the newcastle upon tyne hospitals nhs foundation trust count … · 2020. 6. 24. · the newcastle...

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The Newcastle upon Tyne Hospitals NHS Foundation Trust

Count Procedure

Version No.: 4.0

Effective From: 07 December 2017

Expiry Date: 07 December 2020

Date Ratified: 15 November 2017

Ratified By: Theatre Users Groups

1 Introduction

The overriding objective for the count is that all mops/swabs packs, instruments, single use items and sharps must be accounted for at all times during an invasive surgical procedure, to prevent foreign body retention and subsequent injury to the patient.

Retained objects are considered a preventable occurrence and careful counting and documentation can significantly reduce, if not eliminate these incidents also known as one of the “Never Events”. A Never Event was described as serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. A count must be undertaken for all procedures in which swabs, instruments and sharps could be retained.

It is accepted that some surgical procedures carry a greater risk than others, for example there is a higher risk of retaining swabs and surgical instruments during abdominal and thoracic surgery than there is during ophthalmology surgery.

2 Scope

The scope of this policy is to provide evidence based guidance to all healthcare professionals when they are required to account for all mops/swabs, packs instruments, extras and sharps used during an invasive surgical procedure, to prevent foreign body retention and subsequent injury to the patient.

3 Aims

The aim of this policy is to standardise the procedure for accounting for all mops/swabs and instruments used during operative procedures. This policy is of primary interest to all Theatre Nursing, Non-Nursing Staff and Operating Department Practitioners when performing count activities.

4 Duties (Roles and responsibilities)

The Executive Team is accountable to the Trust Board for ensuring Trust-wide compliance with policy.

Directorate managers and heads of service are responsible to theExecutive Team for ensuring policy implementation.

Managers are responsible for ensuring policy implementation andcompliance in their area(s).

All staff are responsible for complying with policy.

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5 Definitions ANTT Aseptic Non Touch Technique DSC Delayed Sternal Closure HDU High Dependency Unit ITU Intensive Therapy Unit SSD Sterile Services Department TMO Training Manager on Line WHO World Health Organisation 6 Count Competence An introduction to the Count Policy must be included in all new Operating Theatre staff’s Induction programme. Both registered and non-registered staff must successfully complete the Count Competency and documentary evidence should be available. Pre-registered nursing students and student ODP’s must have supernumerary status until they have been deemed competent to assist with the count by an appropriately qualified member of the scrub team. It is recommended that this should be the designated registered student assessor / mentor and done under direct supervision and countersigned. 6.2 Disposable Items

A count must be performed prior to all operations and all items added to the dry wipe count board however minor. Countable items may include but are not limited to the following items:-

Mops/Swabs/Packs

Red swab ties / pack ties

Pledgets / patties

Blades

Atraumatics

Diathermy Tip Cleaners

Bert Bags (Laparoscopic Retrieval Bag)

Needles

Vessel / Nerve Loops

Screws

Any other specials However, Ophthalmology is excluded from counting swabs in certain cases (List monitored by Ophthalmology Theatre Sister).

6.3 Instrument Count

An instrument count will include the following:

All tray instruments

All supplementary instruments

All single use instruments

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The “FULL” count is therefore divided between disposable items (mops/swabs, packs needles etc.) and instruments (including single use instruments). Tray lists must be available to provide an accurate record of instruments. The list must be used to check the instruments prior to the start of surgery and again on completion of the surgery and if scrub/count personnel change over during procedure. Tray list must be held by the count practitioner and each item on the list read out loud and marked off individually when seen. There must be a local traceability system of all instruments used during the procedure. Theatre staff will keep a record of all instrument trays used on individual patients by recording them in the Tray Tracking / Surgi Net system. Supplementary instruments will be entered into the appropriate theatre record book along with the SSD label and patient details. Supplementary instruments will, in future be supplied by SSD with a T-Doc bar-code. These can be recorded in the Tray Tracking / SurgiNet System. Supplementary instruments should be added to the additional spaces at the bottom of the count sheet to be included in the count. Ideally, the count person will be the only member of staff to provide the scrub practitioner with additional instruments. Instruments and items with screws and or removable parts must also be included in the count at the beginning and end of the procedure. The integrity of the instruments must be checked at the beginning and end of the procedure.

6.4 Atraumatics All atraumatic suture packets must be retained until the final count is completed.

Opening all suture packages during the initial needle count is not recommended.

Used needles on the sterile field must be retained in a disposable, puncture resistant needle container.

6.5 Digital Tourniquets (Hands and Feet)

Tourniquets are commonly used to provide a bloodless field in hand and toe surgery and when a digital tourniquet is opened this must be recorded as part of the Count Procedure.

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Documentation of the removal of digital tourniquets is required as part of the Count. Procedure and must include the length of time a tourniquet is in place (i.e. time on and time off). This must be recorded upon the WHO check list and Surginet system. CE marked digital tourniquets that are labelled and/or brightly coloured should be used in accordance with manufacturer’s instructions. Surgical gloves MUST not be used as tourniquets.

6.6 Count Procedure

Prior to the commencement of the surgical procedure, the scrub and count practitioners will perform the count together. This count is conducted audibly i.e. both practitioners must count aloud and in unison. Each count must be performed by two members of staff, one of whom must be a count competent practitioner. The staff involved in the counting procedure must be able to recognise and identify the “Instruments / disposables” in use, and the same two personnel should perform all the counts that are done during the surgical procedure. The surgical team must allow time for these counts to be undertaken without pressure. This should be done in a quiet and controlled environment with reduced noise and no interruptions. As with time out, the Scrub and Count staff should take time out to prepare for the formal count procedure to take place. All music must be turned off and background theatre noise minimised to enable the count to be performed correctly. If any interruption occurs, the count should be resumed at the end of the last recorded item. Trust standard pre-printed Count Sheets must be used to record all disposable items see (Appendix 1). Provision must be made in the theatre for a dry wipe count board, which is permanently fixed to the theatre wall. This should be at an appropriate height and in a position that facilitates easy access and visibility during the procedure.

All disposable items will be recorded on the count sheet and on the count board, so that the scrub practitioner can monitor any additional swabs etc., throughout the procedure. When additional items are added, they must be counted at the time and recorded as part of the documentation to keep the count accurate and current. At all times during a surgical procedure, the scrub practitioner must be aware of the location of all swabs, instruments and medical devices. Neatness in approach must be encouraged to ensure that only necessary equipment is in use at any time.

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A standardised layout for instrument trays must be locally agreed to aid a smooth transition between scrub practitioners should a change over count is necessary. Any mops/swabs packs or any other items placed inside the patient and therefore out of sight must be recorded on the dry wipe count board. Should it be necessary to replace either person during the procedure, a complete count must be performed, recorded and signed by the incoming and outgoing practitioners on the intraoperative record and Surginet. The initial full mop/swab and instrument count must be performed immediately prior to the commencement of surgery. A second count must take place before closure of a cavity within a cavity, before wound closure begins, and finally at skin closure or end of procedure. In the event of a NCEPOD 1 immediate life threatening emergency, it is recognised that it is not always feasible to perform an initial full swab and instrument count. In these circumstances all packaging must be retained to facilitate a count being undertaken at the earliest opportunity. If a scrub practitioner is not required for the procedure (such as dilatation and curettage), the Circulating Practitioner should be a count competent with whom the operating surgeon must perform the count. Any discrepancies must be reported to the surgeon at the earliest opportunity and a verbal acknowledgement must be received. (Refer to ‘Procedure to be followed if a Count is found to be Incorrect’). All documentation must be signed by both the scrub practitioner and the count practitioner; the surgeon must also sign to state that they have been informed the count is correct.

A full handover from the Scrub and Anaesthetic Practitioner must be given to the Recovery / Ward / Critical Care practitioners.

6.7 The Procedure for Counting Swabs

The term “swabs” includes all x-ray detectable gauze products including mops swabs, packs, peanuts, pledgets, patties etc. All swab ties must be retained until the final count is completed

It is the designated Count Practitioners’ responsibility to keep the scrub practitioner supplied with additional mops/swabs pack, and other disposable item. The count practitioner will ensure that nothing is removed from the theatre without the permission of the scrub practitioner, e.g. specimens.

The integrity mops/swabs /packs and x-ray detectable markers must be checked during the count, including attached tapes.

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Mops/swabs and packs must be carefully segregated throughout the procedure to prevent miss counts.

During the procedure, mops/swabs must be counted into separate groups of five only. These must not be added to those already counted until verification of the number in the packet; however on some occasions (for example patties are supplied in packs of 10) items may be counted in groups of 10 any additions must be in multiples of five / ten (patties).

In the event of an incorrect number of mops/swabs (i.e. not five), the entire packet must be removed from the procedure area. The batch and Lot numbers must be identified and the appropriate suppliers notified as required.

All used mops/swabs must be fully opened and placed into the individual pockets of the count bags with an opaque backing. When ten mops/swabs have been bagged and counted the count bag is then rolled up secured and clearly labelled as 10 mops/swabs. They are then stored in clear view of the scrub practitioner.

Packs must be fully opened and the tape checked. When 5 have been bagged and counted the count bag is then rolled up secured and clearly labelled and kept in clear view of the scrub practitioner.

The Scrub and Count Practitioners’ will count any additional disposable items together. These will be added to the count sheet then to the count board.

If a counted item is inadvertently dropped off the sterile field, the circulating practitioner must retrieve it, show it to the scrub practitioner and place it in the appropriate location to be included in the final count.

In all procedural counts, the Scrub and Count Practitioners will count the bagged mops/swabs first those: 1. Hanging in the count bags 2. Any remaining swabs on the instrument trolley 3. Or in the sterile field.

On completion of the final count, a verbal statement must be made to the surgeon by the scrub practitioner to the effect that the final count is completed and correct and all items accounted for.

A verbal acknowledgement must be received from the surgeon to alleviate any misunderstanding.

6.8 Counts during surgical procedures

As there are many different procedures/operations undertaken in the theatres across the trust, a specific number of counts could not be given but:-

A count must be completed before closure of any internal organs or cavities and the surgeon is notified that this is correct.

All procedure counts are conducted in the same order as the pre-operative count; commencing with the discarded unsterile mops/swabs/packs followed by those remaining in the sterile field.

The first count of all items will be conducted at the start of the first layer closure and the surgeon is notified that it is correct.

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On completion of each count a verbal statement by the scrub practitioner, to the effect that the disposable count is correct must be made to the surgeon.

Verbal acknowledgement must be received from the surgeon to alleviate any misunderstanding.

In some cases, it may be necessary to perform additional counts during closure. The scrub practitioner can do as many counts as they deem necessary to ensure they know where all swabs instruments and sharps are through out the procedure.

The count must be conducted at the start of the skin closure and the surgeon is notified that it is correct. It is important to remember that it may not be the Consultant who has carried out the procedure although he may be present in a supervisory capacity. The surgeon closing the wound has been informed and acknowledged that the final count is correct.

A definitive post-surgery count must be done when the dressing is applied and all surgical contact with the patient has ceased but prior to reversal of anaesthesia and the patient leaving theatre.

All remaining loose mops/swabs and packs should be placed in count bags prior to this count to ensure they are disposed of in multiples of five or ten

The scrub practitioner must confirm that they are in receipt of all counted items to the surgeon.

Items which are to remain in the patient by intention, (e.g. drainage tubes, catheters), must be recorded on the intra-operative electronic record and patients notes.

If any countable item are deliberately left inside a patient (e.g. packing gauze, raytec roll). This must be recorded in the electronic intra-operative record / patient’s notes and theatre register. Recording must include date and time. (See section 6.9.2)

Its removal must also be recorded in the intra-operative electronic record, patient notes and theatre register.

WHO SIGN OUT: this must be read out loud ensuring all staff present are participating and responding to their particular section of the questions.

When this has been completed and on the scrub practitioners request, all mops/swabs/packs can then be disposed of by placing into a clinical waste bag swan necked and cable tied and clearly labelled

When a sharps count is complete, all sharps must be placed on the sharps pad, the sharps pad closed securely and then disposed of into the sharps bin by the scrub practitioner.

6.9 Procedure to be followed if a Count is found to be Incorrect

(Whether, unintentionally incorrect or intentionally incorrect).

6.9.1 Unintentionally Incorrect

No mops/swabs, packs or instrument should be left unless this has been deemed to be intentional.

If, at any stage in the operation, there is a discrepancy in the count, the surgeon must be notified immediately and informed specifically

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of what item / items are missing so that he can stop closure and re-check the wound.

The Team Leader in charge of theatre must be notified immediately.

A thorough search of the operating room must be conducted.

If the discrepancy remains, x-rays may be ordered by the surgeon to ensure that the missing item is not in the wound prior to the patient leaving the theatre.

Image intensifier should not be used as they may fail to locate radio opaque swabs.

All missing items must be documented on the count form and in the electronic operation record and signed as incorrect by the surgeon, the scrub practitioner and the count practitioner.

The scrub practitioner must then ensure the count form is filed within the patient’s notes.

The scrub practitioner must complete a Datix incident form.

The Matron for theatres must be informed as soon as possible.

6.9.2 Intentionally Incorrect

On occasions, it is accepted that surgeons will intentionally leave swabs, packs, or any other item included in the count inside the patient with the intention of removing the item or items in the future. When this occurs the following procedure must be followed;

For cardiac procedures where items have been intentionally left in the chest or the sternum has not been closed, the Delayed Sternal Closure Pathway documentation must be complete and the appropriate appendix for each following encounter. The document must be retained in a yellow folder in the patient’s notes and accompany the patient at all times until the item has been removed and the chest / sternum fully closed.

The scrub practitioner must verbally confirm with the surgeon specifically what item / items have been retained in the patient.

All items that have been intentionally left inside the patient must be clearly documented in the patient records (usually the Operation Record), the count form and WHO Check List or in Guideline for carrying out the Cardiothoracic Delayed Sternal Closure document. Clearly stating the type/size and amount of mops/swab/packs and location of any intentionally retained to facilitate the safe removal at the next surgical intervention and clearly stating the date for removal of the swab/pack if this is to be removed on the ward as part of the patient’s post-operative care.

To ensure the safe removal of any intentionally retained mops/swabs/pack items particularly those to be removed on the ward during the immediate post-operative period, clear instructions must be recorded on the back of the surgeon’s operation record and patient records. Recovery Staff must also ensure that this information is provided during the handover to the ward staff when returning patients back to the ward or Critical Care.

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The scrub practitioner must also document any discrepancy within the operating theatre register.

It is further recommended that both the surgeon and the scrub practitioner check this documentation prior to any subsequent surgery for removal of the item / items.

6.10 Procedure to be followed for Multi-disciplinary Surgical Procedures

This advice is supplementary to that laid down in the Policy Statement for Count Procedure and is applicable to all procedures where a change of surgeons takes place and/or more than one surgeon is operating at the same time on different operation sites.

Prior to commencement, a decision must be made by the theatre team as to whether a single count is undertaken or separate (tandem) counts undertaken.

6.10.1 Single Count Procedure

Use count procedure.

6.10.2 Tandem Count Procedure

The theatre Team Leader will be responsible for identifying the roles of all the other theatre staff involved i.e. scrub practitioner(s), count practitioner(s) etc.

A ‘counting’ team of four staff will be used, made up of two scrub practitioners and two count practitioners. Two separate teams each consisting of a scrub and count practitioner, will participate in the count of both instruments and disposable items as outlined in the Trust policy (in some circumstances a single count person may undertake the role for both Scrub Practitioners).

Separate count sheets must be used for each Count.

The count practitioner for each of the scrub practitioners will be responsible for ensuring that all equipment used for their procedure is separately identified at all times during the procedure.

Ideally there will be two white boards situated at opposite ends of theatre and clearly visible to the scrub practitioners. Mops/Swabs etc. from each count must be kept apart at a safe distance.

If one count is completed before the joint procedure is finished, any trays used must be loosely wrapped and left to one side (they must NOT be removed from Theatre). All countable items must be bagged and retained in the theatre until such time as both counts are known to be correct.

6.11 Procedure for Checking Sterility of Instrument Trays, Tins, Caskets and Containers

The following procedure must be undertaken for checking sterility prior to surgical intervention using the instrument tray system.

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All sterile trays, tins/caskets and extras for use during surgical procedures must be fully checked before opened to avoid any contamination of the sterile field.

6.11.1 Preparation

All members of Scrub/Circulating Theatre staff must have been trained in the safe checking and opening of sterile trays, tins/caskets and extras. They must be approved as competent by their clinical mentor before undertaking this as part of their routine clinical practice activities.

6.11.2 Checks to be performed before opening

Circulating Practitioners must check and ensure that the trays, tins/caskets or extras to be opened are intact e.g. no visible tearing of either outer drape or external wrapping or visible signs of contamination.

Discard any trays, tins/caskets or extras that the packaging that contains any moisture as it is not fit for purpose.

All Trays, tins/caskets should be cooled and dry before they are released from the SSD department.

All sterile trays from the SSD department have an expiry date on the tray information label. Staff must be aware that all packaging has a shelf life and must therefore examine each item before opening to check the expiry date has not been exceeded.

Some disposable purchased pre-sterilised items are sterilised using irradiation it is important to note that these items carry an expiry date, which must be checked before opening.

Any tray, tin/casket or package that has auto-clave tape on the outer packaging must be checked to ensure that the tape colour has changed from pink to brown indicating that the item has been through a correct autoclaving process and is deemed to be sterile.

When an item is packaged in a bag, staff must keep it in an upright position and present the inner package to the scrub practitioner or decant into a designated safe zone e.g. sterile bowl.

6.11.3 Opening Trays

Circulating Practitioners – Ensure the trolley is clean and dry before placing the trays ready to open.

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All auto-clave tape must be peeled upwards and care being taken not to tear the outer packaging when opening tray and the binders are carefully removed.

Trays must be opened in a manner whereby the Circulating Practitioner does not lean over and contaminate any part of the sterile inner drapes.

The Circulating Practitioner will peel back the back flap of the tray to open then the two side flaps leaving the front flap until last to minimise the risk of contamination of the tray.

6.11.4 Scrub Practitioners

Expiry date has not passed.

Autoclave tape has changed to brown indicating the sterilisation process has been completed.

The Scrub practitioner will open the front flap of the tray first, then open the two side drapes and lastly peel back the posterior flap when open in a sterile tray to minimise the risk of contamination and maintain the sterile field.

The scrub practitioner must check that the date on the tray list has not expired and that the sterility indicator label has changed from pink to brown indicating that the sterilisation process is complete. If the tray is accepted, the label is peeled off and placed in the patients’ record by the person undertaking the count following the initial instrument count.

If the date has expired or the indicator label has not changed colour, the instruments must not be used and the tray must be returned to SSD for re-processing.

Items must be presented to the scrub person from the designated edge of the sterile field.

A clearly dedicated location must be identified for decanting sterile items and extras when setting up the sterile field e.g. sterile bowl.

Items must not be dropped onto the scrub trolley without the scrub persons consent and knowledge of the item first.

Sutures must be peeled open and presented for the scrub person to take.

Staplers and disposable pre-packaged items should have the paper peeled back and be presented for the scrub practitioner to lift out of the packaging.

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6.11.5 Opening of Tins/ Caskets

Circulating Practitioners – Ensure the trolley is clean and dry before placing the tin/container ready to open as the person responsible for setting up for the case will select instrument trays according to surgeons’ preference card. Each tray must be examined to ensure the following: The following checks of the outside of the Tins/ Caskets should be performed:

Tray wrap integrity has not been breached (no tears or holes in wrap)

Check all of the details on the information label

Check the expiry date

Check the steam indicator has changed from Pink to Brown

Check the SSD tape has change to brown

Check that the Tray binding is intact and secure

Check the autoclave batch number and packer information is displayed

Check the plastic D Ring is complete and intact The person responsible for opening the outer wrap ready for use by the scrub practitioner will undertake a second check as outlined above before opening the tray. If any of the above are incorrect at either check, the tray must be returned to Sterile Services Department for re-wrap / re-processing and a new tray selected that conforms to all of the above requirements. Checks when open

Final Check that indicator label inside the tray has changed colour if it is still PINK DO NOT USE! As the steam has not penetrated the pack and the set will not be sterile

6.11.6 Deviation from Procedure

An incident report must be completed if there is any deviation from the above procedures as a near miss occurrence.

6.12 Procedure for Missing Instruments in Sterile Services Department

6.12.1 Aim

To ensure that the instrument has not been retained in a patient. Of Primary Interest to SSD and Operating Theatre Personnel.

The following action must be taken when a Sterile Services Department operative identifies an instrument tray as incomplete.

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This procedure must be followed at the earliest opportunity.

6.12.2 Procedure

Report the discrepancy to the appropriate speciality theatre Sister or designated deputy.

Do not pack the instrument tray.

Completion of notification form by SSD supervisor and theatre Sister or designated deputy. (Appendix 2)

SSD staff should complete their section and then send the form to the Sister in charge of the speciality to enable them to complete it and record any action taken.

Theatre Sister or designated deputy must assess / undertake the following:

Could instrument be in the patient?

Search linen / rubbish.

Check Count Sheets.

Discuss with scrub / count staff involved.

Discuss with surgeon.

Discuss with SSD Supervisor.

6.12.3 Instrument not found:

Incident form (Datix) must be completed by scrub practitioner, highlighting action taken.

A copy of “reporting form” must be attached to incident form.

Theatre Sister must keep an additional copy of “reporting form”

6.12.4 Replacement of lost instrument

Theatre Sister should inform SSD that the tray can be processed and reused.

If a replacement instrument is not immediately available the tray list must clearly identify the discrepancy.

Theatre is responsible for purchase of a replacement instrument.

Theatre is responsible for ensuring replacement instrument is returned to SSD informing them of the tray name and number to ensure instrument is replaced onto the correct tray.

Theatre Sisters copy of “reporting form” must be completed and filed for reference.

6.13 Procedure for Missing Instruments when trays are opened in Theatre

6.13.1 Aim

To ensure that an instrument has not been sent for repair or been taken out of use whilst waiting for a replacement or that it has been found in the Sterile Services Department

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Of Primary Interest to SSD and Operating Theatre Personnel. The following action must be taken when a member of theatre staff identifies an instrument tray as incomplete. This procedure must be followed at the earliest opportunity.

6.13.2 Procedure

Check repair service database to ascertain whether or not instrument has been sent for repair.

Report the discrepancy to a Sterile Services Department Supervisor.

Completion of a notification form by member of theatre staff that identified the discrepancy (Appendix 3.)

Theatre staff will complete their section and then send the notification form to the Sterile Services Department manager / deputy to enable them to complete it and record any action taken.

6.13.3 SSD Staff must assess / undertake the following:

Search of the wash area.

Search of the packing area.

Discuss with the tray signatory.

Discuss with the tray check signatory.

6.13.4 Instrument found:

Contact theatre staff identified on the report sheet or Sister in charge of the speciality to inform them of the outcome e.g. instrument is away for repair / awaiting replacement or has been found in SSD.

Instrument identified, reprocessed and set aside in the packing room with details of the tray on which it is to be replaced when returned from theatre.

6.13.5 Instrument not found:

Incident form (Datix) must be completed by SSD Supervisor, highlighting action taken. A copy of “reporting form” must be attached to incident form.

SSD Supervisor must keep an additional copy of “reporting form” (See Appendix 2)

If a replacement instrument is not immediately available the tray list must clearly identify the discrepancy.

SSD/Instrument Curator will be responsible for purchase of a replacement instrument.

The instrument Curator is responsible for ensuring replacement instrument is returned to SSD informing them of the tray name and number to ensure instrument is replaced onto the correct tray.

Supervisors’ copy of “reporting form” must be completed and filed for reference.

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7 Training In order to achieve competence in these procedures the practitioner must have completed the Count Competency training and has been deemed competent. Competence must be documented using the Trust standard documentation. 8 Equality and Diversity The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This document has been appropriately assessed. 9 Monitoring Compliance Monitoring Compliance with this policy will be monitored by the Theatre Matrons supported by the speciality Sisters / Charge Nurses and reported to the Directorate Manager who from analysis of incident reports relating to an incorrect count will provide a report to the Clinical Governance and Quality Committee.

Standard / process / issue

Monitoring and audit

Method By Committee Frequency

All Scrub and count Practitioners are competent as per this policy

Audit Theatre sisters

Matrons and Clinical Educators

At least annually

ANTT is undertaken as per this policy

Audit Infection control nurses

IPCC At least annually

No swabs, instruments or needles are unintentionally retained

Serious Incident Review of incident reports (Datix)

Departmental Heads

Theatre User Group

Continuous

All intentionally retained swabs, instruments or needles follow the intentionally retained procedure

Datix Incident Reporting & Review

Departmental Heads

Theatre User Group

Continuous

Audit Theatre Sisters

Theatre User Group

At least annually

Digital Tourniquets are used as per policy


Theatre User Group

At least annually

Count Procedure is undertaken as per policy


Theatre User Group

As a minimum Annually

W.H.O. checklist is completed as per policy


Theatre User Group


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Tandem Procedures are carried out as per policy


Theatre User Group


Sterility of Trays and containers are checked and maintained as per the policy


Theatre User Group


Any deviations from procedure are reported and reviewed as per policy.

Datix Report Theatre Matron

Theatre User Group

Continuous

Missing Instruments are followed up as per the policy

Review Datix Report

Theatre Matron

Theatre User Group

Continuous

Audit Theatre Sister Theatre User Group

At least annually

10 Consultation and review This policy has been reviewed in consultation with the Theatre User Group, Perioperative Matrons and Clinical Educators and will be reviewed on a 3 yearly basis, unless evidence is presented that requires review sooner. 11 Implementation (including raising awareness) This policy is a revision of a previous Count Policy; this revised policy will be introduced and awareness raised through the Theatre User Group, Directorate Communication meetings, senior staff and Departmental staff meetings. 12 References

Association for Perioperative Practice, (2011). Standards and Recommendations for safe perioperative practice.3rd ed. Harrogate: AFPP

Hughey M. (2008). Scrub Gown and Glove Procedures [online] www.brooksidepress.org]

13 Associated Documentation

Delayed Sternal Closure Pathway

Hand Hygiene Policy

Infection Control in the Operating Theatre

Mandatory Training Policy

Waste Management Policy


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Trust Theatre Count Sheets Appendix 1

The Newcastle upon Tyne Hospitals NHS

NHS Foundation Trust PERI OPERATIVE THEATRES COUNT SHEET: CENTRAL OPERATING THEATRES Example Only

Items

Mops 10 x 10

Packs 30 x30

Packs 45 x 45

Pledgets

Stamps

Tonsil Mops

Nasal Tampons

Blades

Atraumatics

Needles

Tapes

Reels

Loops

Suture Boots

Diathermy Tips

Tip Cleaner

Screws

Bulldogs

Tibbs

Saw Blades

Surname MRN Number Forename D.O.B. Address NHS No

Sex Male/ Female

Hospital FH

Theatre

Date

Surgical Count this is a record of the number of, variety of swabs and instruments used within the perioperative fields etc., during the operation performed on the above named patient.

Scrub Practitioner Print ……………………………………………..

Scrub Practitioner Sign ……………………………………………..

Count Practitioner Print …………………………………………..

Count Practitioner Sign ……………………………………………….

Change Over Count / Scrub Print…………………………………

Change Over Count / Scrub Sign……………………………………

Surgeon closing the wound has been informed that the count has been completed and that the count is

Correct / incorrect (circle).

Surgeon Print Name ………………………………..

Signature ……………………………………………..

INTENTIONALLY RETAINED GAUZE Type……………………………………………………… Amount…………………………………………………………..

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Tray Labels and Traceability Stickers

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The Newcastle upon Tyne Hospitals NHS NHS Foundation Trust

PERI OPERATIVE THEATRES COUNT SHEET: Cath Labs Cardio Example Only

Items

Total

30x30 Packs

10x10 Swabs

Sponges

Blades

Atraumatics

Needles

Yellow Vein Lifters

Diathermy Tip

Disposable Clips

Surname MRN Number Forename D.O.B. Address NHS No

Sex Male/ Female

Hospital FH

Theatre

Date



Scrub Practitioner Sign … …………………………………………..

Count Practitioner Print …………………………………………….

Count Practitioner Sign …………………………………………….


Change Over Count / Scrub Sign…………………………………

Surgeon closing the wound has been informed that the count has been completed and that the count is Correct / incorrect (circle).

Surgeon Print Name ……………………………….

INTENTIONALLY RETAINED GAUZE Type/ Size …………………………………………… Amount…………………………………………………….

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Blood Loss Record


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PERI OPERATIVE THEATRES COUNT SHEET: Cardio Theatres Example Only Items

Total

30x30 Packs

10x10 Swabs/Child

15x2.5 Infant

Pledgets

Atraumatics

Blades

Needles

Filter Needles

Tapes

Screws

Ligaclips

Diathermy Tips

Tip Cleaner

Surname MRN Number Forename D.O.B. Address NHS No Sex Male/ Female

Hospital FH Theatre Date Surgical Count this is a record of the number of, variety of swabs and instruments used within the perioperative fields etc., during the operation performed on the above named patient.

Scrub Practitioner Print …………………………………………

Scrub Practitioner Sign………………………………………….

Count Practitioner Print ……………………………………….

Count Practitioner Sign……………………………………………

Change Over Count / Scrub Print……………………………

Change Over Count / Scrub Sign…..…………………………



Signature………………………………………………..

INTENTIONALLY RETAINED GAUZE Type/size………………………………………………… Amount …………………………………………………………

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Items

Total

Abbocath

Bulldogs

Red Slings

Arteriotomy

Shods

Silastic Slings

Clamp Inserts

Coreknots

Staple Inserts

Microvascular Clamps

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PERI OPERATIVE THEATRES COUNT SHEET: OPHTHALMOLOGY THEATRES Example Only Items

Mops 10x10

Mops 10x15

Packs 30x30

Pledgets

Cotton Buds

Dental Rolls

Neuro Patties

Spears

Blades

Atraumatics

Cannula

Needles

Iris Hooks

Ports


Hospital RVI Theatre Date Surgical Count this is a record of the number of, variety of swabs and instruments used within the perioperative fields etc., during the operation performed on the above named patient.


Surgeon Print Name …………………….

Signature ……………………………………..

Scrub Practitioner Print.…..…………….……………………….

Scrub Practitioner Sign…..……………..……………………….

Count Practitioner Print ………………..………………………

Count Practitioner Sign………………………………………..

Change Over Count / Scrub Print… ……………………….

Change Over Count / Scrub Sign……………………………

INTENTIONALLY RETAINED GAUZE Type/ size…………………………………….. Amount……………………………………………….

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Blood Loss Record


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PERI OPERATIVE THEATRES COUNT SHEET: ORTHOPAEDIC THEATRES Example Only Items

Small Mops 10x15

Large Mops 36x11

Packs 45x45

Stamps/Pledgets

Blades

Atraumatics

Needles

Drill

K-wire

Guide wire

Saw blades

Burrs

Screws

Reels

Vessel loops

Tip cleaner


Hospital RVI Theatre Date Surgical Count this is a record of the number of, variety of swabs and instruments used within the perioperative fields etc., during the operation performed on the above named patient.

Scrub Practitioner Print ……………………………………………….

Scrub Practitioner Sign……………………………………………….

Count Practitioner Print ……..…………………………………….

Count Practitioner Sign…………………………………………………

Change Over Count / Scrub Print… ………………………………..



Surgeon Print Name ………………………

Signature ………………………………………

INTENTIONALLY RETAINED GAUZE Type / Size……………………………………………… Amount…………………………………………….

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Blood Loss Record


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The Newcastle upon Tyne HospitalsNHS NHS Foundation Trust

PERI OPERATIVE THEATRES COUNT SHEET NEURO THEATRES Example Only Items

Mops 10x10

Large Mops 36x11

Packs 45x45

Pledgets

Tonsil/Mastoid swabs

Patties

Blades

Atraumatics

Micro vascular Atraumatics

Needles

Screws

Tapes

Reels

Diathermy Tips

Sloops

Fish Hooks

Disposables

Red Ties


Hospital RVI / FH Theatre Date Surgical Count this is a record of the number of, variety of swabs and instruments used within the perioperative fields etc., during the operation performed on the above named patient.


Scrub Practitioner Sign……………………………………………..


Count Practitioner Sign…………………………………….………….

Change Over Count / Scrub Print………………………..………

Change Over Count / Scrub Sign ……………………………….…


Correct /Incorrect (circle).

Surgeon Print Name ………………………………….

Signature ………………………………………………….

INTENTIONALLY RETAINED GAUZE Type / Size………………………….... Amount………………………………………….

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Blood Loss Record


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PERI OPERATIVE THEATRES COUNT SHEET PLASTICS & CHILDRENS THEATRES Example Only

Items

Mops 15x10

Packs 45x45

Stamps

Pledgets

Tonsil/Mastoid swabs

Patties

Palate mops

Blades

Atraumatics

Microvascular Atraumatics

Needles

Screws

Tapes

Diathermy tips

Sloops

Scratch Pads

Digital tourniquet

Surname MRN Number

Forename D.O.B.

Address NHS No

Sex Male/ Female

Hospital RVI / FH Theatre Date Surgical Count this is a record of the number of, variety of swabs and instruments used within the perioperative fields etc., during the operation performed on the above named patient.


Scrub Practitioner sign..……………………………………………..

Count Practitioner Print……………………………………………..

Count Practitioner Sign.…………………………………………….

Change Over Count / Scrub Print………………………………….

Change Over Count / Scrub Sign…………………………………..

INTENTIONALLY RETAINED GAUZE Type/ size……………………………. Amount………………………………….




Signature ……………………………………………..

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Blood Loss Record


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PERI OPERATIVE THEATRES COUNT SHEET GENERAL SURGERY & GYNAE THEATRES Example Only

Items

Mops 15X10

Packs 45X45

Stamps

Tonsil swabs

Netcell

Blades

Atraumatics

Needles

Diathermy tips

Sloops

Tapes

Screws

Bungs

Slings

Surname MRN Number Forename D.O.B Address NHS No Sex Male/ Female

Hospital RVI / FH

Theatre

Date


Scrub Practitioner Print ………………………………………………

Scrub Practitioner Sign ……………………………………………….

Count Practitioner Print ………………………………………………

Count Practitioner Sign…….………………………………………….

Change Over Count / Scrub Print...……………………………….





Signature …………………………………………………..

INTENTIONALLY RETAINED GAUZE Type/Size …………………………………………….. Amount…………………………………………………………

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Blood Loss Record


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PERI OPERATIVE THEATRES COUNT SHEET OBSTETRIC THEATRES

count 1

count 2

count 3

Mops 30 x 30

Mops 10 x 15

Packs 45x45

Vag Roll

Blades

Atraumatics

Hypodermics

TRAYS :-

LSCS

PROCEDURE

30 TEAR

C x SUTURE

ERPC

HYSTERECTOMY

RETRACTOR

EXTRAS

Surname MRN Number

Forename D.O.B.

Address NHS No

Sex Male/ Female

Hospital RVI

Theatre

Date


Scrub Practitioner Print ………………………………………….. Scrub Practitioner Sign.…………………………………………..


Count Practitioner Sign…………………………………………….


Change Over Count / Scrub Sign….………………………………



Signature …………………………………………………..

INTENTIONALLY RETAINED GAUZE Type/Size ……………………………………….. Amount…………………………………………………………

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BACK PAGE

Blood Loss Record


TIME IN -

LEGS UP -

K T S -

LEGS DOWN -

TOB -

T O P -

TIME OUT -

LIQUOR

BLOOD

BLOOD

BLOOD

BLOOD

BLOOD

BLOOD

BLOOD

BLOOD

BLOOD

BLOOD

TOTAL

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Affix patient identification label in box below or complete details

Surname Patient I.D No.

Forename D.O.B.

Address NHS No.

Sex. Male / Female

Postcode

Adult Cardio-Thoracic Theatre – Integrated care pathway Instrument Tracking Record Has the Bar Code Identification been entered on the computer system? Yes No Attach bar code stickers Date: - Name: - Signature:-

http://www.newcastle-hospitals.org.uk/index.aspx

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Appendix 2 Action to be taken following Report of Missing Instrument by SSD Supervisor SSD Staff Date & Time Reported ………………………………………………………………………………….. Instrument(s) Missing…………………………………………………………………………………….. Tray (& number if appropriate)…………………………………………………………………………… Reported to Sister…………………………………………………………………………………………. Speciality…………………………………………………………………………………………………… Supervisor Reporting Incident …………………………………………………………………………… SSD Supervisor / Deputy must now send this form to the Sister in Charge of the Speciality for completion Theatre Staff Date and Time Tray Used…………………………………………………………………………………… Theatre Number……………………………………………………………………………………………….. Scrub Person…………………………………………………………………………………………………..

Actions Taken

Tick Box Undertaken by (Print Name)

Date

Laundry searched

Rubbish searched

Count/instrument sheets checked

Discuss with Scrub Person

Discuss with Count Person

Discuss with surgeon

Instrument found (Delete as appropriate) YES signed / Date ……………………………………….. Instrument NOT found Action Taken (Please document date and time instrument replaced) Speciality Sister’s Signature …………………………………..Date………………………………………

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Appendix 3

Action to be taken following report of missing instrument by Theatre staff 1. THEATRE STAFF Date and time reported Instrument(s) missing Tray (and number if appropriate Theatre number Scrub Nurse Tray and contents searched by Repair database checked by Instrument sent for repair? (Circle) YES NO Reported to SSD supervisor by SSD Instrument sheet signed by Documentation of missing instrument 2. Sterile Services Department Reported to supervisor Date/time

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Action taken Tick box Undertaken by date

Search washing area

Search packing area

Discuss with tray signatory

Discuss with tray check signatory

Instrument Found (Delete as appropriate) YES Signed / Date Instrument not found Action taken (please document date/time replaced) Signature of SSD manager

Count Procedure Equality Analysis form Nov 2017 Page 1 of 4 Dec 2013

The Newcastle upon Tyne Hospitals NHS Foundation Trust Equality Analysis Form A

This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval. PART 1 1. Assessment Date: 15/11/2017 2. Name of policy / strategy / service:

Count Procedure Policy

3. Name and designation of Author:

Claire Winter, Sheina Baldwin,

4. Names & Designations of those involved in the impact analysis screening process:

Claire Winter, Sheina Baldwin, Gill O’Meara

5. Is this a: Policy X Strategy Service

Is this: New Revised X

Who is affected: Employees X Service Users Wider Community 6. What are the main aims, objectives of the policy, strategy, or service and the intended outcomes? (These can be cut and

pasted from your policy)

The aim of this policy is to standardise the procedure for accounting for all swabs and instruments used during operative procedures. This policy is of primary interest to all Theatre Nursing, Non-Nursing Staff and Operating Department Practitioners when

performing count activities.


7. Does this policy, strategy, or service have any equality implications? Yes No

If No, state reasons and the information used to make this decision, please refer to paragraph 2.3 of the Equality Analysis Guidance before providing reasons:

8. Summary of evidence related to protected characteristics

Protected Characteristic

Evidence i.e. What evidence do you have that the Trust is meeting the needs of people in various protected Groups related to this policy/service/strategy – please refer to the Equality fact files available via the link below (add link)

Does evidence/engagement highlight areas of direct or indirect discrimination? If yes describe steps to be taken to address (by whom, completion date and review date)

Does the evidence highlight any areas to advance opportunities or foster good relations. If yes what steps will be taken? (by whom, completion date and review date)

Race / Ethnic origin (including gypsies and travellers)

The policy does not discriminate on the grounds of race/ethnic origin, sex, religion and belief, sexual orientation, age, disability, gender reassignment, marriage and civil partnership and maternity and pregnancy.

No No

Sex (male/ female)

As above No No

Religion and Belief

As above No No

Sexual orientation including lesbian, gay and bisexual people

As above

No

No

Age

As above No No


Disability – learning difficulties, physical disability, sensory impairment and mental health. Consider the needs of carers in this section

As above No No

Gender Re-assignment

As above No No

Marriage and Civil Partnership

As above No No

Maternity / Pregnancy

As above No No

9. Are there any gaps in the evidence outlined above. If ‘yes’ how will these be rectified?

No

10. Engagement has taken place with people who have protected characteristics and will continue through the Equality Delivery System and the Equality Diversity and Human Rights Group. Please note you may require further engagement in respect of any significant changes to policies, new developments and or changes to service delivery. In such circumstances please contact the Equality and Diversity Lead or the Involvement and Equalities Officer. Do you require further engagement Yes No X


11. Could the policy, strategy or service have a negative impact on human rights? (E.g. the right to respect for private and

family life, the right to a fair hearing and the right to education?

No

PART 2 Signature of Author

Claire Winter, Sheina Baldwin

Print name

Date of completion

24/11/2017

(If any reader of this procedural document identifies a potential discriminatory impact that has not been identified, please refer to the Policy Author identified above, together with any suggestions for action required to avoid/reduce the impact.)

the newcastle upon tyne hospitals nhs foundation trust count … · 2020. 6. 24. · the newcastle...

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