Special Edition on Operating Room Imperatives Special Edition- Operating Room Imperatives | Page 6

perspectives
By Karen deKay, MSN RN CNOR CIC
It Takes a Team to Protect Patients from RSI Infections
R
etained surgical items (RSI) remain a serious concern in
perioperative care. Each year, RSIs are among the top
sentinel events reported to The Joint Commission. Last year,
ECRI Institute listed RSI as No. 3 in its list of top 10 health
technology hazards. It is estimated that there is one RSI for
every 1,000 to 1,500 abdominal procedures and one RSI in
every 8,000 inpatient procedures.
Perioperative nurses are reminded of the importance of
following counting procedures and the impact of an RSI when
a miscount occurs and fuels an in-service education session or
performance improvement project. However, it’s important to
remember that there is more to RSI than leaving a device or
sponge behind—it is also the infection that can develop as a
patient’s body responds to the foreign object.
Cotton gauze sponges are by far the most common cause of
RSI, accounting for 48 percent to 69 percent of items retained
after surgery. The fibrous material in these sponges also leads to
more serious tissue reactions. If not detected and immediately
removed, a retained sponge can cause poor wound healing,
cysts or fistulas, and even death.
There are two primary types of foreign body reactions
that develop in response to a retained sponge: exudative and
aseptic fibrous. An exudative inflammatory reaction forms an
abscess with an accumulation of pus around the retained item
that creates pressure and is very symptomatic. With exudative
inflammatory response to a retained sponge, the body may try
to expel the infection through a path of least resistance—this
is called transmigration. Depending on the proximity to vital
organs, the body could move the infected sponge through
an external opening such as the rectum or through a forced
opening into the bowel or bladder, often creating a fistula.
Unfortunately, the body is most often unable to expel the
retained sponge.
Exudative reactions typically occur soon after the initial
procedure and often require a second surgery. However, there
also are cases of patients presenting with symptoms of exudative
inflammatory response for years. In one case, a 54-year-old
who had abdominal surgery 17 years prior presented with
weakness, diarrhea and a 40-pound weight loss leading to
death. Upon autopsy a matted surgical sponge was found
in the ileal lumen along with multiple intestinal fistulas. In
another case, a 64-year-old experienced a retained sponge
during vaginal mesh surgery. She developed an abscess that
caused poor wound healing.
An aseptic fibrous reaction can also be the result of a retained
sponge, causing adhesion, encapsulation, or granuloma. While
these reactions have less severe and delayed symptoms, they
often lead to a second surgery with the removed sponge culture
being negative, yet still causing pain and suffering for the patient.
Sharing stories about patients with RSI infection helps
surgical team members and infection preventionists consider
the scope of patient harm when used surgical items are not
accounted for correctly.
Many perioperative nurses have experienced that sinking
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feeling at the end of a procedure when the count is not correct.
While we know that even one RSI is too many, we also face
many challenges during a case with productivity pressures
and interruptions that can disrupt the count. Technologies can
help to reduce the risk for RSI; however, prevention through
standardized accounting practices is the safest way to protect
patients from the harmful and even deadly infections caused
by a RSI—and it takes a team.
RSI prevention requires interdisciplinary collaboration with
each team member performing a specific role that is outlined in
AORN’s Guideline for Prevention of Retained Surgical Items. The
recommendation for two people, one being the RN circulator,
to conduct the count is one such recommendation. Here are
other best practices AORN recommends:
• Any soft goods used in a procedure should be radiopaque
so they can be visualized on X-ray, including towels placed in
the wound, as well as gauze.
• The paper band around bundled sponges should be
removed and discarded prior to the count so each sponge can
be counted individually.
• Sponges should not be cut or altered, as this increases the
risk that a portion of sponge may be left behind.
• The surgeon should perform a methodical look and touch
before closing a surgical cavity because sponges that absorb
blood can be mistaken for tissue.
• Accounting of all surgical goods should be out loud and
tracked visually, such as on a white board.
• Counting should follow the same sequence/order each
time it is performed. The count should start at the incision,
move to the mayo stand, then to the patient and drape before
counting at the back table and off the field.
• A pocketed sponge bag or similar system should be used
to visually separate and accurately account each sponge.
• Linen and waste containers should remain in the procedure
room until the count is complete.
• When personnel switch for a short duration such as
breaks or lunch during a case, count what items are in use on
the field. When there is permanent relief, perform a complete
count to account for all items that are there.
A methodical, standardized practice for sponge counting
is very important, because the moment you deviate from a
best practice an error is more likely to occur. Standardized
accounting practices for all surgical items, such as those
recommended in the AORN Guideline for Prevention of
Retained Surgical Items should happen in every procedural
area, including labor and delivery. 
Karen deKay, MSN, RN, CNOR, CIC, is a perioperative
practice specialist for AORN. deKay has been a registered nurse
for more than 30 years, working primarily in the perioperative
area, education, and infection control. She was the lead author
for revision of the AORN Guideline for Environmental Cleaning
and serves as the AORN representative for the CDC’s Healthcare
Infection Control Practices Advisory Committee (HICPAC).
Operating Room Imperatives 2020 • www.healthcarehygienemagazine.com