Labor and Delivery: Leave No Sponge Behind - KIPSQ

1 Produced by ECRI Institute PSOPSO NAVIGATORTML abor and delivery : Leave No Sponge Behind XNOVEMBER 2013 Volume 3, Number 4 Unintentional retention of surgical items after the completion of a medi-cal procedure was the number one type of sentinel event reviewed by the Joint Commission between 2010 and 2012 (Joint Commission), proving to be a difficult problem to surgical items (RSIs) are also never events, as defined by the National Quality Forum (NQF), and have been on the list of events that the Centers for Medicare and Medicaid Services has refused to pay for since 2008 (CMS). A study of almost 10,000 paid malpractice claims for surgical never events reported to the National Practitioner Data Bank between September 1, 1990, and September 30, 2010, found that almost half were for RSIs, with a median payment of $33,953, but with the highest payment of nearly $4 million (Mehtsun et al.)

2 While RSIs are frequently associated with surgery, this problem ex-tends beyond the operating room. Vaginal deliveries, for example, have a high potential for retained sponges (Garry et al.). The incidence of RSIs after vaginal delivery is unknown, though one facility estimated it to be 1 in 5,000 (Lutgendorf et al.). In New Jersey, 36% of 111 RSI events reported between 2005 and 2009 were obstetrics-related (NJ DHSS). Similarly, one-quarter of 161 RSIs reported in Minnesota over a five-year period also occurred with deliveries, and nearly all were sponges used during vaginal births (MDH). Retained sponges can cause serious issues such as infection, pain, and secondary postpartum hemorrhage (Lamont et al.).Counting sponges and instruments is a highly recommended RSI prevention practice (Goldberg and Feldman), as it has been shown that missing counts are associated with RSIs (Gawande et al.)

3 Counts have also been recommended for vaginal deliveries (ICSI), but researchers state that this is a fairly uncommon occurrence in the Labor and delivery department (Chagolla et al.; Garry et al.; Lamont et al.; MDH). ECRI Institute PSO received a total of 13 reports of Sponge counting issues during vaginal deliveries submitted in 2012. No Sponge counting issues occurring during vaginal deliveries were reported by the Kentucky Institute for Patient Safety and Quality PSO; however, mem-bers should be aware of this WE ARE SEEINGL ogically, incorrect counts are associated with an increased risk of RSI, with one study estimating a 20-fold increase (Stawicki et al.). One study noted that Sponge counts after episiotomies and tear closures were often not conducted (Gawande et al.). The following case illustrates the prob-lem of count issues after vaginal deliveries:An episiotomy was performed during delivery and was subsequently repaired; however, the Sponge count was noted to be incorrect.

4 The Sponge was found and removed at the mother s four-week postpartum of Sponge use is necessary to help avoid retention. For example, procedures should specify a common location for used sponges to be counted before disposal (ICSI). Consider the following example:The nurse was unable to verify the Sponge count after vaginal delivery , because numerous sponges were used and discarded in the under-buttock , sponges are the most common RSIs reported (Gawande et al.) due to frequent use and the fact that they can be difficult to visualize because they are often small and can blend in after being soaked with blood (Agrawal). Counts for various items, particularly sponges , used during vaginal deliveries should be instituted consistently in policies and procedures throughout the organization. For more detailed information about count policies and procedures, see the November 2013 national PSO radiopaque sponges should be used for vaginal deliveries so that in the event of retention, the Sponge can be found by x-ray (ICSI).

5 Other technologies recommended to prevent RSI retention include bar coding, which can only be used to count sponges , and radio-frequency identifi-cation, which can be used to both count sponges and identify retention (Goldberg and Feldman).Some facilities have recommended the use of larger sponges , reason-ing that they will be less likely to be overlooked during removal ( , 4 8 inch radiopaque sponges , 4 18 inch or 18 18 inch laparotomy pads) (Chagolla et al.; Lamont et al.; Lutgendorf et al.). Additionally, sponges should not be cut during the procedure (ICSI). Facilities may wish to review Sponge use in the Labor and delivery area to understand the quantity of sponges typically needed. One facility found that most vaginal deliveries used five sponges , so their Labor and delivery carts were altered accordingly.

6 Researchers at this organization commented that more sponges are usually needed for relatively rare 5200 Butler Pike, Plymouth Meeting, PA 19462-1298, USA Tel +1 (610) 825-6000 Fax +1 (610) 834-1275 Web E-mail PSO NAVIGATOR2 NOVEMBER 2013 2013 ECRI Institute PSOevents, such as postpartum hemorrhage or vaginal lacerations. (Lutgendorf et al.) Keeping track of sponges is fundamental to ensuring that none are left Behind . sponges need to be separated during counts, both before and after use, as they can easily become stuck together. Standardizing the location of used sponges , whether in a particular area or receptacle, is another way to ensure that they do not get lost; the location should be easy to access, and sponges should not be placed in the waste bucket until a final count has been completed.

7 Employing pocketed bags to hold used sponges is another frequently recom-mended prevention tactic. Involve Labor and delivery staff when deciding which bag to use. (Goldberg and Feldman; ICSI)Sometimes the vaginal area is intentionally packed with sponges or gauze to be kept in place past the immediate recovery period (one to two hours postdelivery) for issues such as postpartum hemorrhage; this packing is often not included in the traditional Sponge count. Diligence and communication for the timely removal of packing is necessary to prevent it from becoming an RSI. (ICSI)REFERENCESA grawal A. Counting matters: lessons from the root cause analysis of a retained surgical item. Jt Comm J Qual Patient Saf 2012 Dec;38(12):566-74. PubMed: for Medicare and Medicaid Services (CMS). Hospital-acquired conditions (HAC) in acute inpatient prospective payment system (IPPS) hospitals [online].

8 2012 Oct [cited 2013 Jul 16]. BA, Gibbs VC, Keats JP, et al. A system-wide initiative to prevent retained vaginal sponges . MCN Am J Matern Child Nurs 2011 Sep-Oct;36(5):312-7. PubMed: DJ, Asanjarani S, Geiss DM. Policy for prevention of a retained Sponge after vaginal delivery . Case Rep Med 2012;2012:317856. Also available at AA, Studdert DM, Orav EJ, et al. Risk factors for retained instruments and sponges after surgery. N Engl J Med 2003 Jan 16;348(3):229-35. Also available at JL, Feldman DL. Implementing AORN recommended practices for prevention of retained surgical items. AORN J 2012 Feb;95(2):205-16. PubMed: for Clinical Systems Improvement (ICSI). Prevention of unintentionally retained foreign objects during vaginal deliveries [online]. 2012 Jan [cited 2013 Jul 17]. Commission. Sentinel event data: general information, 1995-2012 [online].

9 [cited 2013 Jul 16]. T, Dougall A, Johnson S, et al. Reducing the risk of retained swabs after vaginal birth: summary of a safety report from the National Patient Safety Agency. BMJ 2010 Jul 19;341:c3679. PubMed: MA, Schindler LL, Hill JB, et al. Implementation of a protocol to reduce occurrence of retained sponges after vaginal delivery . Mil Med 2011 Jun;176(6):702-4. PubMed: WT, Ibrahim AM, Diener-West M, et al. Surgical never events in the United States. Surgery 2013 Apr;153(4):465-72. PubMed: Department of Health (MDH). Retained foreign objects [online]. Spotlight Patient Saf 2009 Apr [cited 2013 Jul 22]. Quality Forum (NQF). List of SREs [online]. [cited 2013 Jul 16]. Jersey Department of Health and Senior Services (NJ DHSS). Overview: retained foreign objects during vaginal deliveries and caesarian sections [online].

10 Patient Saf Initiat Newsl 2009 Sep [cited 2013 Jul 15]. SP, Moffatt-Bruce SD, Ahmed HM, et al. Retained surgical items: a problem yet to be solved. J Am Coll Surg 2013 Jan;216(1):15-22. PubMed: INSTITUTE PSOR onni P. Solomon, , Executive Vice President and General Counsel; Karen P. Zimmer, , , FAAP, Editor, PSO Navigator; Medical Director; Amy Goldberg-Alberts, , FASHRM, CPHRM, Program Director; Barbara G. Rebold, , , , CPHQ, Director, PSO OperationsPaul A. Anderson, Director, Risk Management Publica-tions; Theresa V. Arnold, , Manager, Clinical Analysis; Michael Baccam, , Copyeditor; Sharon Bradley, , CIC, Infection Preventionist; Maura N. Crossen-Luba, , CPH, Healthcare Writer; Andrea Fenton, Web Editor; Robert C. Giannini, NHA, Patient Safety Analyst and Consultant; Ambily Gracebaby, , Clinical Informatics Analyst and Consultant; Kelly C.