Counting sterile towels

AORN Journal, April, 2008 by Denise Downing

QUESTION: One of our surgeons wanted to pack the wound of an obese patient with towels rather than laparotomy sponges. The circulating nurse and scrub person did not want to use the towels because the towels were not part of the preprocedure count nor were they x-ray detectable. The circulating nurse was afraid that the towels could be left in the surgical wound inadvertently. Because sterile towels do not have radiopaque markers, should we be counting them? What procedure should be followed when towels are missing and there is a count discrepancy? Would radio-frequency identification (RFID) technology help with lost towels?

ANSWER: AORN's "Recommended practices for sponge, sharp, and instrument counts" states that

   All sponges used during a surgical procedure
   should be x-ray detectable. Radiopaque indicators
   facilitate locating an item presumed lost or
   left in the surgical field when a count discrepancy
   occurs. (1(p294))

All sponges, sharps, instruments, and miscellaneous items that are used within a wound and are not intended to be left in the wound after closure should contain a radiopaque marker. Radiopacity allows for the retained item to be identified or the surgeon to rule out a retained item with an x-ray taken after an incorrect count. (2)

   Only towels with radiopaque markers should
   be used in the wound. If towels are used in the
   open wound, they should be included in the
   count as miscellaneous items and should be
   easily distinguishable from other towels. (1(294))

Most towels are not x-ray detectable or designed for use as laparotomy sponges or wound packing. Some towels produce lint and have color dyes that can be irritating. If sterile towels are used for packing and were not counted, are not distinguished from other towels on the field, or are not radiopaque, it will be difficult to determine if a sterile towel discrepancy exists. Without a radiopaque strip, an x-ray will not detect the towels left in the surgical wound?

Towel manufacturers have designed towels for visceral packing that contain a radiopaque strip and can be confidently used intraoperatively. Some manufacturers sell sponges and towels that not only have a radiopaque strip, but also contain a radio-frequency identification (RFID) tag. Originally, RFID technology was developed for the retail industry to prevent theft. Improved performance of the technology has made it economical to attach RFID tags (ie, tiny microchips that act as transponders by responding to radio signals sent by transceivers or a RFID scanner) to surgical supplies. (4) A handheld wand scanning device has been developed to detect sponges and towels that have been tagged with RFID chips. Radiological technology, such as RFID, can assist with ensuring that all potential foreign objects have been removed from the surgical site. In one study, the results demonstrated "100% detection accuracy using RFID sponges and the RFID wand device, with a 0% false negative rate and a 0% false positive rate." (5)

Despite efforts to make the scanning device 100% accurate, the system is not fail-proof and user error can occur. Surgical team members must understand that retained sponges or towels may be missed if the clinician

* performs the scan incorrectly,

* holds the wand too far from the skin to detect the sponge or towel,

* does not scan the entire surgical site with the wand, or

* performs the scan too early in the count process.

Continued use of RFID systems will help to further research for a design that is user fail-safe.

When a discrepancy is noted during the counting process, perioperative team members should respond in a step-by-step manner.

* Report the discrepancy to the surgeon and surgical team members.

* Suspend the procedure, if the patient's condition permits.

* Perform a methodical, manual exploration of the surgical wound.

* Visually inspect the area surrounding the surgical field, including the floor, kick buckets, linen and trash receptacles, and under the OR bed.

* Assess the patient's condition, and if the patient is unstable, perform an x-ray or scan the surgical site as soon as possible.

* Perform an intraoperative x-ray if the item is radiopaque and if the patient's condition permits.

* Consult a radiologist to determine whether an x-ray would be beneficial to find a missing item that is not radiopaque.

* Have both the radiologist and surgeon read the x-ray and consult on the reading.

* Employ other technologies (eg, bar code readings, RFID scanning), if available, and if the patient's condition permits.

** Ensure that proper wand scanning technique is used.

** Rescan the patient if the missing item has an RFID tag and the first scan does not show the missing item.

* Document all measures taken and their outcomes on the patient's medical record.

* Report the incident according to facility policy.

* Perform a review of the incident or near-miss event for cause, effect, and prevention using a collaborative process to promote consistency in practice across disciplines. (1,6,7)