Trauma: When There's No Time to Count

Article Outline

• ABSTRACT
• No Time to Count
• Incidence of Retained Foreign Objects
• Consequences of Retained Foreign Objects
• Preventive Measures
• Trauma Preparedness
• Case Scenario
• Case Scenario Discussion
• Conclusion
• References
• Copyright

ABSTRACT 

TRAUMA IS THE LEADING CAUSE OF DEATH for people younger than age 45 in the United States. To help prevent death or disability, critically in jured trauma patients must reach definitive care within the “golden hour.”

OFTEN, THE PERIOPERATIVE TEAM has no more than 10 minutes to prepare the room before a patient who has suffered multiple, critical, traumatic injuries is rushed into the OR.

FOR THE TRAUMA PATIENT'S SAFETY, the perioperative team must be diligent and use creative measures to efficiently ensure that all surgical counts are completed. Foregoing surgical counts places the trauma patient at an increased risk for unintentionally retained foreign objects.

In the United States, trauma is the leading cause of death for persons younger than 45 years of age.¹ Trauma is defined as a severe physical injury that creates a risk of death or significant disability and may be caused by an external force or violence.² According to the National Trauma Data Bank's annual report released in January 2006, the greatest number of trauma deaths are caused by injuries related to motor vehicle traffic accidents. Falls and firearms are the second and third most common causes of trauma deaths. Mortality is not the only consequence of trauma. For every trauma victim who dies, at least six trauma victims are seriously injured.

To help prevent death or disability, the critically injured trauma patient must reach definitive care within a short window of time, often called the “golden hour.”³ A level I trauma center must have specially trained physicians and allied health staff members available to provide care for the critically injured trauma patient 24 hours a day, seven days a week. Level I is the highest designation a hospital can receive from the American College of Surgeons. To provide specialized care, a level I trauma center must have appropriate equipment and facilities.⁴ Traumas may occur anywhere, anytime, and level I trauma centers must be prepared at all times.³

The time between the announcement of an incoming an emergent trauma until the patient arrives in the OR may be only a matter of minutes in a level I trauma center. The patient may come from the emergency department (ED) or from the helipad directly to the OR. Often, the perioperative team has no more than 10 minutes to prepare the room before the trauma team is crashing through the door with a patient who has suffered multiple, critical, traumatic injuries.

Completing the initial surgical counts before the trauma patient enters the OR is a major challenge for the perioperative team. For the trauma patient's safety, the perioperative team must be diligent, take responsibility, and use creative measures to efficiently ensure that all initial surgical counts are completed. Foregoing surgical counts places the trauma patient at an increased risk for unintentionally retained foreign objects. One study revealed that in 10% of the procedures in which retained sponges were found, sponge counts had not been performed.⁵

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No Time to Count 

Sometimes a trauma patient comes directly to the OR from the helipad or the ED with

The surgical trauma team is alerted as the patient is being transported from the helicopter or is being rushed down the hallway. In this situation, the patient usually is in the OR in less than four minutes. In these extreme emergency situations, there truly is no time to count. AORN's “Recommended practices for surgical counts” states that surgical counts may be omitted to preserve a patient's life or limb and that the omission and reasons for the omission of counts must be documented appropriately.⁶ Documentation provides an alert that there may be an increased risk for a retained foreign object.⁶ Intraoperative x-rays should be taken before final closure to rule out any retained foreign objects.⁶, ⁷ According to AORN's recommended practices on counts, there is an increase in accuracy when x-rays are read by a radiologist.⁶ Perioperative team members also must follow institutional policy for an unresolved or incorrect count.⁷

Even when the count is unresolved, the surgeon may believe it is more important to end the surgical procedure than to wait for intraoperative x-rays because of the critical status of the patient.⁸ Sometimes, the surgeon declines the intraoperative x-rays or count resolution because the patient's abdomen is left open and the patient will be returning to the OR for re-exploration and closure at a later date. The patient's abdomen may be left open with laparotomy sponges as packing for tamponade.⁹ According to AORN's recommended practices, if laparotomy sponges are used as packing, the number of sponges used should be documented and the count should be reconciled with the surgeon.⁶

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Incidence of Retained Foreign Objects 

Unintentionally retained foreign objects in patients is a serious problem in health care throughout the world.¹⁰ According to Gwande et al¹¹ unintentionally retained foreign objects occur in more than 1,500 patients each year. The true incidence of unintentionally retained foreign objects is unknown, however, and is thought to be higher because the known numbers are derived from malpractice claims.¹² The study by Gwande et al also revealed that the risk for unintentionally retained foreign objects increases for those patients who

Other factors that increase the risk of unintentionally retained foreign objects are changes in nursing personnel during a procedure, lack of complete surgical counts, and excessive blood loss.¹³ All of these risks factors may be present in the ordinary course of care for a trauma patient. There also are human factors that increase the risk for unintentionally retained foreign objects such as stress, lack of accountability, communication breakdown, distractions, interruptions, and surgical team fatigue.⁷

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Consequences of Retained Foreign Objects 

Unintentionally retained foreign objects may cause severe illness or injury and even death. The consequences of a retained foreign object may include physical, medical, and emotional effects on the patient. Some known consequences of retained foreign objects include

In addition to potentially devastating effects for the patient, consequences for the perioperative team may include

Lawsuits involving retained foreign objects are difficult to defend because of the doctrine of res ipsa loquitur (ie, the thing speaks for itself). Unintentionally retained foreign objects are considered avoidable incidents and create a strong inference of negligence.⁶, ¹⁶

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Preventive Measures 

Although institutional policies and procedures together with AORN recommended practices and guidelines have helped standardize the counting process, incidences of unintentionally retained foreign objects still occur.¹⁶, ¹⁷ AORN clearly defines what items should be counted, when and how items should be counted, and who should count and acknowledges the associated risk factors. Counting is considered an error-prone process because of the distraction-prone environment of the OR and the repetitiveness and redundancy of the process.⁷, ¹⁶ Performing surgical counts is a simple preventive measure that is dependent on human performance and practice and, is therefore, subject to human error.⁵

Perioperative staff members should be proactive in devising strategies to help prevent human error and reduce the risk of unintentionally retained foreign objects in their clinical practice settings. Counting policies should be reviewed, revised, and updated as necessary to adapt them to specific clinical practice settings according to AORN's recommended practices and guidelines.¹⁴ AORN has published recommended practices on surgical counts since 1976 and has been on the forefront of developing counting policies for the patient's safety. The policy should be concise but clearly defined and available for perioperative staff members to review at all times in the practice setting.¹⁷ Performance improvement audits should be performed to ensure that count polices are carried out and not merely documented.¹⁰

It is important to develop mechanisms to report “near misses” in order to track trends that are helpful in devising strategies to reduce risks.⁷ According to AORN, reporting errors and near misses is the first step in reducing errors.⁶ To encourage staff members to report errors and near misses, perioperative managers should focus on preventing and reducing risks rather than laying blame. Performing a root cause analysis (RCA) helps determine what caused the error or near miss and helps team members devise solutions to prevent it from recurring or turning into an adverse or sentinel event. An RCA helps pinpoint the process, policy, and/or procedure that may need to be revised or updated by reviewing all possible contributing factors (eg, human, equipment, controllable, uncontrollable, external, internal).¹¹, ¹⁸

Actions should be taken to improve and promote effective communication between surgical team members. The Joint Commission states that communication is a critical component to providing quality care.¹⁹ Establishment of a “time out for the count” may be one strategy to improve communication.⁵

It also has been suggested by the Joint Commission International Center for Patient Safety that routine intraoperative x-rays be performed for known high-risk procedures.¹⁰ It has been reported, however, that three out of 29 intraoperative x-rays taken for incorrect sponge counts were falsely reported to be negative.²⁰ To improve the accuracy of the radiological interpretation, the x-rays should be read by a radiologist.⁶

Continuity should be promoted by having the same perioperative team start and complete a case that is considered high risk.¹⁰ If this is not possible, a count should be performed at the time of permanent relief of either the scrub person or circulating nurse or both. Although all items may not be visible at the time, an attempt should be made to reconcile the count between the initial and relieving staff members.⁶, ¹⁶

Most foreign objects left in a patient are retained sponges (ie, gossyipiboma).⁵, ¹⁷ Surgical sponges are soft goods that may include various size gauze pads, cotton pledgets, peanuts, dissectors, tonsil sponges, laparotomy sponges, and surgical towels.⁶, ¹⁰ Radio-frequency identification (RFID) is an emerging technology;¹² RFID-tagged sponges are electronically marked with a microchip that may range from the size of a rice kernel to the size of a penny. Passing a handheld, battery-powered scanning wand over the patient can detect whether a retained sponge with an RFID tag is present.²¹, ²² The wand also allows determination of the number of retained sponges without the sponges being separated.²¹ This system is not devised to replace surgical counts but to provide a safeguard.²² Clinical evaluations performed by surgeons and nurses have determined that the use of RFID sponges may be subject to human error, however. Possible human error concerns are holding the scanner too far away from the surgical site or not scanning the surgical site entirely. In spite of this, RFID sponges have been highly rated for ease of use and possibly decreasing the risk of incorrect counts.²³

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Trauma Preparedness 

At Memorial Hermann Hospital, Houston, Texas, a level I trauma center, the designated trauma OR is checked on every shift to ensure that the room is properly prepared for a trauma procedure. The designated OR trauma room is set-up 24 hours a day, seven days a week and is equipped and stocked to handle any trauma surgical procedure. This reduces the need for the circulating nurse to leave the OR for supplies or equipment, such as prepping supplies; gowning, gloving, and draping supplies; trauma packs; and trauma instrumentation, including a self-retaining retractor, sternal saw, and trauma clamps. These items are positioned where they are ready to be opened at a moment's notice. Compression stockings and devices and temperature-regulating blankets and equipment are available. All essential surgical equipment is plugged in and turned on, including headlights and a tourniquet machine. All suction units are intact and ready for immediate use.

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Case Scenario 

At approximately 23:13 hours, trauma team members at a level I trauma center are alerted via their pagers that the helicopter has responded to a motor vehicle accident. The patient is an 18-year-old woman with

The estimated time of arrival at the trauma center is 13 minutes. The trauma team includes an anesthesia resident, trauma surgeon, surgery resident, OR charge nurse, ED charge nurse, and the hospital administrator.

At 23:28 hours, the surgical trauma resident calls to schedule the patient for an exploratory laparotomy. The surgical trauma resident alerts the OR charge nurse that the patient is coming straight to the OR from the helipad and that the patient has a head injury, is intubated, and is hemodynamically unstable. The OR charge nurse alerts the OR nursing staff and the chief anesthesia resident that the patient is coming straight up to the OR for an exploratory laparotomy and also provides other pertinent patient information. The neurology physician assistant calls to alert the OR charge nurse that placement of an intracranial pressure monitor also will be performed.

Perioperative staff members proceed immediately to the trauma OR. The scrub person opens her gown and gloves. Having performed a full scrub at the beginning of her shift, she applies a waterless surgical hand antiseptic, and then dons her gown and gloves. This process takes only two minutes.

Meanwhile, the circulating nurse opens the remaining gowns, gloves, trauma pack, instrumentation, and miscellaneous items (eg, suture, ties, skin stapler). The OR charge nurse checks on the status of the patient's blood products. The scrub person drapes the Mayo stand and starts to count with the circulating nurse: 30 laparotomy sponges, 10 radiopaque 4-inch by 8-inch sponges, 10 needles, four blades, and miscellaneous items (eg, electrosurgical unit tips and scratch pad, vessel loops); this process takes approximately two minutes.

The scrub person organizes her back table to prepare to count the 160 instruments with the circulating nurse, which takes another three to four minutes. The instrument count process is easy and efficient because the trauma sets are standardized and the instrument count sheets are preprinted. The trauma instrument set contains retractors, clamps, and instruments to handle any general surgery or vascular procedure. This eliminates the need to open more sets because the definitive surgical plan usually is unknown in trauma procedures. It takes a total of eight minutes to open and perform the initial surgical counts.

At 23:45 hours, 13 minutes after the trauma case was scheduled, the trauma team arrives in the OR with the multi-trauma patient. The circulating nurse is in charge of the room and must remain calm, confident, in control, and focused. The ability of the circulating nurse to immediately prioritize the patient's care accurately and efficiently is essential. The circulating nurse is responsible for delegating tasks so that nothing is duplicated or overlooked. The circulating nurse also must control traffic in the OR. Traffic control allows the circulating nurse to efficiently keep up with the needs of the surgical team, the count, and the charges.

The circulating nurse immediately performs a time out with the entire surgical team by verbally confirming the patient's name and anticipated procedure(s) with the patient's medical record and identification band and ensures that specially requested equipment and the correct blood products are in the room. Consent is implied because of the patient's unconscious condition and imminent, life-threatening injuries. A second RN arrives in the OR to help expedite the surgery cut time. The circulating nurse delegates application of the compression stockings and insertion of the urinary catheter to the second nurse.

The circulating nurse continues to assess the patient while applying a temperature-regulating blanket and then prepares to prep. The scrub person finishes organizing her Mayo stand and back table. The surgical cut time is 00:13 hours, exactly one hour from the time the trauma team was alerted that a trauma patient was on the way to the OR.

The trauma surgeons perform an exploratory laparotomy for spleen and bowel repairs and place a suprapubic catheter and an intracranial pressure monitor. Throughout the procedures, the circulating nurse uses a pocketed bag system to contain and monitor the sponges off the field. The pocketed bag system is dispensed from a carton with wire hooks to hang it from an IV pole, with the clear pocket openings facing the circulating nurse. As each system is filled with five laparotomy sponges, a new system is placed in front. The laparotomy sponges are placed in the pockets with the blue anchoring loop hanging outside the pocket, indicating that the circulating nurse has double-checked that there is only one sponge in each pocket. This allows the anesthesia care provider to easily evaluate the sponges for blood loss. This system also allows the circulating nurse to easily see the sponges for counting, which decreases errors caused by sponges sticking together. The filled pocketed bag systems are placed in large red trash bags after the final count has been reconciled.

After the surgeon clears the patient's abdomen of all sponges and thoroughly inspects and irrigates the abdomen, the surgeon counts seven laparotomy sponges with the surgical team as he packs them in the patient's abdomen for tamponade. The seven laparotomy sponges are confirmed with the surgeon and reconciled by having 53 visible counted laparotomy sponges.

The patient's abdomen is left open. The surgeon sutures a Bogota bag in place over the abdominal contents. A Bogota bag (ie, a hospital-sterilized, 2-L IV bag sutured to the abdominal wall) or a specialized vacuum closure system often is used if the abdomen is left open.²⁴, ²⁵ Placement of the Bogota bag or the vacuum closure system protects the abdominal contents and helps prevent abdominal compartment syndrome.²⁴, ²⁵

The circulating nurse documents seven laparotomy sponges as packing and completes a variance report according to hospital policy. This documentation alerts caregivers that an x-ray of the patient's abdomen should be completed intraoperatively and read by a radiologist before the patient's abdomen is closed permanently. The circulating nurse also includes in her report to the intensive care unit (ICU) nurse that there are seven laparotomy sponges packed in the patient's abdomen. The patient is transported to the surgical trauma ICU without incident.

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Case Scenario Discussion 

In the case scenario, the perioperative team was as prepared as a team can be for trauma. They took the initiative and responsibility for completing the counts rather than assuming that there would be no time to count. The perioperative team members stayed committed and focused on providing safe, quality care. The scrub person first focused on completing the initial counts and then on the organization of her field. She understood that she would have time to organize her field while the patient was being positioned and prepped.

AORN recommended practices state that accuracy, efficiency, and continuity is achieved if a standardized count procedure and sequence is followed.⁶ The team conducted the initial surgical counts in the usual logical progression: laparotomy sponges; 4-inch by 8-inch sponges; needles; blades; miscellaneous items; and finally, the instruments. The instruments were counted in sequence according to the preprinted count sheets. The body cavity counts and final counts also were performed in the same logical progression starting with the surgical field, Mayo tray, back table, and then the items off the field (eg, items in kick buckets and pocketed bags).

Use of the pocketed bag system helped the circulating nurse keep track of the sponges throughout the procedure, which helped minimizes the possibility of a count discrepancy.⁶ The perioperative team members completed the final surgical counts, even though they knew the patient would return for re-exploration and closure at a later date. The team wanted to ensure that all laparotomy sponges were accounted for and no other items were unintentionally retained.

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Conclusion 

Performing surgical counts accurately and efficiently is a basic perioperative intervention used to achieve the nursing outcome that the surgical patient is free from signs and symptoms of injury from retained foreign objects. Perioperative nurses are ethically bound to provide a safe environment for all patients and must collaborate with all team members to ensure that measures are taken to protect the patient and provide the highest quality of care.

The nature of trauma places the patient at a higher risk for retained foreign objects and, as professionals and patient advocates, the perioperative team must help reduce these risks. There are extreme circumstances when there truly is no time to count during trauma; however, the perioperative trauma team must be prepared and organized to use every minute efficiently to perform surgical counts accurately for optimal patient safety.

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