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The Hidden Costs of Reconciling Surgical Sponge Counts
The Hidden Costs of Reconciling Surgical Sponge Counts VICTORIA M. STEELMAN, PhD, RN, CNOR, FAAN; ANN G. SCHAAPVELD, BSN, RN; YELENA PERKHOUNKOVA, PhD; HILLARY E. STORM, MSN, RN, CNOR; MICHELLE MATHIAS, BSN, RN
ABSTRACT Retained surgical sponges are serious adverse events that can result in negative patient outcomes. The primary method of prevention is the sponge count. Searching for sponges to reconcile counts can result in inefficient use of OR time. The purpose of this descriptive study was to estimate the cost of nonproductive OR time (ie, time spent not moving forward with the surgical procedure) spent reconciling surgical sponge counts and the cost of using radiography to rule out the presence of retained sponges. We included 13,322 patient surgeries during a nine-month period. Perioperative personnel required from one to 90 minutes of additional time to reconcile each of 212 incorrect/ unresolved counts. The total annualized cost of OR time spent searching for sponges and ruling out the presence of potentially retained sponges using radiography was $219,056. These costs should be included in comprehensive cost analyses when considering alternatives to supplement the surgical count. AORN J 102 (November 2015) 498-506. ª AORN, Inc, 2015. http://dx.doi.org/ 10.1016/j.aorn.2015.09.002 Key words: cost, medical/surgical errors, patient safety, retained surgical sponge, retained surgical item.
R
etained surgical items (RSIs), which include sponges, needles, and instruments, have been one of the most frequent sentinel events reported to The Joint Commission for the last 10 years1 and are estimated to occur in one in 5,500 surgeries.2 These serious adverse events have resulted in negative patient outcomes, including reoperation,3,4 readmission or prolonged hospital stay,3,4 infection or sepsis,3 fistulas or bowel obstructions,3 visceral perforation,3 and death.3 Cotton gauze sponges account for 52% to 69% of RSIs2-4 and result in more serious tissue reaction than metal items. The national standard for the prevention of retained surgical sponges relies heavily on manual counting, an ongoing process requiring the attention of OR personnel throughout the procedure.5 When the count is initially incorrect, the surgical
team must undertake a search for the missing sponge. The actual time required and the associated costs of searching for a misplaced sponge are unknown because counts that are successfully reconciled through corrective actions are often unreported. Likewise, the time and costs associated with using radiography intraoperatively to rule out the presence of a retained sponge have not been adequately measured. The purpose of this descriptive study was to estimate the cost of nonproductive OR time (ie, time spent not moving forward with the surgical procedure) required to reconcile surgical sponge counts and the time and costs of using radiography to rule out retained surgical sponges. Our research question is: What are the annualized costs of nonproductive OR time spent searching for missing sponges and the use of radiography to rule out the presence of a retained sponge? This information is needed by perioperative http://dx.doi.org/10.1016/j.aorn.2015.09.002 ª AORN, Inc, 2015
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nurses when evaluating the cost-effectiveness of purchasing alternatives (eg, adjunct technology) to supplement the surgical sponge count.
LITERATURE REVIEW
The current AORN “Guideline for prevention of retained surgical items”5 recommends manual counting, an ongoing process requiring the attention of OR personnel throughout the procedure. The RN circulator and scrub person perform a count before the start of the procedure, and the RN circulator completes documentation either manually or electronically. He or she updates this documentation throughout the procedure as items are added to or removed from the sterile field. This national standard recommends conducting subsequent closing counts when closing a cavity within a cavity, the first layer of tissue (eg, fascia), and the final layer (ie, the skin).5 Additional counts also may be performed when changing personnel. When performing these counts, the RN circulator and scrub person compare the number of sponges counted with the ongoing documentation of the number and types of sponges that are expected to be present. Results are considered correct or incorrect/unresolved. If the team discovers a discrepancy, they can perform a series of steps to reconcile the count. The steps include notifying the surgeon so that he or she can search the wound and having the scrubbed team members search the sterile field while the RN circulator searches nonsterile areas (eg, trash bags). The circulating nurse also can request additional personnel to assist in locating the sponge. If the count remains incorrect, the surgeon usually orders a radiograph to determine whether the missing sponge is in the patient and to rule out a retained sponge. The AORN guideline recommends that additional measures be performed based on the individual health care organization’s own risk analysis.5 Researchers conducted a meta-analysis of 19 research studies and found the following risk factors for RSIs:
blood loss greater than 500 mL, longer surgeries, surgeries in which more than one procedure was performed, lack of a count, the presence of more than one surgical team, unexpected intraoperative factors, and incorrect counts.6
The reliance on the surgical count for patient safety is problematic. Researchers conducting a retrospective review of
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adverse events occurring from 2000 to 2004 in a New York hospital system found the sensitivity of surgical counts to be 77%, and the positive predictive value was only 1.6%.7 In another large study, researchers found that 62% of RSIs were detected by postoperative radiography after the surgical count was reported as being correct.2 A Healthcare Failure Mode and Effect Analysis identified 57 potential failures during perioperative management of surgical sponges. Causes of these failures, particularly distraction and multitasking, are difficult to control. This explains in part why the surgical count does not adequately prevent retained sponges.8 Count discrepancies are common. In a prospective observational study, researchers found count discrepancies in 12.8% of elective general surgery cases.9 These discrepancies usually are unreported after the team reconciles the count, and the amount of time allocated to reconcile the count is unknown. Furthermore, the time spent reconciling counts draws the attention of nursing personnel away from other high-priority safety issues, including paying attention to the surgeon who is still operating. If the count is not reconciled or the patient is considered at high risk, radiography often is used to determine whether a retained sponge is present. This use of radiography delays completion of the surgery and extends OR time. In a large study comparing radiographs performed intraoperatively versus postoperatively, intraoperative imaging failed to detect 33% of retained items.2 In addition to giving a potentially misleading report, the cost of this additional time, the radiograph, and the radiologist’s fee for reading the image can be significant and may not be reimbursed. The cost of routinely using intraoperative radiographs for ruling out a retained item is estimated to be $11.5 million for every surgical item detected through this method.10 This is important in today’s health care reimbursement model with payment fixed by diagnosis-related group, reducing that procedure’s contribution margin and overall profitability. The AORN guideline for prevention of RSIs recommends that “Perioperative personnel should evaluate existing and emerging adjunct technology to determine the application that may be most suitable in their setting.”5(p342) A computerassisted counting system using two-dimensional data matrix-labeled (ie, bar-coded) sponges and a scanner are available to assist with the reconciliation of the surgical sponge count. Studies have shown that this technology significantly increases the identification of misplaced and miscounted sponges.11,12 This technology is reported to be
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cost-effective compared with radiography, but it could increase the time spent counting.11-13 Data matrix technology does not rule out the presence of a retained sponge or detect sponges misplaced in the room. Another adjunct technology is low-frequency radiofrequency (RF). Manufacturers sew an RF tag into surgical sponges; this allows personnel to use a handheld wand or preoperatively place the patient on a mattress with embedded wands. This mattress allows the patient and the surrounding field to be scanned for the presence of a retained sponge, a process that takes approximately 10 seconds. The sensitivity of the handheld wand has been found to be 100%, even when used to care for patients who are morbidly obese.14 The mattress, which scans the body for retained sponges in a hands-free manner, has been found to be 100% sensitive in subjects who are not morbidly obese and 96.9% sensitive in subjects who are morbidly obese.15 When considering the cost-effectiveness of adjunct technologies, perioperative managers, directors, and value analysis teams often consider the cost of the supplies (eg, sponges) alone. This limited view does not provide an accurate picture of the potential cost-effectiveness of adjunct technology because it does not take into consideration the cost of current practices.
METHODS We conducted a retrospective review of existing data retrieved from the health information system (HIS) of a large Level 1 trauma and academic medical center. The Institutional Review Board of the University of Iowa, Iowa City, determined that this study did not meet the regulatory definition of human subjects research and did not require review. The sample included all patients undergoing surgery in the main OR from February 1, 2014, until October 31, 2014 (nine months in total). Exclusion criteria included ophthalmology, dentistry, and nonsurgical procedures; aborted surgical procedures; surgeries during which the patient died; and surgeries performed outside of the main OR. This sample is large enough to provide clinically relevant results and allow us to annualize cost estimates. Circulating nurses recorded data for individual patients in a questionnaire embedded in the surgical log of Epic module Optime. The questionnaire consisted of questions regarding three individual counts: initial closing, final closing, and additional counts (eg, bladder closure, personnel change). If the person completing the survey answered “yes”
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to the first question (ie, “was a search required?”), he or she had to respond to four subsequent questions:
type of sponge missing, actions taken, number of minutes required to complete the search, and location of the sponge if found.
At the end of each procedure, the RN circulator was required to electronically verify the initial and final count. We retrieved data from the facility’s HIS using SAP Business ObjectsTM software (surgical volume, surgical service, procedure duration, triage) and Crystal reports (details about searches for sponges). We also collected data from event reports entered into the facility’s patient safety net electronic reporting system. We reviewed all events reported within the category of “count incomplete or not done” (eg, emergency procedures) and “count incorrect” (for incorrect sponge counts). We determined the cost per minute of operating time using published data (ie, $62 per minute) to enhance generalizability.16 Although staff members are attempting to reconcile the count, surgeons sometimes continue with the procedure (eg, closing the wound); at other times, surgeons redirect their efforts to assisting with locating the sponge. When progress on the surgery is suspended for the search, it is nonproductive operating time. We conservatively estimated that 50% of the time spent searching for a missing sponge is nonproductive. We also calculated radiology costs of ruling out a retained sponge based on published data to maximize generalizability. Average radiology costs cited in the literature were $286 per patient,10 and OR time associated with obtaining an intraoperative radiograph was approximately 30 minutes.17 We analyzed data using SAS 9.3 software and using descriptive statistics to describe the number of surgical procedures and their duration and the number of searches and their duration and costs. We analyzed data in aggregate and by surgical service.
RESULTS Overall, we reviewed records for 13,322 patient surgeries (Table 1). The most frequent surgical services involved were orthopedics (23.1%), general surgery (19.7%), and neurosurgery (14.6%). The vast majority of procedures were elective (79.9%). Overall, only 6.3% of procedures were emergent. The neurosurgery and orthopedic services had the highest and lowest percentages of emergent procedures, respectively (14.3%, 1.6%). The mean duration of procedures was 136.5 minutes (standard deviation [SD] 118.1). On average, the longest procedures were transplant procedures (229 minutes).
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Table 1. Urgency of Surgeries and Duration of Procedures Performed by Surgical Service Number of Procedures (% of all) Surgical Service Cardiothoracic General Surgery Adult/Plastics General Surgery Pediatrics
Duration of Procedures (minutes) Emergent
Mean SD
Median
131 (16.4)
62 (7.8)
188.8 140.4
156
2,069 (78.6)
357 (13.6)
206 (7.8)
129.3 101.6
102
455 (73.5)
139 (22.5)
25 (4.0)
62.8 58.3
47
n
Elective
Urgent
797
604 (75.8)
2,632 619 948
865 (91.2)
43 (4.5)
40 (4.2)
140.3 90.3
135
Neurosurgery
1,950
1,305 (66.9)
366 (18.8)
279 (14.3)
134.6 121.6
103
Orthopedics
3,079
2,474 (80.4)
555 (18.0)
50 (1.6)
121.8 90.8
102
Otolaryngology
1,598
1,485 (92.9)
53 (3.3)
60 (3.8)
146.9 153.1
101
Transplantation
211
100 (47.4)
91 (43.1)
20 (9.5)
229.2 130.2
207
Vascular
575
444 (77.2)
62 (10.8)
69 (12)
162.7 133.7
127
Urology
913
837 (91.7)
51 (5.6)
25 (2.7)
188.8 140.4
156
13,322
10,638 (79.9)
836 (6.3)
136.5 118.1
105
Gynecology
All Services
1,848 (13.9)
SD ¼ standard deviation.
Perioperative personnel required additional time and effort to reconcile 212 surgical sponge counts (Table 2). Of these, 143 occurred during first closing counts and 63 occurred during final closing counts. The services most often involved with this process were neurosurgery (23.6%), orthopedics (21.2%), and general surgery adult/plastics (19.3%). The greatest percentage of procedures performed by a surgical service in which a search was required was in the
transplantation service (3.8%; eight of 211) and neurosurgery (2.6%; 50 of 1,950). Of all the searches, 87.7% resulted in a reconciled (ie, correct) surgical count and no event report was generated. Of the 199 searches in which the type of sponge was identified, 108 searches were for radiopaque 4 4s, 82 were for laparotomy sponges, five were for both 4 4s and laparotomy sponges, and four were for episiotomy sponges. Sponges were found in the following areas:
Table 2. Searches and Outcomes of Searches by Surgical Service Number of Searches (% of procedures by surgical service) Surgical Service Cardiothoracic General Surgery Adult/Plastics General Surgery Pediatrics
All
Reconciled Searches
First Final Found in Found on Found Outside Unreconciled Closing Closing Additional All Patient Sterile Field Sterile Field Searches
8
4 (0.5)
4 (0.5)
0 (0)
6
2
1
3
2
41
32 (1.2)
9 (0.3)
0 (0)
40
6
23
11
1
1
0 (0)
1 (0.2)
0 (0)
1
0
1
0
0
7 (0.7)
4 (0.4)
1 (0.1)
8
2
3
3
4
47
1
20
26
3
Gynecology
12
Neurosurgery
50
34 (1.7) 16 (0.8)
0 (0)
Orthopedics
45
32 (1.0) 13 (0.4)
0 (0)
41
2
26
13
4
Otolaryngology
28
14 (0.9) 10 (0.6)
4 (0.3)
20
1
6
13
8
Transplantation
8
7 (3.3)
0 (0)
1 (0.5)
8
1
2
5
0
Urology
7
5 (0.9)
2 (0.3)
0 (0)
7
0
4
3
0
Vascular
12
8 (0.9)
4 (0.4)
0 (0)
8
1
5
2
4
212 143 (1.1) 63 (0.5)
6 (0)
186
16
91
79
26
All Services
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91 on the sterile field (42.9%), 79 in the nonsterile areas of the OR (37.2%), and 16 in the wound (7.5%). In addition, sponges were not located in 26 searches (12.2%). The most frequently reported steps taken to reconcile the search were searching the sterile (77.4%) and nonsterile (58.5%) fields (Table 3). The time required to conduct a search ranged from one to 90 minutes. For nine searches, nurses recorded the number of minutes as “greater than 30.” For these searches, the analysis was completed using 30 minutes. Thus, the overall time (1,700 minutes) is an underestimate of the actual time. The annualized cost of this operating time was $140,533. Assuming 50% of the time spent searching for a sponge was nonproductive, the adjusted annualized cost of nonproductive OR time spent on reconciling the count was $70,266 (Table 4). Fifty-two patients received a total of 55 intraoperative radiographs to rule out the presence of a retained sponge (Table 5). Three patients had radiographs taken for more than one incision. Nearly half the radiographs (n ¼ 25) were taken during liver transplantation procedures per hospital protocol because the patient was considered at high risk for a retained sponge. Twenty-four radiographs were obtained because the sponge was not found, resulting in an incorrect final closing count. Other reasons for radiographs included emergency procedures with no count performed (n ¼ 4) and second-look laparotomy procedures (n ¼ 2). Surgical sites included the
abdomen (n ¼ 34), head and neck (n ¼ 5), leg (n ¼ 4), chest (n ¼ 3), spine (n ¼ 3), groin (n ¼ 3),
Table 3. Steps Taken to Reconcile Sponge Counts Step
Number of Searches (% of all searches)
Surgeon Notified
84 (39.6%)
Wound Searched
34 (16.0%)
Sterile Field Searched
164 (77.4%)
Nonsterile Area(s) Searched
124 (58.5%)
Additional Personnel
24 (11.3%)
Other
14 (6.6%)
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hip (n ¼ 2), and hand (n ¼ 1). During this nine-month study, the cost of obtaining and reading these radiographs, based on the published average cost per radiograph ($286),10 was $14,872; the cost of OR time to obtain the radiographs, based on 30 minutes per radiograph,12 was $96,720. The combined annualized costs of obtaining, reading, and waiting for results of the radiographs was $148,789. The total annualized cost of searching for missing sponges and using radiography to rule out the presence of a retained sponge was $219,056.
DISCUSSION Despite the high-profile nature of retained surgical sponges, these events continue to occur.18-20 Retained surgical items have remained among the most frequently reported sentinel events for the past 10 years1 and comprise half the malpractice settlements for surgical “never events.”21 The Joint Commission requires investigation of RSIs after surgery, defining after surgery as “any time after completion of the skin closure; even if the patient is still in the OR under anesthesia.”22 This definition provides an incentive for surgical teams to stop the progress of surgery while searching for a sponge, obtaining a radiograph for a missing sponge, and waiting for the radiograph to be read. Count discrepancies are common.9,23 Even though the majority of misplaced sponges in our study were not in the wound, efforts to locate the sponge take time and attention away from the surgical procedure and other high-priority tasks in the OR and may increase surgical duration. This study quantifies the time required to search for misplaced sponges and estimates the associated costs of these searches using published data to enhance generalizability. In most cases (87.7%), the searches resulted in a correct final count and would not have been reported through the hospital event reporting system, which has been the source of data used in previous research.10 Likewise, previous cost analyses of the use of intraoperative radiography for ruling out a retained sponge have not included the cost of the OR time.10 This study provides new knowledge about these additional costs.
Limitations Estimated costs in this study are likely lower than actual costs. First, staff members likely did not report every search performed because of “documentation fatigue,” a result of being overloaded with documentation requirements. This may explain why we found fewer count discrepancies compared
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Table 4. Cost of OR Time for Reconciling Surgical Sponge Counts by Surgical Service Duration of Searches (minutes) Surgical Service Cardiothoracic General Surgery Adult/Plastics General Surgery Pediatrics
Cost of OR Time ($)
Annualized Searches Total Range Mean SD Median Nine Monthsa Annualized Nonproductivea,b,c 8
161þ 1-50
20.1 15.9
15.0
9,982.00
13,309.33
6,654.67
41
216þ 1-30
5.3 6.1
2.0
13,392.00
17,856.00
8,928.00
62.00
82.67
41.33
1
1
Gynecology
12
224þ 1-60
18.7 22.9
4.0
13,888.00
18,517.33
9,258.67
Neurosurgery
50
275þ 1-30
5.5 7.1
2.0
17,050.00
22,733.33
11,366.67
Orthopedics
45
299þ 1-90
6.6 13.9
3.0
18,538.00
24,717.33
12,358.67
Otolaryngology
28
311þ 1-45
11.1 13.2
3.0
19,282.00
25,709.33
12,854.67
Transplantation
8
102 3-40
12.8 12.3
8.5
6,324.00
8,432.00
4,216.00
Urology
7
26 1-10
3.7 3.7
2.0
1,612.00
2,149.33
1,074.67
Vascular
12
85þ 1-30
7.1 8.4
5.0
5,270.00
7,026.67
3,513.33
212
1,700 1-90
8.0 12.0
3.0
105,400.00
140,533.33
70,266.67
All Services
SD ¼ standard deviation. a Based on OR time ¼ $62/minute.1 b Estimated at 50% time. c Actual total was greater because some durations were recorded as greater than 30 minutes. Reference 1. Macario A. What does one minute of operating room time cost? J Clin Anesth. 2010;22(4):233-236.
with an earlier observational study that found sponge count discrepancies in 12.8% of general surgery cases.9 Second, the number of minutes for searches were at times recorded as “greater than 30.” When this value was entered, we used 30 minutes to calculate time and cost. Thus, the actual number of minutes spent searching for misplaced sponges was likely greater than reported here. Moreover, we conservatively estimated nonproductive OR time spent searching for a sponge as 50% of the time reported. This time may vary between facilities, particularly related to practices for halting or continuing wound closure when a count is reported as incorrect. Some hospitals use intraoperative radiography routinely for patients identified as high risk for an RSI. In the study setting, facility protocol requires radiography when the count is incorrect or not performed and for liver transplantation procedures. In a recent meta-analysis, if radiography was used for all patients with higher risk factors (ie, blood loss greater than 500 mL, longer duration of procedure, lack of surgical counts, more than one surgical team, unexpected intraoperative factors, incorrect count),6 the number of radiographs obtained to rule out a retained sponge would be much greater. Thus, the annualized costs of radiography may be higher in other settings.
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Because costs may vary in different settings, we used published data for the cost of OR time spent obtaining and waiting for radiography results.10,17 We selected these published values to provide more generalizability to our findings.
Recommendations for Perioperative Practice The standard of perioperative practice for many years has included counting surgical items.5 However, the sensitivity of the surgical count for identification of an RSI is only 77%.2 A proactive risk analysis of managing surgical sponges found 57 potential failure points during this process, 43 of which occurred frequently enough to be considered high risk and require control. Frequent causes of these failures include distraction, multitasking, and time pressure/emegencies.8 These causes are inherent in the work in the OR and are extremely difficult to eliminate. This likely explains why RSIs have been one of the most frequent sentinel events reported to The Joint Commission for the last 10 years.1 Seeking to improve patient safety, AORN recommends that perioperative nurses evaluate existing and emerging adjunct technology.5 If managers, directors, and value analysis teams conduct a cost analysis that focuses exclusively on the cost of sponges, they may consider the purchase of adjunct AORN Journal j 503
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Table 5. Cost of Radiography for Ruling Out a Retained Surgical Sponge by Surgical Service Cost of Radiography ($) Nine Months Surgical Service
Patients
Location(s) Number of X-rays Duration (minutes)a,b
Cardiothoracic
3
Chest 2 Chest and leg 1
General Surgery Adult/Plastics
7
Abdomen 6 Abdomen and leg 1
General Surgery Pediatrics
0
Gynecology
1
Neurosurgery
ORc
X-rayb
Annualized OR and X-ray
90
5,580.00
858.00
8,584.00
210
13,020.00
2,002.00
20,029.33
Abdomen 1
30
1,860.00
286.00
2,861.33
3
Head 2 Spine 1
90
5,580.00
858.00
8,584.00
Orthopedics
6
Hand 1 Hip 2 Leg 1 Spine 2
180
11,160.00
1,716.00
17,168.00
Otolaryngology
3
Neck 2 Neck and leg 1
90
5,580.00
858.00
8,584.00
Transplantation
26
Abdomen 25 Groin 1
780
48,360.00
7,436.00
74,394.66
Abdomen 1 Groin 2
90
5,580.00
858.00
8,584.00
96,720.00 14,872.00
148,789.33
Urology
0
Vascular
3
All Services a
52
55
1,560
1
Based on $286 per x-ray. Based on 30 minutes of OR time per x-ray.2 c Based on OR time ¼ $62 per minute.3 b
References 1. Williams TL, Tung DK, Steelman VM, Chang PK, Szekendi MK. Retained surgical sponges: findings from incident reports and a cost-benefit analysis of radiofrequency technology. J Am Coll Surg. 2014;219(3):354-364. 2. Dossett LA, Dittus RS, Speroff T, May AK, Cotton BA. Cost-effectiveness of routine radiographs after emergent open cavity operations. Surgery. 2008;144(2):317-321. 3. Macario A. What does one minute of operating room time cost? J Clin Anesth. 2010;22(4):233-236.
technology to be cost prohibitive. However, there are costs aside from material costs associated with current practices. Perioperative nurses should conduct comprehensive analyses of time and other costs associated with searching for a missing sponge and ruling out a retained sponge with radiography when considering alternatives, such as adjunct technology, to supplement the surgical sponge count and prevent retained sponges. Although the focus of this study was on the time and cost of reconciling a sponge count and using radiography to rule out a retained sponge, we also gained knowledge about the surgical services involved and the location of misplaced sponges. Clinicians may think that sponge counts are only important in abdominal and thoracic surgery. However, we found that most 504 j AORN Journal
misplaced sponges occurred in neurosurgery and orthopedics. This supports the need to be vigilant about sponge counts in all services. It also is common for clinicians to meet resistance when reporting a missing sponge to the surgeon, who may believe that the sponge is elsewhere in the room. In our study, sponges were found inside the wound 8.6% of the time that they were found. This supports the need for perioperative nurses to actively engage the surgeon in the search for a missing sponge. Future perioperative research should focus on measuring the costs of retained sponges and the costs of preventing retained sponges. First, the cost of retained sponges should be measured, including the cost of reoperation, litigation, and lost
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revenue from lower rates of reimbursement related to “never events.” Research should focus on the cost-effectiveness of different interventions for the prevention of retained sponges and include the costs of radiography, if used to rule out the presence of a retained sponge. Last, research should focus on staff member and surgeon satisfaction with current practices for prevention of retained sponges, and researchers should conduct a comparison of satisfaction before and after changes are made in the clinical setting.
7.
8.
9.
10.
CONCLUSION Time spent searching for sponges draws the attention of personnel away from other high-priority tasks (eg, blood administration, airway issues, technology safety issues) and decreases the efficiency of completing the surgical procedure. We have measured the time spent and associated costs of reconciling the surgical sponge count. These costs are often hidden, particularly when the count is reconciled or reported as correct and no event report is filed. These hidden costs have not been previously measured. We also estimated the cost of ruling out a retained sponge using radiography, including the cost of radiographs and OR time waiting for the results. These costs should be included in comprehensive cost analyses when considering alternatives to supplement manual counting.
Editor’s notes: Epic is a registered trademark and Optime is a trademark of Epic, Verona, WI; SAP Business Objects and Crystal are registered trademarks of SAP America, Newtown Square, PA; SAS 9.3 is a registered trademark of the SAS Institute Inc, Cary, NC.
11.
12.
13.
14.
15.
16. 17.
References 1. Summary data of sentinel events reviewed by The Joint Commission. 2014. The Joint Commission. http://www.jointcommission .org/assets/1/18/2004_to_2014_2Q_SE_Stats_-_Summary.pdf. Accessed July 29, 2015. 2. Cima RR, Kollengode A, Garnatz J, Storsveen A, Weisbrod C, Deschamps C. Incidence and characteristics of potential and actual retained foreign object events in surgical patients. J Am Coll Surg. 2008;207(1):80-87. 3. Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med. 2003;348(3):229-235. 4. Lincourt AE, Harrell A, Cristiano J, Sechrist C, Kercher K, Heniford BT. Retained foreign bodies after surgery. J Surg Res. 2007;138(2):170-174. 5. Guideline for prevention of retained surgical items. In: Guidelines for Perioperative Practice. Denver, CO: AORN; 2015:347-363. 6. Moffatt-Bruce SD, Cook CH, Steinberg SM, Stawicki SP. Risk factors for retained surgical items: a meta-analysis and
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22.
23.
proposed risk stratification system. J Surg Res. 2014;190(2): 429-436. Egorova NN, Moskowitz A, Gelijns A, et al. Managing the prevention of retained surgical instruments: what is the value of counting? Ann Surg. 2008;247(1):13-18. Steelman VM, Cullen JJ. Designing a safer process to prevent retained surgical sponges: a healthcare failure mode and effect analysis. AORN J. 2011;94(2):132-141. Greenberg CC, Regenbogen SE, Lipsitz SR, Diaz-Flores R, Gawande AA. The frequency and significance of discrepancies in the surgical count. Ann Surg. 2008;248(2):337-341. Williams TL, Tung DK, Steelman VM, Chang PK, Szekendi MK. Retained surgical sponges: findings from incident reports and a cost-benefit analysis of radiofrequency technology. J Am Coll Surg. 2014;219(3):354-364. Cima RR, Kollengode A, Clark J, et al. Using a data-matrix-coded sponge counting system across a surgical practice: impact after 18 months. Jt Comm J Qual Patient Saf. 2011;37(2):51-58. Greenberg CC, Diaz-Flores R, Lipsitz SR, et al. Bar-coding surgical sponges to improve safety: a randomized controlled trial. Ann Surg. 2008;247(4):612-616. Regenbogen SE, Greenberg CC, Resch SC, et al. Prevention of retained surgical sponges: a decision-analytic model predicting relative cost-effectiveness. Surgery. 2009;145(5):527-535. Steelman VM. Sensitivity of detection of radiofrequency surgical sponges: a prospective, cross-over study. Am J Surg. 2011; 201(2):233-237. Steelman VM, Alasagheirin MH. Assessment of radiofrequency device sensitivity for the detection of retained surgical sponges in patients with morbid obesity. Arch Surg. 2012;147(10): 955-960. Macario A. What does one minute of operating room time cost? J Clin Anesth. 2010;22(4):233-236. Dossett LA, Dittus RS, Speroff T, May AK, Cotton BA. Costeffectiveness of routine radiographs after emergent open cavity operations. Surgery. 2008;144(2):317-321. Chen WS, Maluf H, Dehner LP, Lind AC. Cutaneous gossypiboma: a potential diagnostic pitfall. J Cutan Pathol. 2012;39(10): 894-898. Kruglick SM, Nikolaidis P, Casalino DD. Ileal conduit gossypiboma. J Urol. 2012;187(2):686-687. Meyerson JM, Noria S, Melvin WS. A retained foreign body mimicking colon cancer. Surg Laparosc Endosc Percutan Tech. 2012;22(4):e220-e221. Mehtsun WT, Ibrahim AM, Diener-West M, Pronovost PJ, Makary MA. Surgical never events in the United States. Surgery. 2013;153(4):465-472. The Joint Commission. Frequently asked questions: retained foreign body after surgery. 2014. http://www.jointcommission .org/assets/1/18/retained_foreign_objects_faqs.pdf. Accessed July 29, 2015. Christian CK, Gustafson ML, Roth EM, et al. A prospective study of patient safety in the operating room. Surgery. 2006;139(2): 159-173.
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Victoria M. Steelman, PhD, RN, CNOR, FAAN, is an associate professor in the College of Nursing, The University of Iowa, Iowa City, IA. Dr Steelman served as a consultant for RF Surgical Systems, Inc., Carlsbad, CA. As funding for this study was provided by a grant from RF Surgical Systems, Dr Steelman has declared an affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Ann G. Schaapveld, BSN, RN, is a research specialist in the College of Nursing, The University of Iowa, Iowa City, IA. Ms Schaapveld has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Yelena Perkhounkova, PhD, is a statistician/biostatistics manager in the College of Nursing, The University of Iowa, Iowa City, IA. Dr Perkhounkova has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Hillary E. Storm, MSN, RN, CNOR, is an advanced practice nurse in the main OR, The University of Iowa Hospitals and Clinics, Iowa City, IA. Ms Storm has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Michelle Mathias, BSN, RN, is a clinical coordinator for perioperative nursing in the main OR, The University of Iowa Hospitals and Clinics, Iowa City, IA. Ms Mathias has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
TM
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ABSTRACT Retained surgical sponges are serious adverse events that can result in negative patient outcomes. The primary method of prevention is the sponge count. Searching for sponges to reconcile counts can result in inefficient use of OR time. The purpose of this descriptive study was to estimate the cost of nonproductive OR time (ie, time spent not moving forward with the surgical procedure) spent reconciling surgical sponge counts and the cost of using radiography to rule out the presence of retained sponges. We included 13,322 patient surgeries during a nine-month period. Perioperative personnel required from one to 90 minutes of additional time to reconcile each of 212 incorrect/ unresolved counts. The total annualized cost of OR time spent searching for sponges and ruling out the presence of potentially retained sponges using radiography was $219,056. These costs should be included in comprehensive cost analyses when considering alternatives to supplement the surgical count. AORN J 102 (November 2015) 498-506. ª AORN, Inc, 2015. http://dx.doi.org/ 10.1016/j.aorn.2015.09.002 Key words: cost, medical/surgical errors, patient safety, retained surgical sponge, retained surgical item.
R
etained surgical items (RSIs), which include sponges, needles, and instruments, have been one of the most frequent sentinel events reported to The Joint Commission for the last 10 years1 and are estimated to occur in one in 5,500 surgeries.2 These serious adverse events have resulted in negative patient outcomes, including reoperation,3,4 readmission or prolonged hospital stay,3,4 infection or sepsis,3 fistulas or bowel obstructions,3 visceral perforation,3 and death.3 Cotton gauze sponges account for 52% to 69% of RSIs2-4 and result in more serious tissue reaction than metal items. The national standard for the prevention of retained surgical sponges relies heavily on manual counting, an ongoing process requiring the attention of OR personnel throughout the procedure.5 When the count is initially incorrect, the surgical
team must undertake a search for the missing sponge. The actual time required and the associated costs of searching for a misplaced sponge are unknown because counts that are successfully reconciled through corrective actions are often unreported. Likewise, the time and costs associated with using radiography intraoperatively to rule out the presence of a retained sponge have not been adequately measured. The purpose of this descriptive study was to estimate the cost of nonproductive OR time (ie, time spent not moving forward with the surgical procedure) required to reconcile surgical sponge counts and the time and costs of using radiography to rule out retained surgical sponges. Our research question is: What are the annualized costs of nonproductive OR time spent searching for missing sponges and the use of radiography to rule out the presence of a retained sponge? This information is needed by perioperative http://dx.doi.org/10.1016/j.aorn.2015.09.002 ª AORN, Inc, 2015
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nurses when evaluating the cost-effectiveness of purchasing alternatives (eg, adjunct technology) to supplement the surgical sponge count.
LITERATURE REVIEW
The current AORN “Guideline for prevention of retained surgical items”5 recommends manual counting, an ongoing process requiring the attention of OR personnel throughout the procedure. The RN circulator and scrub person perform a count before the start of the procedure, and the RN circulator completes documentation either manually or electronically. He or she updates this documentation throughout the procedure as items are added to or removed from the sterile field. This national standard recommends conducting subsequent closing counts when closing a cavity within a cavity, the first layer of tissue (eg, fascia), and the final layer (ie, the skin).5 Additional counts also may be performed when changing personnel. When performing these counts, the RN circulator and scrub person compare the number of sponges counted with the ongoing documentation of the number and types of sponges that are expected to be present. Results are considered correct or incorrect/unresolved. If the team discovers a discrepancy, they can perform a series of steps to reconcile the count. The steps include notifying the surgeon so that he or she can search the wound and having the scrubbed team members search the sterile field while the RN circulator searches nonsterile areas (eg, trash bags). The circulating nurse also can request additional personnel to assist in locating the sponge. If the count remains incorrect, the surgeon usually orders a radiograph to determine whether the missing sponge is in the patient and to rule out a retained sponge. The AORN guideline recommends that additional measures be performed based on the individual health care organization’s own risk analysis.5 Researchers conducted a meta-analysis of 19 research studies and found the following risk factors for RSIs:
blood loss greater than 500 mL, longer surgeries, surgeries in which more than one procedure was performed, lack of a count, the presence of more than one surgical team, unexpected intraoperative factors, and incorrect counts.6
The reliance on the surgical count for patient safety is problematic. Researchers conducting a retrospective review of
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adverse events occurring from 2000 to 2004 in a New York hospital system found the sensitivity of surgical counts to be 77%, and the positive predictive value was only 1.6%.7 In another large study, researchers found that 62% of RSIs were detected by postoperative radiography after the surgical count was reported as being correct.2 A Healthcare Failure Mode and Effect Analysis identified 57 potential failures during perioperative management of surgical sponges. Causes of these failures, particularly distraction and multitasking, are difficult to control. This explains in part why the surgical count does not adequately prevent retained sponges.8 Count discrepancies are common. In a prospective observational study, researchers found count discrepancies in 12.8% of elective general surgery cases.9 These discrepancies usually are unreported after the team reconciles the count, and the amount of time allocated to reconcile the count is unknown. Furthermore, the time spent reconciling counts draws the attention of nursing personnel away from other high-priority safety issues, including paying attention to the surgeon who is still operating. If the count is not reconciled or the patient is considered at high risk, radiography often is used to determine whether a retained sponge is present. This use of radiography delays completion of the surgery and extends OR time. In a large study comparing radiographs performed intraoperatively versus postoperatively, intraoperative imaging failed to detect 33% of retained items.2 In addition to giving a potentially misleading report, the cost of this additional time, the radiograph, and the radiologist’s fee for reading the image can be significant and may not be reimbursed. The cost of routinely using intraoperative radiographs for ruling out a retained item is estimated to be $11.5 million for every surgical item detected through this method.10 This is important in today’s health care reimbursement model with payment fixed by diagnosis-related group, reducing that procedure’s contribution margin and overall profitability. The AORN guideline for prevention of RSIs recommends that “Perioperative personnel should evaluate existing and emerging adjunct technology to determine the application that may be most suitable in their setting.”5(p342) A computerassisted counting system using two-dimensional data matrix-labeled (ie, bar-coded) sponges and a scanner are available to assist with the reconciliation of the surgical sponge count. Studies have shown that this technology significantly increases the identification of misplaced and miscounted sponges.11,12 This technology is reported to be
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cost-effective compared with radiography, but it could increase the time spent counting.11-13 Data matrix technology does not rule out the presence of a retained sponge or detect sponges misplaced in the room. Another adjunct technology is low-frequency radiofrequency (RF). Manufacturers sew an RF tag into surgical sponges; this allows personnel to use a handheld wand or preoperatively place the patient on a mattress with embedded wands. This mattress allows the patient and the surrounding field to be scanned for the presence of a retained sponge, a process that takes approximately 10 seconds. The sensitivity of the handheld wand has been found to be 100%, even when used to care for patients who are morbidly obese.14 The mattress, which scans the body for retained sponges in a hands-free manner, has been found to be 100% sensitive in subjects who are not morbidly obese and 96.9% sensitive in subjects who are morbidly obese.15 When considering the cost-effectiveness of adjunct technologies, perioperative managers, directors, and value analysis teams often consider the cost of the supplies (eg, sponges) alone. This limited view does not provide an accurate picture of the potential cost-effectiveness of adjunct technology because it does not take into consideration the cost of current practices.
METHODS We conducted a retrospective review of existing data retrieved from the health information system (HIS) of a large Level 1 trauma and academic medical center. The Institutional Review Board of the University of Iowa, Iowa City, determined that this study did not meet the regulatory definition of human subjects research and did not require review. The sample included all patients undergoing surgery in the main OR from February 1, 2014, until October 31, 2014 (nine months in total). Exclusion criteria included ophthalmology, dentistry, and nonsurgical procedures; aborted surgical procedures; surgeries during which the patient died; and surgeries performed outside of the main OR. This sample is large enough to provide clinically relevant results and allow us to annualize cost estimates. Circulating nurses recorded data for individual patients in a questionnaire embedded in the surgical log of Epic module Optime. The questionnaire consisted of questions regarding three individual counts: initial closing, final closing, and additional counts (eg, bladder closure, personnel change). If the person completing the survey answered “yes”
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to the first question (ie, “was a search required?”), he or she had to respond to four subsequent questions:
type of sponge missing, actions taken, number of minutes required to complete the search, and location of the sponge if found.
At the end of each procedure, the RN circulator was required to electronically verify the initial and final count. We retrieved data from the facility’s HIS using SAP Business ObjectsTM software (surgical volume, surgical service, procedure duration, triage) and Crystal reports (details about searches for sponges). We also collected data from event reports entered into the facility’s patient safety net electronic reporting system. We reviewed all events reported within the category of “count incomplete or not done” (eg, emergency procedures) and “count incorrect” (for incorrect sponge counts). We determined the cost per minute of operating time using published data (ie, $62 per minute) to enhance generalizability.16 Although staff members are attempting to reconcile the count, surgeons sometimes continue with the procedure (eg, closing the wound); at other times, surgeons redirect their efforts to assisting with locating the sponge. When progress on the surgery is suspended for the search, it is nonproductive operating time. We conservatively estimated that 50% of the time spent searching for a missing sponge is nonproductive. We also calculated radiology costs of ruling out a retained sponge based on published data to maximize generalizability. Average radiology costs cited in the literature were $286 per patient,10 and OR time associated with obtaining an intraoperative radiograph was approximately 30 minutes.17 We analyzed data using SAS 9.3 software and using descriptive statistics to describe the number of surgical procedures and their duration and the number of searches and their duration and costs. We analyzed data in aggregate and by surgical service.
RESULTS Overall, we reviewed records for 13,322 patient surgeries (Table 1). The most frequent surgical services involved were orthopedics (23.1%), general surgery (19.7%), and neurosurgery (14.6%). The vast majority of procedures were elective (79.9%). Overall, only 6.3% of procedures were emergent. The neurosurgery and orthopedic services had the highest and lowest percentages of emergent procedures, respectively (14.3%, 1.6%). The mean duration of procedures was 136.5 minutes (standard deviation [SD] 118.1). On average, the longest procedures were transplant procedures (229 minutes).
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Table 1. Urgency of Surgeries and Duration of Procedures Performed by Surgical Service Number of Procedures (% of all) Surgical Service Cardiothoracic General Surgery Adult/Plastics General Surgery Pediatrics
Duration of Procedures (minutes) Emergent
Mean SD
Median
131 (16.4)
62 (7.8)
188.8 140.4
156
2,069 (78.6)
357 (13.6)
206 (7.8)
129.3 101.6
102
455 (73.5)
139 (22.5)
25 (4.0)
62.8 58.3
47
n
Elective
Urgent
797
604 (75.8)
2,632 619 948
865 (91.2)
43 (4.5)
40 (4.2)
140.3 90.3
135
Neurosurgery
1,950
1,305 (66.9)
366 (18.8)
279 (14.3)
134.6 121.6
103
Orthopedics
3,079
2,474 (80.4)
555 (18.0)
50 (1.6)
121.8 90.8
102
Otolaryngology
1,598
1,485 (92.9)
53 (3.3)
60 (3.8)
146.9 153.1
101
Transplantation
211
100 (47.4)
91 (43.1)
20 (9.5)
229.2 130.2
207
Vascular
575
444 (77.2)
62 (10.8)
69 (12)
162.7 133.7
127
Urology
913
837 (91.7)
51 (5.6)
25 (2.7)
188.8 140.4
156
13,322
10,638 (79.9)
836 (6.3)
136.5 118.1
105
Gynecology
All Services
1,848 (13.9)
SD ¼ standard deviation.
Perioperative personnel required additional time and effort to reconcile 212 surgical sponge counts (Table 2). Of these, 143 occurred during first closing counts and 63 occurred during final closing counts. The services most often involved with this process were neurosurgery (23.6%), orthopedics (21.2%), and general surgery adult/plastics (19.3%). The greatest percentage of procedures performed by a surgical service in which a search was required was in the
transplantation service (3.8%; eight of 211) and neurosurgery (2.6%; 50 of 1,950). Of all the searches, 87.7% resulted in a reconciled (ie, correct) surgical count and no event report was generated. Of the 199 searches in which the type of sponge was identified, 108 searches were for radiopaque 4 4s, 82 were for laparotomy sponges, five were for both 4 4s and laparotomy sponges, and four were for episiotomy sponges. Sponges were found in the following areas:
Table 2. Searches and Outcomes of Searches by Surgical Service Number of Searches (% of procedures by surgical service) Surgical Service Cardiothoracic General Surgery Adult/Plastics General Surgery Pediatrics
All
Reconciled Searches
First Final Found in Found on Found Outside Unreconciled Closing Closing Additional All Patient Sterile Field Sterile Field Searches
8
4 (0.5)
4 (0.5)
0 (0)
6
2
1
3
2
41
32 (1.2)
9 (0.3)
0 (0)
40
6
23
11
1
1
0 (0)
1 (0.2)
0 (0)
1
0
1
0
0
7 (0.7)
4 (0.4)
1 (0.1)
8
2
3
3
4
47
1
20
26
3
Gynecology
12
Neurosurgery
50
34 (1.7) 16 (0.8)
0 (0)
Orthopedics
45
32 (1.0) 13 (0.4)
0 (0)
41
2
26
13
4
Otolaryngology
28
14 (0.9) 10 (0.6)
4 (0.3)
20
1
6
13
8
Transplantation
8
7 (3.3)
0 (0)
1 (0.5)
8
1
2
5
0
Urology
7
5 (0.9)
2 (0.3)
0 (0)
7
0
4
3
0
Vascular
12
8 (0.9)
4 (0.4)
0 (0)
8
1
5
2
4
212 143 (1.1) 63 (0.5)
6 (0)
186
16
91
79
26
All Services
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91 on the sterile field (42.9%), 79 in the nonsterile areas of the OR (37.2%), and 16 in the wound (7.5%). In addition, sponges were not located in 26 searches (12.2%). The most frequently reported steps taken to reconcile the search were searching the sterile (77.4%) and nonsterile (58.5%) fields (Table 3). The time required to conduct a search ranged from one to 90 minutes. For nine searches, nurses recorded the number of minutes as “greater than 30.” For these searches, the analysis was completed using 30 minutes. Thus, the overall time (1,700 minutes) is an underestimate of the actual time. The annualized cost of this operating time was $140,533. Assuming 50% of the time spent searching for a sponge was nonproductive, the adjusted annualized cost of nonproductive OR time spent on reconciling the count was $70,266 (Table 4). Fifty-two patients received a total of 55 intraoperative radiographs to rule out the presence of a retained sponge (Table 5). Three patients had radiographs taken for more than one incision. Nearly half the radiographs (n ¼ 25) were taken during liver transplantation procedures per hospital protocol because the patient was considered at high risk for a retained sponge. Twenty-four radiographs were obtained because the sponge was not found, resulting in an incorrect final closing count. Other reasons for radiographs included emergency procedures with no count performed (n ¼ 4) and second-look laparotomy procedures (n ¼ 2). Surgical sites included the
abdomen (n ¼ 34), head and neck (n ¼ 5), leg (n ¼ 4), chest (n ¼ 3), spine (n ¼ 3), groin (n ¼ 3),
Table 3. Steps Taken to Reconcile Sponge Counts Step
Number of Searches (% of all searches)
Surgeon Notified
84 (39.6%)
Wound Searched
34 (16.0%)
Sterile Field Searched
164 (77.4%)
Nonsterile Area(s) Searched
124 (58.5%)
Additional Personnel
24 (11.3%)
Other
14 (6.6%)
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hip (n ¼ 2), and hand (n ¼ 1). During this nine-month study, the cost of obtaining and reading these radiographs, based on the published average cost per radiograph ($286),10 was $14,872; the cost of OR time to obtain the radiographs, based on 30 minutes per radiograph,12 was $96,720. The combined annualized costs of obtaining, reading, and waiting for results of the radiographs was $148,789. The total annualized cost of searching for missing sponges and using radiography to rule out the presence of a retained sponge was $219,056.
DISCUSSION Despite the high-profile nature of retained surgical sponges, these events continue to occur.18-20 Retained surgical items have remained among the most frequently reported sentinel events for the past 10 years1 and comprise half the malpractice settlements for surgical “never events.”21 The Joint Commission requires investigation of RSIs after surgery, defining after surgery as “any time after completion of the skin closure; even if the patient is still in the OR under anesthesia.”22 This definition provides an incentive for surgical teams to stop the progress of surgery while searching for a sponge, obtaining a radiograph for a missing sponge, and waiting for the radiograph to be read. Count discrepancies are common.9,23 Even though the majority of misplaced sponges in our study were not in the wound, efforts to locate the sponge take time and attention away from the surgical procedure and other high-priority tasks in the OR and may increase surgical duration. This study quantifies the time required to search for misplaced sponges and estimates the associated costs of these searches using published data to enhance generalizability. In most cases (87.7%), the searches resulted in a correct final count and would not have been reported through the hospital event reporting system, which has been the source of data used in previous research.10 Likewise, previous cost analyses of the use of intraoperative radiography for ruling out a retained sponge have not included the cost of the OR time.10 This study provides new knowledge about these additional costs.
Limitations Estimated costs in this study are likely lower than actual costs. First, staff members likely did not report every search performed because of “documentation fatigue,” a result of being overloaded with documentation requirements. This may explain why we found fewer count discrepancies compared
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Table 4. Cost of OR Time for Reconciling Surgical Sponge Counts by Surgical Service Duration of Searches (minutes) Surgical Service Cardiothoracic General Surgery Adult/Plastics General Surgery Pediatrics
Cost of OR Time ($)
Annualized Searches Total Range Mean SD Median Nine Monthsa Annualized Nonproductivea,b,c 8
161þ 1-50
20.1 15.9
15.0
9,982.00
13,309.33
6,654.67
41
216þ 1-30
5.3 6.1
2.0
13,392.00
17,856.00
8,928.00
62.00
82.67
41.33
1
1
Gynecology
12
224þ 1-60
18.7 22.9
4.0
13,888.00
18,517.33
9,258.67
Neurosurgery
50
275þ 1-30
5.5 7.1
2.0
17,050.00
22,733.33
11,366.67
Orthopedics
45
299þ 1-90
6.6 13.9
3.0
18,538.00
24,717.33
12,358.67
Otolaryngology
28
311þ 1-45
11.1 13.2
3.0
19,282.00
25,709.33
12,854.67
Transplantation
8
102 3-40
12.8 12.3
8.5
6,324.00
8,432.00
4,216.00
Urology
7
26 1-10
3.7 3.7
2.0
1,612.00
2,149.33
1,074.67
Vascular
12
85þ 1-30
7.1 8.4
5.0
5,270.00
7,026.67
3,513.33
212
1,700 1-90
8.0 12.0
3.0
105,400.00
140,533.33
70,266.67
All Services
SD ¼ standard deviation. a Based on OR time ¼ $62/minute.1 b Estimated at 50% time. c Actual total was greater because some durations were recorded as greater than 30 minutes. Reference 1. Macario A. What does one minute of operating room time cost? J Clin Anesth. 2010;22(4):233-236.
with an earlier observational study that found sponge count discrepancies in 12.8% of general surgery cases.9 Second, the number of minutes for searches were at times recorded as “greater than 30.” When this value was entered, we used 30 minutes to calculate time and cost. Thus, the actual number of minutes spent searching for misplaced sponges was likely greater than reported here. Moreover, we conservatively estimated nonproductive OR time spent searching for a sponge as 50% of the time reported. This time may vary between facilities, particularly related to practices for halting or continuing wound closure when a count is reported as incorrect. Some hospitals use intraoperative radiography routinely for patients identified as high risk for an RSI. In the study setting, facility protocol requires radiography when the count is incorrect or not performed and for liver transplantation procedures. In a recent meta-analysis, if radiography was used for all patients with higher risk factors (ie, blood loss greater than 500 mL, longer duration of procedure, lack of surgical counts, more than one surgical team, unexpected intraoperative factors, incorrect count),6 the number of radiographs obtained to rule out a retained sponge would be much greater. Thus, the annualized costs of radiography may be higher in other settings.
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Because costs may vary in different settings, we used published data for the cost of OR time spent obtaining and waiting for radiography results.10,17 We selected these published values to provide more generalizability to our findings.
Recommendations for Perioperative Practice The standard of perioperative practice for many years has included counting surgical items.5 However, the sensitivity of the surgical count for identification of an RSI is only 77%.2 A proactive risk analysis of managing surgical sponges found 57 potential failure points during this process, 43 of which occurred frequently enough to be considered high risk and require control. Frequent causes of these failures include distraction, multitasking, and time pressure/emegencies.8 These causes are inherent in the work in the OR and are extremely difficult to eliminate. This likely explains why RSIs have been one of the most frequent sentinel events reported to The Joint Commission for the last 10 years.1 Seeking to improve patient safety, AORN recommends that perioperative nurses evaluate existing and emerging adjunct technology.5 If managers, directors, and value analysis teams conduct a cost analysis that focuses exclusively on the cost of sponges, they may consider the purchase of adjunct AORN Journal j 503
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Table 5. Cost of Radiography for Ruling Out a Retained Surgical Sponge by Surgical Service Cost of Radiography ($) Nine Months Surgical Service
Patients
Location(s) Number of X-rays Duration (minutes)a,b
Cardiothoracic
3
Chest 2 Chest and leg 1
General Surgery Adult/Plastics
7
Abdomen 6 Abdomen and leg 1
General Surgery Pediatrics
0
Gynecology
1
Neurosurgery
ORc
X-rayb
Annualized OR and X-ray
90
5,580.00
858.00
8,584.00
210
13,020.00
2,002.00
20,029.33
Abdomen 1
30
1,860.00
286.00
2,861.33
3
Head 2 Spine 1
90
5,580.00
858.00
8,584.00
Orthopedics
6
Hand 1 Hip 2 Leg 1 Spine 2
180
11,160.00
1,716.00
17,168.00
Otolaryngology
3
Neck 2 Neck and leg 1
90
5,580.00
858.00
8,584.00
Transplantation
26
Abdomen 25 Groin 1
780
48,360.00
7,436.00
74,394.66
Abdomen 1 Groin 2
90
5,580.00
858.00
8,584.00
96,720.00 14,872.00
148,789.33
Urology
0
Vascular
3
All Services a
52
55
1,560
1
Based on $286 per x-ray. Based on 30 minutes of OR time per x-ray.2 c Based on OR time ¼ $62 per minute.3 b
References 1. Williams TL, Tung DK, Steelman VM, Chang PK, Szekendi MK. Retained surgical sponges: findings from incident reports and a cost-benefit analysis of radiofrequency technology. J Am Coll Surg. 2014;219(3):354-364. 2. Dossett LA, Dittus RS, Speroff T, May AK, Cotton BA. Cost-effectiveness of routine radiographs after emergent open cavity operations. Surgery. 2008;144(2):317-321. 3. Macario A. What does one minute of operating room time cost? J Clin Anesth. 2010;22(4):233-236.
technology to be cost prohibitive. However, there are costs aside from material costs associated with current practices. Perioperative nurses should conduct comprehensive analyses of time and other costs associated with searching for a missing sponge and ruling out a retained sponge with radiography when considering alternatives, such as adjunct technology, to supplement the surgical sponge count and prevent retained sponges. Although the focus of this study was on the time and cost of reconciling a sponge count and using radiography to rule out a retained sponge, we also gained knowledge about the surgical services involved and the location of misplaced sponges. Clinicians may think that sponge counts are only important in abdominal and thoracic surgery. However, we found that most 504 j AORN Journal
misplaced sponges occurred in neurosurgery and orthopedics. This supports the need to be vigilant about sponge counts in all services. It also is common for clinicians to meet resistance when reporting a missing sponge to the surgeon, who may believe that the sponge is elsewhere in the room. In our study, sponges were found inside the wound 8.6% of the time that they were found. This supports the need for perioperative nurses to actively engage the surgeon in the search for a missing sponge. Future perioperative research should focus on measuring the costs of retained sponges and the costs of preventing retained sponges. First, the cost of retained sponges should be measured, including the cost of reoperation, litigation, and lost
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Reconciling Surgical Sponge Counts
revenue from lower rates of reimbursement related to “never events.” Research should focus on the cost-effectiveness of different interventions for the prevention of retained sponges and include the costs of radiography, if used to rule out the presence of a retained sponge. Last, research should focus on staff member and surgeon satisfaction with current practices for prevention of retained sponges, and researchers should conduct a comparison of satisfaction before and after changes are made in the clinical setting.
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CONCLUSION Time spent searching for sponges draws the attention of personnel away from other high-priority tasks (eg, blood administration, airway issues, technology safety issues) and decreases the efficiency of completing the surgical procedure. We have measured the time spent and associated costs of reconciling the surgical sponge count. These costs are often hidden, particularly when the count is reconciled or reported as correct and no event report is filed. These hidden costs have not been previously measured. We also estimated the cost of ruling out a retained sponge using radiography, including the cost of radiographs and OR time waiting for the results. These costs should be included in comprehensive cost analyses when considering alternatives to supplement manual counting.
Editor’s notes: Epic is a registered trademark and Optime is a trademark of Epic, Verona, WI; SAP Business Objects and Crystal are registered trademarks of SAP America, Newtown Square, PA; SAS 9.3 is a registered trademark of the SAS Institute Inc, Cary, NC.
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Victoria M. Steelman, PhD, RN, CNOR, FAAN, is an associate professor in the College of Nursing, The University of Iowa, Iowa City, IA. Dr Steelman served as a consultant for RF Surgical Systems, Inc., Carlsbad, CA. As funding for this study was provided by a grant from RF Surgical Systems, Dr Steelman has declared an affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Ann G. Schaapveld, BSN, RN, is a research specialist in the College of Nursing, The University of Iowa, Iowa City, IA. Ms Schaapveld has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Yelena Perkhounkova, PhD, is a statistician/biostatistics manager in the College of Nursing, The University of Iowa, Iowa City, IA. Dr Perkhounkova has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
Hillary E. Storm, MSN, RN, CNOR, is an advanced practice nurse in the main OR, The University of Iowa Hospitals and Clinics, Iowa City, IA. Ms Storm has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article. Michelle Mathias, BSN, RN, is a clinical coordinator for perioperative nursing in the main OR, The University of Iowa Hospitals and Clinics, Iowa City, IA. Ms Mathias has no declared affiliation that could be perceived as posing a potential conflict of interest in the publication of this article.
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