religious, Spiritual belief (including other belief)?                 √
 4.8   Sexual Orientation?                                                   √
 TOTAL NUMBER OF ITEMS ANSWERED ‘YES’ INDICATING INDIRECT DISCRIMINATION = 2

Signatures of authors / auditors:                              Date:




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              Equality and Human Rights
           Compliance / Percentage Calculation
Number of ‘Yes’ answers for DIRECT discrimination.   0


Number of ‘Yes’ for INDIRECT discrimination.         0


Total answers for POLICY CONTENTS discrimination.    0


Percentage content non compliant                     =0   (Divide a+b by 36 x 100)




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