Counting Instruments
Surgical instruments are tools that have specific functions including cutting, occluding, grasping, exposing, suturing, and holding. The type of surgical procedure, along with the surgeon’s preference will dictate the type of instruments to be used for the surgery.
Instruments must be included in the surgical count for all procedures that enter a major body cavity. Healthcare institutions have policies and procedures outlining when this practice can be deviated from.
As mentioned earlier, minimally invasive procedures entering a major body cavity also require an instrument count for the initial count. This includes endoscopic and non-endoscopic procedures. There is always a chance that a minimally invasive procedure might convert to open surgery.
Counting Instruments on a Stringer
- Instruments that are ringed are strung along an instrument stringer that is assembled in the processing area in a standardized set.
- These instruments need to be removed from the tray/container and exposed so that both the scrub and circulating nurses can visually verify them during the audible count.
- Some institutions use cluster counting in which groups are counted together. For example, scissors — cluster counting would be for 6 scissors, instead of two mayo, two Metzenbaum, and two suture scissors.
- Cluster counting can make an instrument count more efficient. However, if there is not a cluster, an itemized individual count will occur for this instrument.
Counting Other Instruments
- Other instruments in the tray must also be removed and exposed while counting.
- Cluster counting can also apply to non-stringed instruments such as pickups and retractors.
- Instruments should not be put on the mayo stand until they have been counted.
- Instruments that have separate parts, must be accounted for during assembly and disassembly; for example, screws or ratchets. This reduces the risk of leaving a piece behind if it becomes loose and falls into the wound or sterile field.
- When counting, the scrub nurse should also inspect and ensure that all parts of the instrument are present and functioning.
What Happens if an Instrument Breaks or Falls During the Procedure?
- If an instrument breaks, it needs to be removed from the sterile field, and all the pieces must be accounted for. If a broken instrument is returned from the surgical site, the scrub nurse needs to communicate this immediately to the surgical team.
- A replacement instrument can be added and counted on the count sheet by the circulating nurse.
- These instruments in their entirety need to remain in the room to be reconciled for a correct count.
- Instruments that fall off the sterile field during the procedure will be recovered by the circulating nurse and retained for the closing count.
Entering a Cavity with Large number of Instruments
- In lieu of completing an instrument count when a procedure requires many instruments, an X-ray may be used for the final instrument count before incision closure.
- Using an X-ray can be done only if it is outlined in the institution’s policy and procedures.
(ORNAC, 2021, Phillips, 2020, AORN, 2022)