IFPN Guideline
for
Surgical Counts - Sponges, Sharps, and Instruments

Purpose:

To promote safe, quality perioperative patient care internationally. This recommended practice is intended to standardize sponge, sharp and instrument counts and includes basic principles as guidelines adaptable in surgical settings internationally.

General Criteria:

Each facility should have a policy and procedure for surgical counts that specify: when counts should be performed, by whom, items to be counted, documentation of counts, including incorrect counts, and any additions or deletions of counts for specified procedures (e.g. cystoscopy, ophthalmology) according to defined risk.

A full count of sponges, sharps, miscellaneous items (any small item such as hernia tapes, ligaclip bars), and instruments shall be performed when peritoneal, retro peritoneal, pelvic and thoracic cavities are entered. Counts should be done for any procedure in which sponges, sharps, miscellaneous items, and instruments could be retained in the surgical patient.

The registered nurse is accountable for counts during the surgical procedure.

Count procedure should be performed by two persons (scrub and circulating nurse), one of whom shall be a registered nurse.

For procedures where there is no scrub nurse, the count should be done with the surgeon and circulating nurse.

If a count is interrupted, the count shall be recommenced.

The same two persons should perform all counts. When there is a change in personnel, a complete count shall be performed.

Items shall be viewed and counted audibly and concurrently.

All items should be completely separated during a count.

Counts should be performed in the same sequence: sponges, sharps, miscellaneous items, and instruments at the surgical site and immediate area, the mayo stand, the back table and discarded items.

Items added during the procedure shall be counted immediately and recorded on the count sheet.

Preprinted count sheets for sponges, sharps, and instruments should be used and included in the patient's record.

The scrub nurse should be aware of the location of all counted items throughout the procedure.

Items shall not be removed from the operating room until the final count is completed and correct.

Results of counts shall be announced audibly to the surgeon, and verbal acknowledgment received from the surgeon.

In the event an incision is reopened after the final count, closure count shall be taken again.

In an extreme emergency situation, when a count cannot be performed, an X-ray should be taken prior to patient leaving the operating room if patien's status permits, or as soon as possible.

Sponge Count (gauze, laparotomy sponges, cottonoids, peanuts, dissectors)

An initial sponge count should be done on all procedures.

Sponges should be counted:

  • Before the start of the procedure
  • Before closure of a cavity within a cavity
  • Before wound closure (at first layer of closure)
  • At skin closure

Only X-ray detectable sponges should be used.

Sponges should be standardized in established number of multiples such as 5, and counted in multiples of five. (Moved from page 3)

Sponges should be completely separated (one by one) when counting.

Packages containing incorrect number of sponges should be bagged, marked,and isolated from the rest of sponges.

Sponges should be attached to an instrument when used within a cavity.

Sponges and attached tapes shoul not be cut.

X-ray detectable sponges shall not be used as dressings, and should not be used as packing to remain in patient. If used and left in patient as packing intentionally, the number and type shall be documented on the count sheet and on the patient's record.

Dressings should only be added at skin closure.

Soiled sponges should be discarded off the sterile field, then handled using protective equipment (gloves, forceps), and after counting contained in plastic bags in the established number of multiples.

Soiled dissecting sponges should be kept in their original container or small basin until counted.

Sharp Count (needles - suture and hypodermic, blades, safety pins)

An initial sharp count should be done on all procedures.

Sharps should be counted:

  • Before the start of the procedure
  • Before closure of a cavity within a cavity
  • Before wound closure (at first layer of closure)
  • At skin closure

Suture needles should be counted according to the marked number on the package. Multiple suture needles in a package should be verified with the circulator when package opened.

Needles should be contained in a needle counter/container, loaded on a needle driver, or sealed packages.

Needles should be handed to the surgeon on exchange basis.

Hands free / no touch technique is recommended for passing scalpels.

Used needles, blades should be contained in a disposable puncture resistant container.

All parts should be accounted for if a needle or blade breaks.

If a needle puncture occurs, the needle, glove(s) should be removed from the sterile field. Policy for puncture wounds should be followed.

Instrument Count

Instruments should be counted:

  • Before the start of the procedure
  • Before wound closure (at first layer of closure)

Instrument sets should be standardized (same type and same number of instruments in each set).

Instruments with component parts should be counted singly, not as a whole unit, with all component parts listed (e.g. one balfour, one blade, three screws).

Instruments should be inspected for completeness.

If an instrument falls to the floor or is passed off the sterile field, it should be kept aside until the final count.

All parts of a broken or disassembled instrument should be accounted for in its entirety.

All instruments should be removed from the operating room at the end of the procedure.

Documentation

Counts should be recorded on a count sheet.

Names and titles of personnel performing the counts should be recorded on the count sheet and the patient's record.

Results of surgical counts shall be recorded as correct or incorrect.

Instruments and sponges specifically left with the patient should be documented on the count sheet and the patient's record.

Any action taken in the event of a count discrepancy should be documented on the patient's record.

Reasons for not conducting a count should be documented on the patient's record.

Count Discrepancies

When the count is incorrect:

  • Perform a recount
  • Notify the surgeon and supervisor
  • Conduct a search (floor, garbage, linen)
  • Request X-ray to be taken
  • Document results on the count sheet, and patient's record

When the count is not performed:

  • Notify the surgeon and supervisor
  • Request an X-ray to be taken at completion of procedure
  • Document the count as not done, the reason(s) why, and results of the X-ray, if taken, on the appropriate records according to facility's policy/procedure.

References:

  • ACORN. (1998). Counting of Accountable Items. Standards, Guidelines and Policy Statements. (reference: A6, pp. 1-5)

  • AORN. (2000). Recommended Practices for Sponge, Sharp, and Instrument Counts. Standards, Recommended Practices & Guideline. (pp. 213-219) Denver: AORN, Inc.

  • NATN. (1998). The Count (Swabs, Instruments and Needles). Principles of Safe Practice in the Perioperative Environment, Clinical Practice - Section 3 (pp. 79-82).

  • ORNAC. (1998). Surgical Counts. Recommended Standards for Perioperative Nursing Practice. (4th edition. pp. 138-145).

  • SATS. (1998). Swab, Instrument and Needle Counta. Guidelines for Basic Theatre Procedures. (pp. 43-46).