1. The Count Revisited VPNG Strategies for Success Cathy Dean Clinical Support & Development Nurse Alfred Hospital Latrobe Perioperative Course Coordinator

2. Objective: Elimination of the RSI

3. Session outline  Identify strategies to improve count practices and eliminate RSIs and to explore ways that current count practices can be further improved  An overview of current count practices  Discuss current available studies on counts and RSI  Identify future directions in using research to prevent RSIs  Improved team communication as a tool in RSI prevention  Technological adjuncts and their role in preventing RSIs  Data collection as a tool to identify trends and emerging patterns in RSIs  Using research findings on trends and patterns to inform practice  Toward the future

4. Current count practices  ACORN standards: detail the minimum standards for management of accountable items  Standardized system designed to reduce risk of RSI  ACORN standards; Local guidelines and State/Territory policies and guidelines  Apply to all members of the surgical team  Scrub & Scouts have the primary responsibility for the management of the count procedure but the surgeon has a significant role.

5. Count practices  Well established formalised process  Core responsibility of the perioperative nurse  Consumables are counted but ACORN do provide leeway on individual facility requirements in the counting of some items.  ACORN standards do require all instruments are counted and reconciled against the tray lists  Variations in what is counted  Variations in process documentation  Individual hospital guidelines on the counting of instruments and instrument trays

6. Counting of all Instruments

7. So how do RSIs occur?  Multiple cases  Multiple teams  Poor team communication – respect and action; unknown to each other  Fatigue  Lack of handover process  Rushed or incomplete count practices  New equipment and procedures  Unfamiliar with procedure or instrument sets

8. Literature  Case reports clinical series & opinions  Little quantative research insight into RSI risk factors to date  What contributes to the RSI risk profile ?  Identification of clinically important differences not agreed on within the literature.  Surgeon perspective and circular in nature.  Limited findings or recommendations that inform practice

9. Questions asked  Body mass index  Emergency procedures  Blood loss  Nursing staff change over  After hours  Lack of counts or no counts  ….what has been extracted?  ….a surgical trainee in the OR ??

10. The Perioperative Nurse  How do we prevent RSIs?  Asking the questions  Collecting the data

11. Data  Understanding the issues through data  Risk Watch – Victoria  Global risk watch : data  Transparent reporting  Agreed terminology  In form our practice in a clear way that can be linked into our everyday practice.

12. Communication  RSIs are rare events …never events  Team communication  Human factors  Surgical safety checklist & time out  Achieving the level playing field with equal and respectful communication

13. Risk watch 2004-2014  Retained curette laparoscopic surgery  Disposable verres needle sheath  A retained pack in a laparotomy case  Raytec gauze hip replacement  Retained pack – vaginally  Artery forceps  Measuring pins  Fractured guide wires

14. Preventing RSIs  Good systems; good communication  High functioning teams training programs in communication  Formal Human factors training  Standardised practices  Data informing practice quickly and effectively  Adoption of adjunct technologies that seamlessly achieve high confidence levels in reconciling the count.

15. Technological adjuncts  Reducing the incidence of RSIs  Query an added layer of complexity

16. RFI for RSIs  Packs & Raytec  Disposable trocars and sheaths  Instrumentation  Reliable detectors for all items  Enjoying confidence that no thing is left behind

17. Safety Programs  National Safety Standards  Board to ward approach  Strategies based on emerging trends  Inform practice  Adopt strategies quickly

18. Complex Surgery complex counts Complex environment

19. Communication  Complex environment  Knowing the team  Pause & introduction  WHO – white board  Understand the plan  All team members understanding the count  To hear and to act

20. Getting it Right together

21. Strategies for success  Realising the RSI as a never event?  Teaching communication  Ongoing communication support within the interdisciplinary team  Board to ward  Equal and respectful  Data to inform practice and practice change  Adjunct technological aids to enhance safety and eliminates RSIs

23. References  ACORN standards 2014-2015  Australian Institute of Health and welfare Canberra, Sentinel events in Australian public hospitals 2004-05. July 2007.  Boyd, C., & Lottenberg, L., (2015) Preventing Retained Surgical Sponges: clinical and Economic Considerations. General Surgery News (2015).  http://www.globalpatientsafetyalerts.com/English/ContributingOrganizations/ Pages/default.aspx http://www.globalpatientsafetyalerts.com/English/ContributingOrganizations/ Pages/default.aspx  Copeland, A., Retained surgical sponge (gossypimboma) and other retained surgical items: Prevention and Management. www.uptodate.com (2015)www.uptodate.com  Feldman, D., Prevention of Retained Surgical Items., Mount Sinai Journal of Medicine (2011) 78: 865-871.  Hariharan, D., & Lobo, D., Retained surgical sponges, needles and instruments. Ann R Coll Surg Engl (2013) 95: 87-92.  Hicks, C., Rosen, M., Hobson, D., Ko, C., & Wick, E., Improving safety and Quality of Care With Enhanced Teamwork Through Operating Room Briefings, JAMA Surg (2014) 149 (8): 863-868.  Ivory, K., Listen, hear, act: challenging medicine’s culture of bad behaviour. MJA. (2015) 202 (11)  McDonald, I., Human Behavior behind most surgical errors (2015) http://www.fiecehealthcare.com/story/johns-hopkins-mayo-clinic-causes- surgical-errors-never-events/2015-06-09 http://www.fiecehealthcare.com/story/johns-hopkins-mayo-clinic-causes- surgical-errors-never-events/2015-06-09  Mehtsun, W., Ibrahim, A., Diener-West, M., Pronovost, P., & Makary, M., Surgical Never Events in the United States. Surgery (2013) volume 153 (4).  Moffatt-Bruce, S., Cook, C., Stienberg, S., & Stawicki, S., Risk factors for retained surgical items: a meta-analysis and proposed risk stratification system., Journal of Surgical Research 190 (2014) 429-436

24. References cont.  Orosco, R., Talamini, J., Chang, D., & Talamini, M. Surgical Malpractice in the United States. J Am Coll Surg (2012) 215: 480-488.  Pennsylvania Patient Safety Advisory, Beyond the Count: Preventing retention of Foreign Objects. Vol 6 No 2 June 2009.  http://health.vic.gov.au/clinrisk/sentinel/index.htm : Risk Watch News letters  Rupp, C. et.al. Effectiveness of a Radiofrequency Detection System as an Adjunct to Manual Handling Protocols for Tracking Surgical Sponges: A Prospective Trial of 2,285 Patients. J Am Coll Surg (2012;215:524-533  State Government Victoria, Department of Health, Supporting patient safety Sentinel event program Annual report 2011-12 and 2012-13.  Stawicki, S., et.al., Natural history of retained surgical items support the need for team training, early recognition, and prompt retrieval. The American Journal of Surgery (2014) 208, 65-72.  Stawicki, S., et.al. Retained Surgical Items: A Problem Yet to be Solved. J Am Coll Surg (2013) 15-22.  Steelman, V., Graling, P., & Perkhounkova, Y., Priority Patient Safety Issues Identified by Perioperative Nurses. AORN Journal (2013) Vol 97 No 4.  The Joint Commission Sentinel Event Alert, Preventing unintended retained foreign objects. Issue 51 October 17, 2013.  Williams, T., Tung, D., Steelman, V., Chang, P., & Szekendi, M., Retained Surgical Sponges: Findings from Incident Reports and a Cost-Benefit Analysis of Radiofrequency Technology. J Am Coll Surg (2014) 219:354-364.