Standards for the Management of Swabs, Needles and Instruments in the Operating Theatre

The management o f swabs, needles and instruments in the operating theatre is a high-risk and problem-prone area fo r the operating theatre nurse. The purpose of this research is to formulate specific standards on the management o f swabs, needles and instruments in the operating theatre to ensure the safety o f the patient. An exploratory and descriptive research design was used and executed in 3 hospitals o f a private hospital group in Gauteng. A structured two phase process was followed, ie the development phase and the validation phase. This last phase was done by means o f deliberate debate. It is recommended that these standards be implemented, tested and validated on a national basis and a monitoring and evaluation system should be developed to ensure nursing compliance with these standards. UITTREKSEL Die bantering van deppers, naalde en instrumente in die operasiesaal is 'n hoe risiko, p ro b le e m g e rig te en hoe fre k w e n sie in tera ksie vir die operasiesaalverpleegkundige. Die doel met hierdie navorsing was om spesifieke standaarde vir die bantering van deppers, naalde en instrumente in die operasiesaal teformuleer ten einde die veiligheid van die pasient te verseker. 'n Verkennende and beskrywende standaardformuleringsontwerp is gebruik en binne die konteks van 'n privaathospitaalgroep (drie hospitale) in Gauteng uitgevoer. 'n Gestruktureerde twee-fase proses is uitgevoer, naamlik die ontwikkelings-en valideringsfases. Die laaste fase is deur middel van doelgerigte debatvoering uitgevoer. Dit word aanbeveel dat hierdie standaarde geimplementeer en uitgetoets word en op 'n nasionale basis gevalideer word. Verder word aanbeveel dat 'n monitering-en evalueringstelsel ontwikkel word om te bepaal in hoe 'n mate die verpleegkundiges aan hierdie standaarde voldoen. standards for the management of swabs, instruments and needles in the operating theatre within a specific private hospital group in Gauteng. Standard A standard is a written description of the expected or desired level of performance by the operating theatre nurse in the management of swabs, needles and instruments during a surgical intervention. Swabs Swabs are resources used for absorbing blood and fluids, p rotecting tissues, applying pressure or traction and dissecting tissue during a surgical intervention. A radio-opaque thread or m ark er is in c o rp o rated into commercially manufactured swabs.

An exploratory and descriptive research design was used and executed in 3 hospitals o f a private hospital group in Gauteng.A structured two phase process was followed, ie the development phase and the validation phase.This last phase was done by means o f deliberate debate.It is recommended that these standards be implemented, tested and validated on a national basis and a monitoring and evaluation system should be developed to ensure nursing compliance with these standards.UITTREKSEL Die bantering van deppers, naalde en instrumente in die operasiesaal is 'n hoe risiko, p ro b le e m g e rig te en hoe fre k w e n sie in tera ksie vir die operasiesaalverpleegkundige.Die doel met hierdie navorsing was om spesifieke standaarde vir die bantering van deppers, naalde en instrumente in die operasiesaal teformuleer ten einde die veiligheid van die pasient te verseker.'n Verkennende and beskrywende standaardformuleringsontwerp is gebruik en binne die konteks van 'n privaathospitaalgroep (drie hospitale) in Gauteng uitgevoer.'n Gestruktureerde twee-fase proses is uitgevoer, naamlik die ontwikkelings-en valideringsfases.Die laaste fase is deur middel van doelgerigte debatvoering uitgevoer.Dit word aanbeveel dat hierdie standaarde geimplementeer en uitgetoets word en op 'n nasionale basis gevalideer word.Verder word aanbeveel dat 'n monitering-en evalueringstelsel ontwikkel word om te bepaal in hoe 'n mate die verpleegkundiges aan hierdie standaarde voldoen.
standards for the management of swabs, instruments and needles in the operating theatre within a specific private hospital group in Gauteng.

T E R M IN O L O G Y Standard
A standard is a written description of the expected or desired level of performance by the operating theatre nurse in the management of swabs, needles and instruments during a surgical intervention.

Swabs
Swabs are resources used for absorbing blood and fluids, p rotecting tissues, applying pressure or traction and dissecting tissue during a surgical intervention.A radio-opaque thread or m ark er is in c o rp o rated into commercially manufactured swabs.
There are different types of swabs: gauze swabs 3" X 3" (7.6 x 7.6) cm which are used for small incisions; 4" x 4" (10 x 10) cm; raytec swabs or dissecting swabs and other swabs such as:-• large abdominal swabs; with attached tapes • small abdominal swabs; usually used in the bladder

INTRODUCTION
T h e o p e r a tin g th e a tr e n u rse is p ro fessionally-ethically responsible for establishing and m aintaining a safe and therapeutic environm ent during surgical interventions in the operating theatre.Certain policies and procedures should be in place to guide peri-operative nursing care.This article focuses on the m anagem ent o f sw abs, instrum ents and needles during surgical interventions in the operating theatre.The nurse and surgeon have a shared responsibility reg ard in g th e co n tro l o f these sw abs, instruments and needles.Such control in the operating theatre is a high risk, problem-prone and high volume charge and control has to be done in terms of strict regulations in this regard (Atkinson, 1992: 219;Makheta, and Smith 1986).
An operating theatre nurse manager attended World Congresses for Operating Theatre Nurses in 1991Nurses in , 1993Nurses in and 1995. .In 1991 the new m ethod o f sw ab control was first discussed and in 1993 was proposed for implementation in the South African hospital group in which this research is conducted.A theatre forum was established within the group made up of nursing service managers and operating theatre unit managers and through the endeavour of this dynamic group it was decided to implement this new method of swab control.
It soon became clear that standards on the m anagem ent of sw abs, instrum ents and needles for the operating theatre had to be compiled to ensure quality nursing care in this regard.The aim of this research is to formulate • peanut swabs or lahey swabs; small round gauze sponges used for blunt dissection or to absorb fluid in delicate procedures • large and small tonsil swabs which are cotton filled gauze with a cotton thread attached • neuro-patties made of compressed rayon or cotton, used moist on delicate structures such as the brain or spinal cord.

Needles and instrum ents
Needles and instrumenU are surgical aids used during a surgical intervention that can cause injury/complications if left in the patient after completion of the operation.

Nurse
A nurse in this context is a registered nurse with or without the qualification in operating Curationis, Vol. 19, No. 4, December 1996 theatre nursing science, who scrubs for surgical procedures in theatre.

New method
New method implies the counting of swabs in fives and doing away with swab racks in the operating theatre.

Old method
Old method refers to displaying swabs on a swab rack in the operating theatre.
Quality operating theatre nursing care refers to the substantial compliance with standards.
The focus in this study is on the standards for swabs, needle and instrument control in the operating theatre.The process of quality improvement involves the formulation of standards, monitoring and evaluation of the real performance against these standards and resp o n d in g by c o rre c tin g the nursing interactions which do not comply (Muller, 1996;228).Quality nursing necessitates the im p le m e n ta tio n o f a s p e c ific q u ality improvement programme to meet the needs of the nursing service.The formulation of specific standards is one of the first steps in the formal process of quality improvement and reflects the view of the nursing service on quality as w ell as accepted criteria for excellence (MuUer, 1996: 228).
Standards are classified according to structure, process and outcome.Structure includes all structured elements needed to implement a standard safely.Process reflects the scientific manner in which the nurse performs the action, whilst outcome reflects the intention in both the structure and process standards (A ffara & S tyles, 1991; M uller, 1996; 228-232).
The operating theatre nurse has got certain professional responsibilities regarding the m a n a g e m e n t o f sw a b s, n e e d le s and instruments in theatre.These responsibilities are discussed in accordance with the following principles given by Makheta and Smith (1986) and Atkinson (1992).Before the operation swabs may not be checked in the ante-rooms and one of the two people counting must be a registered nurse.The floor nurse, using an aseptic technique, opens the pack and gives the scrub nurse the swabs who then will remove the rubber band or paper tag, document, check and hand this to the check nurse.The scrub nurse holds the bundle up and checks that each swab has a secured tape and an opaque indicator.He/she checks each swab separately into a bowl while counting audibly and must not count one bundle on top of another.The floor nurse must count audibly with the scrub nurse.If extra swabs are required during the operation, the same procedure is to be followed with number added on, e.g. 5 + 5 + 5 Small dissecting swabs (laheys) are counted by holding one secure between fingers, counting that one and then pointing with the finger to the remaining four which are then placed in a gallipot.Ensure that each has an X-Ray opaque indicator.If any bundle of swabs opened is found to be incorrect, the swabs and document must be removed from the theatre to prevent later confusion.The incorrect swabs must be given to the unit manager who must follow up this occurrence.
No opened swabs are to be allowed in theatre if they are not counted.Swabs may not be used for cleaning theatres.

e) Use o f th e w hite b o a rd in th eatre
The white board in theatre must reflect at least the following information;-the patient's name, identification number, name of the doctor, procedure to be done, large abdominal swabs 5 + 5, raytec swabs 5 + 5 and lahey swabs 5 + 5.

f) C ountdow n d u rin g operation
The countdown during a surgical intervention must be carried out by the original two counters.Soiled swabs are discarded from the operative field into an open basin on top of the kick-about (roundabout).The scrub nurse must open up a raytec swab before discarding.
The floor nurse will wear gloves and use a Rampiey sponge holder to touch swabs.When he/she has 5 swabs, the anaesthetist's attention is drawn to assess bloodloss.When the countdown of swabs commences, the check nurse will touch each swab with the swab holder, audibly count with the scrub nurse and place it in a plastic bag, counting once again to five.Dissecting swabs and raytec swabs are put in separate plastic bags which do not leave the theatre.The number five (5) on the board is crossed out -this indicates that this bundle is out of circulation.This procedure is repeated for every five (5) swabs of the same type on the rack.Before closure of the cavity, an audible check is done of the remaining swabs on the rack and those in use on the trolley and operating field.A line is drawn through the remaining fives on the board, for example: • abdominal swabs i + i +5 +5 • raytec swabs $ +f) +5 • lahey,swabs ^+ 5.
g) Rules fo r co u n tin g sw abs The rules for counting swabs in theatre accord with the scrub nurse's specific preference, complying with at least the following; there should be a minimum of three (3) counts of swabs, although this is not a hard and fast rule.
If the scrub nurse is doing a long difficult procedure using many swabs she can do five to six counts.It is up to the individual but the first swab count must be done before the peritoneum is closed, the next count is done before fascia is closed and the last count before the skin is sutured.All instruments must be counted audibly by the scrub nurse.The floor nurse ticks these off on the operating check list.The major sets are checked first, for example laparotomy set, then extra instrum ents for example, the gastrectomy extras.Particular care must be taken when counting screws, such as bladder retractors and tips of suction nozzles before the peritoneum is closed.All instillments are counted by the original two checkers, the surgeon is notified and must acknowledge the information.The instrument count is recorded in a similar fashion to the swab count.

Needles
Needles, such as Mayo's are counted audibly by the scrub nurse and check nurse and the number should be recorded on the board.They are kept in a gallipot on the trolley when not in use.Before the peritoneum is closed, an audible count is done by the original two people and the number on the board crossed through.The foil packets from which the atraumatic sutures are taken, are kept until the end of the case so that the suture packets and needles correlate.
A final needle count is done before the peritoneum is closed and reported to the surgeon who must acknowledge this.It must be recorded on the patient's file that the needle count is correct.
P ro c ed u re to be followed w hen a sw ab, needle o r a n in stru m e n t is found in a previous o p era tin g site a) A knovm sw ab, needle o r in stn u n e n t to be rem oved The nursing unit manager o f the theatre complex must receive the removed item and place it in appropriate container such as a specimen bag for a swab or instrument and a specimen bottle for a needle.The patient's particulars must be reflected on the attached sticker.Swab, instrument and needle counts and completions of records are to be carried out as previously outlined.A statement must be written by the scrub nurse and floor nurse which are handed to the nurse manager.

b) R em oval o f foreign body
If a foreign body turns out to be a swab, needle or instrument left behind during a previous operation, the item is identified and the guide lines for the previous procedure are followed.P rocedure to be followed w hen the scrub nurse an d floor n u rse a re relieved during a procedure in w hich instrum ents, swabs an d needles are counted In exceptional circumstances where a case is expected to overlap nurses' shifts, the scrub nurse and check nurse may be relieved.The original scrub nurse and check nurse must complete a full count of all the instruments and swabs and record the inform ation.The relieving scrub and check nurses must do a full count of instruments and swabs while the original scrub nurse and floor nurse are in attendance.O nce the relieving team is satisfied that all instruments and swabs are accounted for, the original team may leave and complete relevant documents.At the end of the operation the relieving team will count in s tru m e n ts an d sw ab s as in n o rm al circum stances.The operating form and operation register must reflect full particulars and signatures o f both the original and relieving team.

RESEARCH DESIGN AND M ETHOD
An exploratory, descriptive design was fo llo w ed , u sin g a stru c tu re d stan d ard fo rm u la tio n m ethod co n sistin g o f the development and validation phases.During the development phase a literature study was performed to serve as the theoretical basis for the standards.Semi-structured purposeful debates were held to clarify certain issues pertaining to staff and whether the new method of swab, needle and instrum ent management was acceptable to the theatre nurses.The purpose of the debates also was to ensure ownership of the standards and to verify the content validity of the provisionally formulated standards.Because these standards are in use within the context of a specific private hospital group in Gauteng, national validation was not performed.

Sample
The research was conducted in a private hospital group involving three hospitals in G auteng.T he professional nursing and medical staff formed the target population.
The sample for the formulation and vahdation of the specific standards consisted of two groups.T he first group com prised the members of the com m ittee for standard formulation ie the deputy nursing service manager (professional nurse), operating room charge nurse and deputy, infection control nurse, clinical tutor and a practising general surgeon of the three hospitals.
Convenience sampling was used to include the professional scrub nurses on duty between the months of June and July 1995.A total of 52 scrub nurses took part in the debates of whom 33 were in possession of the operating theatre certificate.

Reliability
Measures implemented to ensure reliability of validation results lay in ensuring that a r e p re se n ta tiv e n u m b er o f p articip a n ts involved in operating theatre nursing in the three hospitals had equal opportunity to give input to the provisional standards.

Validity
A literature study on provisional specific standards was carried out to ensure theoretical or content validity of the standards.The standards were validated by Uie role-players (refer to sam pling m ethod) during the validation phase.The completed provisional standards were then presented to the regional O p e ra tin g T h e a tre N u rse s' Forum for determination of face-validity.The final stage o f v a lid a tio n lie s in th e te stin g an d im plem entation of the standards before national validation can be done.

Ethical considerations
Permission was granted by management and heads of departm ents to undertake this research.P articipants individually gave permission to participate in the process of standard formulation as well as the debates.

RESULTS
The following standards w ere form ulated and validated: 1. P hilosophy There is a written philosophy in the operating theatre reflecting at least the following; 1.1 the rights of the patient in terms of a safe environment; 1.2 the role of the nurse in the management and control o f sw abs, needles and in s tru m e n ts d u rin g su rg ic a l interventions;

Policies a n d p ro ced u res
There is a written policy and procedure in the operating theatre on at least the following; 2.1 the management of swabs, needles and instruments during surgical intervention; 2 .2lo s t sw a b , in s tru m e n t or n e e d le procedures.
2.3 safety measures when the scrub nurse is relieved during a procedure; 3. E q u ip m e n t an d stocks 3.1 Only swabs with an X-Ray opaque line running through them are used: • large abdominal swabs • small abdominal swabs • large dissecting swabs (raytec) • sm all dissecting sw abs (lahey or peanuts) • large tonsil swabs • small tonsil swabs • vascular swabs (Plugging) • neuropatties Curationis, Vol. 19, No. 4, December 1996 3.2 At least the following are available: • sterile latex gloves • roundabout or single basin stand • basin or bucket • Ramply sponge holder • white board on wall with white board marker • control document • plastic bags in which to place used swabs in • instruments needed for the specific surgical operation • suture material containing needles • protective eye wear (goggles); mask; aprons; sterile gowns.

P ack ing of sw abs
The nurse or health care worker ensures safe and accurate packing o f sw abs by the following: 4.1 use clean uncontaminated swabs; 4.2 check all swabs for any loose threads or pieces of lint adhering to swab; 4.3 ensure all swabs are X-Ray opaque; 4.4 check abdominal swabs have a 25cm tape and that it is secure; 4.5 count all swabs in bundles of five; 4.6 check that two people do a simultaneous check; 4.7 ensure swab control document contains at least the following: • date • type of swab • number of bundles • two legible signatures of checkers; 4.8 tape all bundles with tape or rubber band; 4.9 ensure that all swabs leaving the C.S.S.D. comply with the following: • autoclave tape has changed colour 6.12 when five swabs are discarded count them down onto plastic bag with the floor nurse; all used swabs are displayed in the basin; 6.13 ask anaesthetist to observe bloodloss; 6.14 instruct nurse to put an oblique line (/) through bundle of five checkeid, re-count into plastic bag putting another line through i.e.
• abdominal swabs 5 + 5 with oblique line • raytec 5 + 5 with oblique line • lahey 5 + 5 with obhque line; 6.15 do first count before peritoneum is closed; 6.16 do second count before fascia is closed; 6.17 do third count before skin is sutured; 6.18 count instruments with nurse before peritoneum is closed; 6.19 count suture needles with nurse and compare with suture packets and check off on white board; 6.20 correct counts are reported to surgeon who must acknowledge this audibly; 6.21 document all swabs, sutures used on costing sheet.
7. The procedure for a lost swab, needle or instrum ent complies w ith a t least the following: 7.1 The scrub nurse will: • inform surgeon of missing item; • inform the theatre charge nurse; • search operation field thoroughly; • have relevant X-Rays taken of patient according to doctor's prescription; • if swab, needle or instrument is not found, all particulars of incident are recorded in patient's file and operating room register; • write a statem ent in term s o f the hospital policy; 7.2 If the swab, needle or instrument is found in a previous operating site the scrub nurse will: • give the swab/needle/instrument to o perating theatre nursing service manager; • attach patient's particulars on label; • carryout counts of swabs, needles and instruments and complete records as previously outlined; • write statement as outlined before and give to the appropriate people.
8. Safety is ensured when the scrub nurse and circulating nurse a re relieved during a procedure d uring which instrum ents a re counted.
8.1 The scrub nurse will: • ask the surgeon if she may be relieved; • com plete a full co u n t o f all the instruments, swabs and needles with relieving scrub nurse and circulating nurse; • leave when relieving team are satisfied that all instruments, needles and swabs are accounted for; • at end of operation, relieving team will count swabs, needles and instruments as in normal circumstances; • the patient's file and theatre register m ust reflect full p articu lars and signatures of both the reheving and original team.

LIM ITATIONS
Time was too limited to do an in-depth study due as the researcher was a student on the operating theatre nursing science diploma course.Being a student meant the researcher was not in a position of authority to implement change and therefore research was limited to three hospitals within the group.Time also did not allow the researcher to validate the standards in the quantification phase by determination of the statistical content validity of each standard.

RECOM M ENDATIONS
The following recommendations are made: • The implementation and testing of these standards with flexibility allowed for specific needs of the individual, operation performed and surgeon's preference.
• Formation of a Standard Formulation Committee in every Operating Theatre Service.
• Continuous revision of these standards.
• National validation of the standards.
• The development of a monitoring and e v a lu a tio n sy stem to e v a lu a te the compliance with these standards, as part of th e O p e ra tin g T h e a tre q u a lity improvement programme.

CONCLUDING REMARKS
The formulation of standards is the first step in the quality improvement programme of the operating theatre.It is in ^rta n t to identify those nursing or clinical in te r^o n s that may have high risks, such as the management of control of swabs, needles and instruments.The process of quality improvement has to be followed through by means of evaluation to see if nurses are indeed complying with the standards.
a) P rio r to sterilizatio n Use clean, uncontaminated, new swabs.Check all swabs and shake well before folding and packing; no wool, threads or pieces of lint should adhere to the swab.Swabs must be X-Ray opaque and abdominal swabs must have 25cm tapes.The first and second checker must do a simultaneous check.Each bundle must contain five swabs, abdominal, raytec and tonsil swabs are kept together with tape or a rubber band.Point balls are sewn together and each bundle must contain a signed document.b)T he sw ab control docum entThe swab control document must have a date, the types of swabs, the number of bundles and two signatures with designations.c) P re-p ack sterile sw abs Pre-pack sterile swabs are large abdominal swabs with a paper tag around series, as a control document.The information on the peel-packet serves as a control document for the raytec swabs.Unsoiled leftover swabs must be returned to Central Sterilising Department in a clean container for recycling.d) Before th e op eratio n h) L ahey sw abs Lahey swabs are not removed from the trolley, but checked into a gallipot/receiver.i) In te ra c tio n w ith surg eo n It is important that the correct swab count is re p o rte d to th e su rg e o n w ho m u st acknowledge this.T he p ro c e d u re fo r a lost sw ab, in stru m e n t o r needle If the count is incorrect, inform the surgeon and do a recount.The missing item must be looked for in the surgical cavity as well as in the theatre.In the event of the missing article not being found, the scrub nurse must inform the registered nurse in charge.X-Rays, must be taken and if the article is seen, the surgeon must re-open the cavity.If no article shows on X-Ray the surgeon records on the patient's file stating the missing article does not show on X-Ray.The scrub nurse will endorse the facts about missing items in red on the operative form and in the operation register.The scrub nurse and check nurse must write a statement and hand it to the nurse in charge.The original statements are photo copied to distribute to the follow ing significant supervisors; C hief Nursing Service Manager, Clinical Manager, Theatre Nursing Service Manager, Scrub Nurse and Floor Nurse.Curationis, Vol. 19, No. 4, December 1996 a) C on trol o f in stru m e n ts a n d needles