Rectifying counts; neurostimulators; double gloving; reprocessing single-use devices; simultaneous counting

AORN Journal,  Sept, 2002  by Carol Petersen

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Question: When we have a discrepancy In a closing needle count, some of our nurses believe it is acceptable to use the opened suture packages to rectify the count. Sometimes when a procedure becomes hectic, the circulating nurse forgets to record the added needle on the count board or tally sheet. During the closing counts, if there is a discrepancy in the needle count but the suture packages on the field match the number of needles, the sharps count Is documented as correct. This practice currently is being challenged by a nurse who recently joined our staff. Is it acceptable to use suture packages to confirm or rectify the closing needle counts?

Answer: Using suture packages to rectify a discrepancy in a closing needle count is not recommended. Any discrepancies between the number of needles used during the procedure and the count board or tally sheet during the closing counts should be considered incorrect, and facility policy should be adhered to regarding incorrect counts. Although it may seem logical to compare the number of suture packages with the number of needles on the field, there is no assurance that the number of suture packages is accurate. For example, if there is a missing needle and one of the suture packages was inadvertently discarded in the trash, surgical team members may believe all needles have been accounted for. The missing needle, however, may be retained in the patient or drapes, creating a risk for the patient and personnel.

AORN's "Recommended practices for sponge, sharp, and instrument counts" advise that sharps, which include needles, be counted audibly and viewed concurrently by two individuals, one of whom is an RN. AORN recommends that concurrent counts be taken before the procedure begins to establish a baseline, just before closure of a cavity within a cavity, before wound closure begins, when skin closure begins or at the end of the procedure, and at the time of permanent staff member relief. Suture needles should be counted initially, before opening individual suture packages, by the number marked on the suture package. As the individual suture packages are opened, the number of actual needles should be verified by the scrub person and circulating nurse. Any time additional items are added to the sterile field during the procedure, they also should be counted simultaneously by the scrub person and circulating nurse, after which the circulating nurse should record the items on the count board or tally sheet. (1)

Relying on a match between the number of suture packages and the number of needles on the sterile field may give a false sense of security. Multiple factors can lead to an inaccurate count during a surgical procedure. Simultaneous verification of counts between two people helps ensure accurate counts. If there is a discrepancy between the number of needles and the count board or tally sheet, facility policy should be adhered to regarding nursing actions and protocols for incorrect counts. (2)

Question: We recently had a patient scheduled for a hernia repair who had implanted bilateral neurostimulators to control tremors associated with Parkinson's disease. We understand that the electrosurgical unit (ESU) may Interfere with the neurostimulator. What precautions should be taken for patients with neurostimulators regarding the use of the ESU?

Answer: Special precautions should be taken when using the ESU with patients who have neurostimulators. Neurostimulators are used to treat neurological conditions, such as movement disorders, intractable pain, or urinary incontinence. (3) Electrodes are placed in specific regions of the nervous system with regard to the patient's pathology. Neurostimulation used to treat movement disorders, such as those caused by Parkinson's disease, involves implanting leads in specific regions of the brain that then are connected to a programmable pulse generator. This is referred to as deep brain stimulation (DBS). Electrodes also maybe implanted in the spine to control intractable pain and for sacral nerve stimulation used for urinary incontinence.

The pulse generator is similar to a cardiac pacemaker in design and delivers electrical stimulation to targeted structures in the appropriate area of the nervous system. After it is programmed, the pulse generator can be turned on and off by the patient or clinician using a magnet or patient-therapy controller. In the OR, the pulse generator may be affected by or have an adverse effect on some medical equipment (eg, cardiac pacemakers, cardioverters/defibrillators, external defibrillators, ultrasonic equipment, ESU) or procedures (eg, radiation therapy, some magnetic resonance imaging procedures). (4)

The ESU may damage the neurostimulator's circuitry. For patients with neurostimulators, surgical team members should take additional precautions that include, but are not limited to

* adhering carefully to the neurostimulator manufacturer's instructions;

* checking with the patient's neurologist or primary care physician regarding how the pulse generator functions during a surgical procedure because the neurostimulator manufacturer may recommend turning it off during a surgical procedure for the safety of the patient; (5)