Counting small needles

AORN Journal,  June, 2008  by Sharon Giarrizzo-Wilson

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QUESTION: We are having a heated debate about counting needles on 5-0 or smatter suture. The surgeons say 5-0 and smatter suture needles cannot be detected on x-ray and become encapsulated by the body, so they pose no harm to the patient. Our facility risk manager wants us to count art needles regardless of size. What does AORN recommend on this subject?

ANSWER: Regardless of the needle size, the potential for injury exists. The Occupational Health and Safety Administration (OSHA) requires that all sharps, regardless of type or size, be appropriately discarded in impervious biohazard containers to prevent employee exposure to bloodborne pathogens. (1) Without an accurate baseline count of sharps, it would be impossible to determine whether all sharps have been properly contained. Furthermore, negating the sharps count may lead to an incorrect count on a subsequent procedure if a needle from a previous procedure is inadvertently left in the room.

A needle or sharps count should be performed on all procedures as a proactive injury-prevention strategy. (2) AORN believes there is a collaborative obligation between the perioperative nurse and scrubbed team members to accurately account for sharps in an effort to protect the patient from a retained foreign body and team members from injury. "The recommended practices for sponge, sharp, and instrument counts" provides direction re gaming when to perform the sharps count, including

* to establish a baseline,

* before closure of a cavity within a cavity,

* before wound closure,

* during skin closure or final procedure closure, and

* whenever permanent relief of a team member occurs. (3)

Surgical needles are the most frequently miscounted items during the count reconciliation process. (4) When an incorrect count occurs, a collaborative effort should be made to locate the missing needle. (3,5) If the needle cannot be located, an intraoperative x-ray should be taken and read by a radiologist before wound closure. An exception may be made during ophthalmologic procedures where the internal eye and conjunctiva can be examined through direct microscopic visualization. (6,7)

Discussions about the effectiveness of conventional radiographic techniques to detect small needles are fueled by the limited availability of scientific data. (4) Recent clinical inquiries completed by perioperative nurses highlight the inconsistencies in radiological detection of 17-mm and smaller needles (ie, [less than or equal to] 5-0 suture). (6,8) These recent investigations replicated needle imaging by exposing synthetic radiographic training torsos with simulated radiographic density similar to the weight of human subjects. Although these published results contribute to the body of clinical knowledge on this topic, application to clinical practice may be influenced by inadequate radiographic exposure, patient weight, location of the needle within the cavity, and needle properties (eg, density). (4,8)

The ultimate decision to count or not to count suture needles that are 5-0 or smaller requires thoughtful deliberation of the effect on patient and worker safety. The hazards associated with retained small needles on patient outcomes have not been fully investigated. (4) Furthermore, AORN clearly states that needles of all sizes should be counted to promote a safe patient care and work environment, and regulatory guidelines require safe handling of sharps. Manual counting provides an advantage over reliance on radiographic imaging, especially when smaller sized needles may not be detected.

REFERENCES

(1.) Occupational Health and Safety Administration. Occupational exposure to bloodborne pathogens; needlestick and other injuries; final rule. Fed Regist. 2001;66(12):5318-5325.

(2.) Murphy EK. Operating room record, count cause concern [OR Nursing Law]. AORN J. 1990; 53(2):491-494.

(3.) Recommended practices for sponge, sharp, and instrument counts. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2008:293-302.

(4.) Egorova NN, Moskowitz A, Gelijns A, et al. Managing the prevention of retained surgical instruments: what is the value of counting? Ann Surg. 2008;247(1):13-18.

(5.) American College of Surgeons. Statement on the prevention of retained foreign bodies after surgery. Bulletin of the American College of Surgeons. 2005;90 (10). http://www.facs.org/fellows_info/statements /st-51.html. Accessed March 25, 2008.

(6.) Barrow CJ. Use of x-ray in the presence of an incorrect needle count. AORN J. 2001;74(1):80-81.

(7.) Highfield L. Ophthalmology needles: to count or not to count. Insight. 1995;20(3):16-17.

(8.) Macilquham MD, Riley RG, Grossberg P. Identifying lost surgical needles using radiographic techniques. AORN J. 2003;78(1):73-78.

SHARON GIARRIZZO-WILSON

RN, MS, CNOR

PERIOPERATIVE NURSING SPECIALIST

AORN CENTER FOR NURSING PRACTICE

COPYRIGHT 2008 Association of Operating Room Nurses, Inc.
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