In 2018 a serious incident occurred during surgery at the Nuffield Orthopaedic Centre (NOC). Following a hip replacement operation, an acetabular trial (an instrument for checking fit before the final components are inserted) was identified as missing by the theatre sterile services unit (TSSU). An X-ray revealed that the instrument had been left inside the patient. The resulting investigation introduced improved accountability for instruments through a temporary instrument count procedure (TICP), with nursing staff being required to count each item on the surgical trays individually, both before the start of the surgical procedure and at the conclusion of the operation, but ahead of wound closure. Given that some orthopaedic procedures use up to 25 trays with potentially more than 70 items per tray, the requirements of the TICP, introduced with immediate compliance, posed a significant challenge for the surgical teams.
With individual instrument counts taking up to 30 minutes to complete, the disadvantages introduced by the TICP included:
- Increased patient time under anaesthesia
- Slower patient turnaround resulting in a reduced number of operations
- Decreased scrub team coordination due to nurse preoccupation with the count.
My response: Enhanced instrument count procedure
In response to the challenges posed by the TICP, I developed an enhanced instrument count procedure (EICP), which has resulted in an easier, quicker, safer approach to instrument counting. The EICP has augmented the instrument checklists supplied by the TSSU by introducing instrument folders. These folders contain photographs of trays against which the scrub teams identify instruments, accounting for them quickly and accurately. I have also designed an optional summary sheet for complex cases, which further enhances the ease and accuracy of recording the instrument counts.
In order to achieve a practical, value-adding EICP, I worked with a variety of stakeholders and earned senior management support by presenting the benefits of a systematic approach to addressing the TICP. This commenced, following implementation of the TICP, with my raising concerns about its impact on safety and efficiency, persuading senior management to permit me to address the issue.
I worked in partnership with supplier representatives, surgeons and other scrub team leaders to determine what was possible in terms of tray rationalisation. In so doing, we reduced tray contents by removing unrequired instruments from trays in line with specific surgical needs. Once optimum tray contents were determined, I worked with the TSSU to ensure the implementation of the instrument reductions and improved tray layouts.
With the trays revised, I turned my attention to designing and creating illustrated instrument folders with which I included enhanced checklists to accurately reflect their contents. These checklists bring value by including the itemisation of instrument parts (for instance, whereas the TSSU checklist represents the Linvatec Tendon Harvester as a single item, my enhanced checklist specifies its four individual parts for ease of counting). I co-opted a colleague, using her photographic skills to produce accurate visual representations for the instrument folders. I used the photographs of the instrument trays with the checklists to produce laminated instrument folders for each of the NOC’s hip and knee procedures, cross-referencing one against the other (and subsequently expanding the range of folders to include shoulder procedures).
To produce the instrument folders, I required additional stationery and made the case for procurement of photographic paper, laminating sheets and folders. I had to overcome routine problems of printer malfunction and stationery shortage and had to fit the EICP work around my usual scrub activities, duty manager responsibilities and other administrative tasks. The completed instrument folders also provide basic information advising staff on which trays they require for each procedure.
In order to achieve practical adoption of my EICP, I needed to persuade senior management and colleagues of the need to change the way we accounted for instruments. I needed to convince senior management of the impossibility of counting several hundred items from a checklist that did not itemise components in line with the reality in the trays, risking surgical delays and increasing patient time under anaesthesia. Once example instrument folders were completed, I presented them to the safety standards for invasive procedures (SSIP) group, being commended for ‘outstanding work’ by the group’s chair. I also gave regular updates to the hip and knee clinical improvement (HKCI) group, being commended by several consultant surgeons for my efforts.
With the support of the SSIP and HKCI groups, I expanded production of the instrument folders and introduced their use into theatre practice.
Benefits
The EICP offers benefits for both patients and for staff colleagues.
Patient benefits are:
- Shorter time under anaesthesia
- Quicker patient turnaround
- Decrease in likelihood of serious incidents
- Improved efficiency resulting in increased number of operations, with a knock-on effect for waiting lists.
Colleague benefits have been:
- Simplified, faster count procedure using visual aids
- Reduced pressure on scrub practitioners
- More harmonious working relationship between the scrub team and surgeons
- Greater control over trays, ensuring accurate instrument returns
- Saving money due to opening fewer trays and having fewer instruments to re-sterilise
- Easy identification of instruments when looking for specific items
- Improved instrument familiarisation for new theatre staff
- Reduced potential for confusion through more clearly identified individual parts
- Ergonomic improvements due to tray rationalisation and clearer information about the contents of the trays.
Professional responses
My EICP has received recognition from a variety of sources. The NOC theatres deputy matron has written:
‘All of our hip and knee surgeons are impressed with Andrea’s picture books and are noticing benefits these are having.’
‘Andrea’s books have now been noticed by other orthopaedic specialities within our department.’
The Oxford University Hospitals (OUH) NHS Foundation Trust theatre matron wrote of the EICP:
‘This is a huge project and the plan is to roll this out to other specialities where we have experienced similar challenges.’
An OUH consultant surgeon responded to the EICP by commenting:
‘It makes a huge difference for the scrub team in being able to quickly recognise they have all the instruments back … Hope we can use this routinely.’
Other evidence of the positive impact my EICP has had is as follows:
- I was finalist in the ‘Innovation’ category of the British Journal of Nursing Awards 2021, being awarded third place
- I was a finalist in the ‘Nurse/Midwife of the Year’ category of the Oxford University Hospitals NHS Foundation Trust Annual Staff Recognition Awards 2019
- I was nominated for the ‘Innovation’ category of the Royal College of Nursing Nurse Awards 2020
- I received positive theatre practitioner feedback from colleagues
- I received several positive commendations from senior NHS leaders, including a divisional medical director, a theatre matron, a divisional director of nursing and a divisional lead for practice development and education
- I received a commendation in the OUH’s governance and safety meeting minutes
- The use of the instrument folders has been incorporated into the OUH ‘Swabs, Sharps, Instruments and Accountable Items Policy’.
Conclusion
The journey to achieving implementation of my EICP was an amazing 6 months of problem-solving, stakeholder engagement, collaborative working and clinical justification. I would like to acknowledge the invaluable assistance of Katarzyna Piotrowska, NOC Theatre Assistant, who contributed her photographic skills—as well as her friendship—to producing the instrument folders. I thank Emma Walduck, currently in the OUH clinical governance team, who supported my initiative as my line manager in the NOC. I also thank Caroline Tomkins, now Operational Services Manager at Hampshire Hospitals NHS Foundation Trust, for promoting my initiative within the OUH management teams and beyond during her time as OUH Theatre Matron. I also want to thank my partner, John Partington, for his support and assistance in composing this article. All my colleagues, from within the NOC and also among supplier representatives, have inspired me to strive for improvements through streamlining the instrument count process and I thank them. I am pleased to know my endeavours have been so well received and are making a positive, lasting impact on the working lives of scrub practitioners in the NOC.