The surgical count plays a vital role in enabling the perioperative practitioner to enhance the surgical patient’s safety.
Surgical items, such as instruments, swabs and sharps used by the surgical team to perform invasive procedures, are foreign bodies to the patient and must be accounted for at all times to prevent retention and injury to the patient (Association for Perioperative Practice (AfPP), 2007; Association of Perioperative Registered Nurses (AORN), 2006; Rothrock, 2002).
The surgical count must be undertaken by a scrub practitioner and a circulating practitioner, one of which must be a registered member of the perioperative team (registered nurse or operating department practitioner (ODP)). The count should not be completed between two circulators or two scrub practitioners (Rationale 1).
The scrub practitioner must take the lead for carrying out the surgical counts. This must be done in a systematic manner involving the circulating practitioner. Both members must count audibly and in unison with each other to acknowledge the items (Rationale 2).
A surgical count must be performed for all clinically invasive procedures and recorded instantly. This documentation must be filed into the patient's care record before leaving the theatre environment.
The theatre environment should have a dry-wipe white board, which is pre-printed and displays all the significant items used. The board must be a permanent fixture within the theatre and be visible and accessible to every team member.
An initial full surgical count must be completed prior to the surgery commencing (Rationale 3).
A second count must occur before the closure of a cavity or a cavity within a cavity (Rationale 4).
A final count must occur at the commencement of the closure of the skin or at the end of the procedure. In cases involving surgery within a natural cavity (for example: mouth, vagina, anus), a final count must be performed at the commencement of the closure of the wound with a further consolidation count at the end of the procedure prior to the scrub trolley being removed from the surgical field (Rationale 5).
On completion of the final count, the scrub practitioner must communicate to the operating surgeon that the cavity/final surgical count is correct and that all items are accounted for. The operating surgeon should also verbally acknowledge the fact that he/she has heard the scrub practitioner (Rationale 6).
If during the surgery the scrub practitioner needs to be replaced, a full surgical count must be undertaken and documented within the patient's care record and the theatre register.
When a surgical count is taking place there should be no interruptions. Once a count has been started it should be completed. If interrupted, the count should resume at the last recorded item.
Additional items required during the surgery must be counted when given onto the sterile field and recorded on the dry-wipe white board (Rationale 7).
The instrument check lists should be available and provide an accurate record of the instruments on the set. This should be used to check the instruments at the beginning and end of every case.
The instruments should be counted in an audible, organised style, which usually follows the pre-printed check list. The circulating practitioner can then use the check list to document that instruments are correct and complete the tracking documentation.
Instruments that come with screws, removable parts or are disassembled into their component parts must be checked and accounted for.
Instruments should be counted before they are separated and organised by the scrub nurse, for example setting up of a mayo table (Rationale 8).
Any instruments that are found to be damaged or not working must be removed from use and labelled for repair.
Staff involved in the surgical counts must be able to recognise and identify the instruments they are counting.
If an instrument tray is incorrect when doing the initial count, it should be either be removed and a new one opened or continue to be used if the scrub practitioner is satisfied that the instrumentation required for the procedure is present. However, in both circumstances, the missing instrument must be documented on the instrument check list and sterile services informed.
If any supplementary instruments are opened then the packets must be retained with the instrument checklists for reference during cavity and the final counts.
All swabs, including mastoids, pledgets, neurosurgical patties and packs, must have an X-ray detectable marker throughout the width of it for all invasive procedures (Rationale 9).
All swabs, including mastoids, pledgets, neuro patties and packs must be counted in the numbers they are packed in eg swabs in bundles of five and neuro patties in bundles of 10. This includes cotton wool balls that are used for ear, nose and throat surgery (Rationale 10).
If there is a package containing less or more than the number that should be there, they are to be collected, bagged, labelled and passed off to the circulating practitioner. These swabs must then be removed from the theatre (Rationale 11).
Any tags or bands holding the swabs together should be removed and the items separated and counted (Rationale 12). The tags should be retained by the scrub practitioner as a means of checking the amount of swabs later if there are any discrepancies.
The recommended sequence for counting swabs is from large to small, ie 6x4s, mastoids, pledgets and from the patient out ie swabs at the surgical field, trolley and in the bowl stand/bucket.
The integrity of the X-ray marker must checked when the items are being counted.
The integrity of swabs with tapes, eg abdominal packs, must be checked when items are being counted (Rationale 13).
Swabs should be left in full view of the surgeon carrying out the procedure at all times (Rationale 14).
Used items should be counted off the sterile field in the number they were counted in originally eg swabs in five and neuro patties in 10, as soon as possible. This should be done by counting the items with the circulator and put in a clear plastic bag.
The circulating practitioner holding the bag should be wearing gloves and secure the bag once all swabs are in it (Rationale 15).
If using different types of swabs the bag should be labelled with the size of swab inside.
If an item is dropped at any time during the invasive procedure, it should be collected by the circulating practitioner and the scrub practitioner must be notified. It must then be placed in an appropriate area, away from the sterile field, but not out of the theatre environment.
Swabs must not be altered in size (except cottonoid swabs for neurosurgical procedures - see below)(Rationale 16).
Only cottonoid swabs may be cut into five appropriately sized pieces when used for neurosurgical procedures (Rationale 17 and 18).
Swabs retained in the wound to act as packs intraoperatively must be documented on the wipe board designated for the surgical count (Rationale 19).
The wipe board must contain the following information:
clearly defined as "swab(s) in the wound/cavity"
size of swabs in situ
number of swabs in situ
When swabs are removed from the wound/cavity, the scrub practioner must show the swabs to the circulating practioner to both acknowledge the items.
The circulating practioner must document the swabs removed on the wipe board but not erase the entry (Rationale 19).
Swabs should not be opened and then have the X-ray marker removed and used as dressings (Rationale 20).
Dressing gauze without an X-ray detector strip should be used for wounds that require gauze dressings and should be opened at the closure of skin (Rationale 21 and Rationale 22).
Sharps and other items
Hypodermics, blades and sutures should be counted and recorded before the invasive procedure starts. These should be collectively counted and added to the wipe board (Rationale 23).
Any extra sharps that are given during the surgery should be individually counted and added to the wipe board, according to the number on the packet and a running total of the amount of the sharp item recorded. Suture packets should be retained and used for repeat counting.
If at any point during the surgery a sharp breaks, the scrub practitioner must be aware of it and have all the pieces returned for correct disposal onto the sharps pad. All pieces must be accounted for at the end of the procedure.
If surgical nylon tapes or silicone vessel 'loops' are cut for the purposes of the procedure being carried out, they must be documented on the wipe board designated for surgical counts and all pieces accounted for when subsequent counts are carried out (Rationale 24).
If at any point during an invasive procedure the surgical count is incorrect, the surgeon must be notified, another count carried out and a thorough search of the surgical field and surrounding area started.
If the missing item(s) are not recovered after a re-count and the search has been completed, the patient must have a plain film X-ray taken of the operative site before leaving the theatre complex (Rationale 25).
If the missing item(s) are microscopic needles of 7/0 gauge and below (8/0, 9/0 etc.), and there is a potential for them not to show up on an X-ray this will need to be documented on the patient's care record, the theatre register and an incident form completed. This is the only time a surgeon can use their discretion as to whether to X-ray for the item(s).
If there are any concerns regarding the locating of missing item(s) the theatre co-ordinator or theatre manager should be contacted in hours and the CSP out of hours.
All missing item(s) must be documented on the patient’s care record, the theatre register and a Trust incident report completed. The type of missing item(s) and the action taken must be included in the report.
The only exception to this procedure not being carried out is if the patient is deemed too unstable.
Swabs that are to remain in situ for wound packing must be documented in both the intraoperative care plan and the theatre register.
All items used for the surgical procedure are to remain within the theatre environment until the surgery is finished and the final count completed. This includes all clinical and non-clinical waste products and theatre laundry.
If the patient requires urethral catheterisation at any point, only dressing gauze must be used not x-ray detectable swabs (Rationale 27).
At all times during the surgical procedure, the scrub practitioner must be aware of his/her swabs, sharps and instruments. It is recommended that neatness should be encouraged so to ensure that only essential items are used for the procedure.
Rationale 1: To lessen the risk of an inaccurate count being undertaken.
Rationale 2: Concurrent verification of counts by two individuals lessens the risk of inaccurate counts.
Rationale 3: To establish a baseline referance for all subsequent counts.
Rationale 4: To identify any retained items prior to closing the cavity.
Rationale 5: To identify all items counted at the start of the procedure are present.
Rationale 6: To facilitate good communication and avoid any misunderstanding.
Rationale 7: Accurate accounting for items throughout the surgical procedure reduces the risk of retaining an item in the wound.
Rationale 8: This is to prevent forgetting to count an item that has been separated into two locations.
Rationale 9: Radiopaque indicators facilitate locating an item presumed lost or retained in a body cavity when a descrepancy occurs.
Rationale 10: A standardised counting procedure reduces error during the counting of swabs.
Rationale 11: Containing and isolating incorrectly packaged swabs helps to reduce the potential for error in subsequent counts.
Rationale 12: To ensure all swabs including the x-ray detectable strip are seen by both practitioners while a count is undertaken, and any descrepancies identified.
Rationale 13: To ensure the tape will not detatch.
Rationale 14: To avoid a swab being retained in the wound inadvertantly.
Rationale 15: To prevent personel exposure to potentially infectious material.
Rationale 16: Altering a swab invalidates subsequent counts and increases the risk of a portion being retained in the wound.
Rationale 17: Cottonoid swabs contain and impregnated x-ray detectable strip which is not removable.
Rationale 18: A standardised counting procedure reduces error during the counting of swabs.
Rationale 19: To facilitate good communication and avoid any misunderstanding that may lead to an inaccurate swab count or a swab being retained in the cavity.
Rationale 20: Altering a swab invalidates subsequent counts and increases the risk of a portion being retained in the wound.
Rationale 21: To prevent any confusion if a count descrepancy occurs.
Rationale 22: To prevent dressing guaze being inavertantly retained in a wound with no method of detection.
Rationale 23: To prevent retaining a foriegn body in the wound.
Rationale 24: To facilitate good communication and avoid any misunderstanding that may lead to an inaccurate count or an item being retained in the wound.
Rationale 25: To inspect the wound/cavity for retained item(s).
Rationale 26: For traceability purposes in the event of a manufacturer/Medicine Healthcare Regulatory Agency (MHRA) alert being issued.
Rationale 27: To avoid an inaccurate count if a descrepancy occurs.
Association of Perioperative Practice (AfPP) (2007) Swab,instrument and needle counts: Managing the risk Association of Perioperative PracticeIn: Standards and recommendations for safe practice. Harrogate, AfPP
Association of Perioperative Registered Nurses (AORN) (2006) Recommended practices for sponge, sharp and instrument counts AORN In: AORN standards, recommended practices and guidelines. Denver, AORN
Rothrock J (2002) p.36-37 Rothrock J In: Alexander's care of the patient in surgery. London, Mosby