A historical perspective on the problem of the retained surgical sponge: Have we really come that far?

Retained surgical items, particularly surgical sponges, are a considered a "never event." Unfortunately, they continued to be reported despite significant efforts to reduce them. Our goal was to identify some of the earliest reports of surgical items, particularly surgical sponges, to see how it was presented in the literature as well as any insights into contributing factors and processes to mitigate the event. We progress forward in time to look at how this issue has been addresses or changed as we enter the 21st century. After this review, it appears that our advances are not as significant as those efforts proposed over 100 years ago. We view this as a call to action for significant change in our operative safety processes and to incorporate available technology.

Gentamicin-Collagen Sponges for the Prevention of Surgical Site Infections: A Meta-Analysis of Randomized Controlled Trials.

BACKGROUND: To study the effectiveness of gentamicin-collagen sponges (GCS) for the prevention of surgical site infections (SSIs). METHODS: A systematic search of the PubMed and Scopus databases was performed (up to April 2015) to identify randomized controlled trials evaluating the efficacy of GCS for the prevention of SSIs. A random effects model was applied. RESULTS: Twenty-one RCTs (8,472 patients) were included. Gentamicin-collagen sponges were associated with a lower risk of SSIs (risk ratio [RR] 0.65; 95% confidence interval [CI] 0.49-0.84). Based on Jadad scores, a lower risk for the development of SSI was presented in lower-quality studies (Jadad <3; RR 0.44; 95% CI 0.27-0.71), but no difference was observed in high-quality studies (Jadad ≥3; RR 0.77; 95% CI 0.58-1.02). No difference was observed in all-cause deaths in the GCS group compared with the control group (RR 0.77; 95% CI 0.56-1.06). CONCLUSIONS: When analyzing lower-quality studies or only clean procedures, GCS significantly reduced the risk of SSI. Further high-quality randomized studies are needed to confirm the benefit of GCS for lowering mortality rates.

Under-reporting of gossipiboma in a third-world country. A sociocultural view.

The paper looks at the reason for the low incidence of retained abdominal packs following an abdominal operation in a third world country like Nigeria. It is generally agreed that this unfortunate situation is underreported. The reason for under-reporting is now given a socio-cultural perspective. Fear of litigation as would hold in the western world does not seem to be paramount here. Other explanations like fear of being made a scapegoat for something which may be due to spiritual attacks may be paramount. The paper concludes by recommending that the removal of impediments to disclosure of this adverse surgical event will lie in education, discouragement of scapegoatism and improvement in hospital services in the third world.

A novel model of invasive fungal rhinosinusitis in rats.

BACKGROUND: Invasive fungal rhinosinusitis (IFRS) is a life-threatening inflammatory disease that affects immunocompromised patients, but animal models of the disease are scarce. This study aimed to develop an IFRS model in neutropenic rats. METHODS: The model was established in three consecutive steps: unilateral nasal obstruction with Merocel sponges, followed by administration of cyclophosphamide (CPA), and, finally, nasal inoculation with Aspergillus fumigatus. Fifty healthy Wistar rats were randomly divided into five groups, with group I as the controls, group II undergoing unilateral nasal obstruction alone, group III undergoing nasal obstruction with fungal inoculation, group IV undergoing nasal obstruction with administration of CPA, and group V undergoing nasal obstruction with administration of CPA and fungal inoculation. Hematology, histology, and mycology investigations were performed. RESULTS: The changes in the rat absolute neutrophil counts (ANCs) were statistically different across the groups. The administration of CPA decreased the ANCs, whereas nasal obstruction with fungal inoculation increased the ANCs, and nasal obstruction did not change them. Histological examination of the rats in group V revealed the hyphal invasion of sinus mucosa and bone, thrombosis, and tissue infarction. No pathology indicative of IFRS was observed in the remaining groups. Positive rates of fungal culture in tissue homogenates from the maxillary sinus (62.5%) and lung (25%) were found in group V, whereas groups I, II, III, and IV showed no fungal culture in the homogenates. CONCLUSION: A rat IFRS model was successfully developed through nasal obstruction, CPA-induced neutropenia, and fungal inoculation. The disease model closely mimics the pathophysiology of anthropic IFRS.

[Vacuum-assisted closure therapy for exposed vascular prosthesis in the groin]. / Vacuümtherapie bij blootliggende vaatprothese in lies.

Groin infections are a severe complication in vascular surgery. The treatment of a groin infection with exposed vascular prosthetic material is challenging. Vacuum-assisted closure (VAC) is a therapy frequently used to close wounds. In groin wounds with exposed vascular prosthetic material, however, VAC has been contraindicated because of the risk of bleeding. We successfully treated 17 groin infections with exposed vascular prosthetic material from 2009 to 2011 by using a double-sponge technique (a combination of polyvinyl alcohol and polyurethane sponges and a continuous negative pressure of 50 mmHg); there were no complications involving haemorrhaging, amputations or re-infection. At a median follow-up duration of 380 days, no further complications occurred and all prostheses could be retained. The double-sponge technique appears to be an effective and simple method for closing an infected groin with preservation of the underlying prosthetic material.

Improving safety in the operating room: a systematic literature review of retained surgical sponges.

PURPOSE OF REVIEW: Gossypibomas are surgical sponges that are unintentionally left inside a patient during a surgical procedure. To improve this patient safety indicator, anesthesiologists will need to work with operating room personnel. This study's goal was to systematically review the literature on retained sponges to identify body location, time to discovery, methods for detection, and risk factors. RECENT FINDINGS: Two hundred and fifty-four gossypiboma cases (147 reports from the period 1963-2008) were identified via the National Library of Medicine's Medline and the Cochrane Library. Gossypibomas (mean patient age 49 years, range 6-92 years) were most commonly found in the abdomen (56%), pelvis (18%), and thorax (11%). Average discovery time equaled 6.9 years (SD 10.2 years) with a median (quartiles) of 2.2 years (0.3-8.4 years). The most common detection methods were computed tomography (61%), radiography (35%), and ultrasound (34%). Pain/irritation (42%), palpable mass (27%), and fever (12%) were the leading signs and symptoms, but 6% of cases were asymptomatic. Complications included adhesion (31%), abscess (24%), and fistula (20%). Risk factors were case specific (e.g. emergency) or related to the surgical environment (e.g. poor communication). Most gossypibomas occurred when the sponge count was falsely pronounced correct at the end of surgery. SUMMARY: More is being discovered about the patterns leading to a retained sponge. Multidisciplinary approaches and new technologies may help reduce this low frequency but clinically significant event. However, given the complexity of surgical care, eliminating retained sponges may prove elusive.

The frequency and significance of discrepancies in the surgical count.

OBJECTIVE: To prospectively evaluate and accurately describe the rate and type of discrepancies encountered in the surgical count. INTRODUCTION: Despite near-universal implementation of manual counting protocols for surgical instruments and sponges, incidents of retained sponges and instruments (RSI) persist. Retrospective analyses have shown that RSI are rare and most often involve final counts erroneously thought to be correct, leading some surgeons to question the value of counting. Crucial data regarding how often the surgical count successfully detects meaningful problems before the patient leaves the operating room is lacking. METHODS: Trained physician-observers documented prospective field observations during 148 elective general surgery operations using standardized intake forms. Data collection focused on the performance of the counting protocols, and the frequency and outcomes of discrepancies (instances in which a subsequent count does not agree with the previous count). RESULTS: A mean of 16.6 counting episodes occurred per case, occupying 8.6 minutes per case. A total of 29 discrepancies involving sponges (45%), instruments (34%) or needles (21%) were observed among 19 (12.8%) operations. Most discrepancies indicated a misplaced item (59%) as opposed to a miscount (3%) or error in documentation (38%). Each discrepancy took on average 13 minutes to resolve. Counting activities after personnel changes were significantly more likely to involve a discrepancy than those for which the original team was present. CONCLUSIONS: One in 8 surgical cases involves an intraoperative discrepancy in the count. The majority of these discrepancies detect unaccounted-for sponges and instruments, which represent potential RSI. Thus, despite the recognized limitations of manual surgical counts, discrepancies should always prompt a thorough search and reconciliation process and never be ignored.

Bar-coding surgical sponges to improve safety: a randomized controlled trial.

OBJECTIVE: A randomized, controlled trial was performed to evaluate a computer-assisted method for counting sponges using a bar-code system. BACKGROUND: Retained sponges are a rare and preventable problem but persist in surgery despite standardized protocols for counting. Technology that improves detection of counting errors could reduce risk to surgical patients. METHODS: We performed a randomized controlled trial comparing a bar-coded sponge system with a traditional counting protocol in 300 general surgery operations. Observers monitored sponge and instrument counts and recorded all incidents of miscounted or misplaced sponges. Surgeons and operating room staff completed postoperative and end-of-study surveys evaluating the bar-code system. RESULTS: The bar-code system detected significantly more counting discrepancies than the traditional protocol (32 vs.13 discrepancies, P = 0.007). These discrepancies involved both misplaced sponges (21 vs. 12 sponges, P = 0.17) and miscounted sponges (11 vs. 1 sponge, P = 0.007). The system introduced new technical difficulties (2.04 per 1000 sponges) and increased the time spent counting sponges (5.3 vs. 2.4 minutes, P < 0.0001). In postoperative surveys, there was no difference in surgical teams' confidence that all sponges were accounted for, but they rated the counting process and team performance lower in operations randomized to the bar-code arm. By the end of the study, however, most providers found the system easy to use, felt confident in its ability to track sponges, and reported a positive effect on the counting process. CONCLUSIONS: Use of automated counting using bar-coded surgical sponges improved detection of miscounted and misplaced sponges and was well tolerated by surgical staff members.

An evaluation of a numbered surgical sponge product.

Surgical sponge counting is an essential patient safety measure in the OR in which all members of the surgical team must participate. The RN acting as circulator is responsible for accurately documenting sponge counts during the surgical procedure. A sequentially numbered sponge product was evaluated in a survey of OR personnel to determine ease of use and whether the product affected the flow of the surgical procedure. Survey respondents reported that the numbered sponge product was easy to use and did not lengthen or affect the flow of the surgical procedure. Respondents also indicated that the product may contribute to patient safety.

Retained foreign bodies after surgery.

BACKGROUND: Medical errors during surgery are not well studied. To define risk factors associated with this type of error, we performed a case control analysis. METHODS: We retrospectively reviewed medical records involving the ICD-9 code (998.4) for unintentional foreign object remaining in the body during surgery and incident reports gathered by the Department of Risk Management over a 10 year period from 1996 to 2005. Thirty cases were matched with at least four randomly selected controls (131 control patients) that underwent the same type of operation during the same time period. RESULTS: Thirty patients had retained foreign objects (52% sponges and 43% instruments). The abdominal cavity was most commonly involved (46%) followed by the thoracic cavity (23%) although no body cavity remained uninvolved. Eight patients required readmission (30%), 25 patients required reoperation (83%), and there was no mortality. When compared with controls, patients with retained foreign objects were more likely to have had a greater number of major surgical procedures at the same time (2.7 versus 1.8, P=0.004), to have multiple surgical teams (13% versus 2%, P=0.02), and more likely to have had an incorrect instrument/sponge count recorded (13% versus 2%, P=0.01). In multivariate analysis, factors associated with a significantly higher risk of retained foreign objects were the total number of major procedures performed [odds ratio 1.6; 95% confidence interval (CI), 1.1-2.3; P=0.008] and an incorrect count (odds ratio 16.2; 95% CI, 1.3-197.8; P=0.02). CONCLUSION: Retained foreign objects after surgery are associated with multiple major surgical procedures being performed at the same time and an incorrect instrument or sponge count. Identification of these risk factors using case-control analysis should influence operating room policy and reduce these types of errors.

The retained surgical sponge.

OBJECTIVE: A review was performed to investigate the frequency of occurrence and outcome of patients who have retained surgical sponges. METHODS: Closed case records from the files of the Medical Professional Mutual Insurance Company (ProMutual, Boston, MA) involving a claim of retained surgical sponges were reviewed for a 7-year period. RESULTS: Retained sponges occurred in 40 patients, comprising 48% of all closed claims for retained foreign bodies. A falsely correct sponge count after an abdominal procedure was documented in 76% of these claims. Ten percent of claims involved vaginal deliveries and minor non-body cavity procedures, for which no sponge count was performed. Total indemnity payments were $2,072,319, and defense costs were $572,079. In three cases, the surgeon was deemed responsible by the court despite the nursing staff's admitting liability and evidence presented that the surgeon complied completely with the standard of care. A wide range of indemnity payments was made despite a remarkable similarity of outcome in the patients studied. CONCLUSIONS: Despite the rarity of the reporting of a retained surgical sponge, this occurrence appears to be encountered more commonly than generally is appreciated. Operating teams should ensure that sponges be counted for all vaginal and any incisional procedures at risk for retaining a sponge. In addition, the surgeon should not unquestioningly accept correct count reports, but should develop the habit of performing a brief but thorough routine postprocedure wound/body cavity exploration before wound closure. The strikingly similar outcome for most patients would argue for a standardized indemnity payment being made without the need for adversarial legal procedures.

Swabs: the forgotten item of nursing care?

Swabs are items used every day in every operating room where invasive procedures are performed. How often do scrub nurses hand surgeons swabs, and how often is thought given to their shape, size and composition and their suitability for use inside our patients?