Leon G. Josephs, MD,FACSChief of Surgery
St. Vincent HospitalWorcester, MA
Retained Surgical SpongesDefine the scope of the problemDiscuss impetus for improvementDiscuss the process improvement
challengesReview St Vincent dataOutcomes and summary
Retained SpongesScope
1/1000-1500 abdominal cases1500 cases per year in US67% require reoperationMedical-legal cost to hospital is
~$150,000
Stawicki, Scientist, 2008
Goals of Process ImprovementNo SRE
No RFBNo wrong siteNo wrong sideNo wrong patient
Impetus for ImprovementRetained Sponge
January 2007 named Chief of SurgeryEarly on, two Retained Sponge casesOne acute, one delayed10/07 Dr. Gibbs ACS Clinical
CongressFocus on why it occurs via RCAProcess Improvement
Retained SpongesImpetus for Improvement
Counts aren’t perfect-80% “correct”X-rays aren’t perfect SRENonpayment events
Retained SpongesWhy
Unmarked towelsPoor quality x-raysPoor nursing standardsPoor wound examPoor communication80% have normal counts
Gibbs,Current ProbsSurg, 2007
Retained SpongesRisk Factors
Risk FactorEmergency surgeryUnexpected changeHigh BMI
Multivariate analysis
Risk Ratio8.84.11.1
Gawande, NEJM, 2003
Retained Sponges69% of all RFBs7% had >154% in abdomen 22% in vagina7% in thorax
Gawande, 2003, NEJM
Retained SpongesChallenges to Improvement
Infrequent event “never happened to me”
Surgeons dislike changeSkeptics among nursing and
physiciansCost
Goals of Process ImprovementZero Retained SpongesReduce Anesthesia TimeReduce Risk to Nursing “sponge
search”Eliminate X-rayImprove OR efficiencyLiability
Process ChangesRevise Counts-AORN standardsEducate nursing and MD staffDefine High Risk Patients for RS
EmergencyMajor change in procedureBMI>30Multiple sites/cavity
MD and Staff Education On line presentation with post testHands on demonstrations with
equipment and wands in all applicable areas – OR, OB and Cath Lab
Retained SpongesDetection Methods
Wound examCountsX-rayRFRFIDBar coded
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
Retained SpongesDetection Study
All high risk patientsCountsX-rayRF Surgical Detection System
Wanding
Detection StudyWhy RF ?
Easy to UseFast and AccurateNot cost prohibitiveGood experience at HUP
RF ProtocolPROCEDURE/PROTOCOL: Items needed
R.F. spongesR.F. consoleR.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.
RF ProtocolWhen 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.
RF ProtocolThe 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
RF Scan ProcedurePosition 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.
RF Scan ProcedureStart 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.
Retained SpongesStudy Design
Measured time to get x-ray and reading
Measured time to prepare and use RF Detection
Reviewed cost and effectiveness180 consecutive high risk patients
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
Retained SpongeDetection
No retained spongesRF decreases anesthesia time by
approximately thirty minutesHigh satisfaction with surgeons and
nurses
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
Retained SpongesImproved patient safetyMD and Nursing staff satisfactionImproved OR and hospital efficiencyRF is an adjunct to good nursing
practice and wound exam by surgeonRF is safer, faster and more cost
effective compared to X-ray for retained sponges
Considering use of RF instruments