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Question: We would like to discontinue performing instrument counts in our OR but our supervisor will not change the policy. When there are five or six trays on the back table, it is practically impossible to count all the instruments. We tried counting only the instruments on the Mayo stand, but that was too confusing as instruments were being transferred to and from the Mayo stand and back table. While we are trying to count, the surgeons complain that we are not watching the sterile field and helping them.

How can we get our supervisor to change the policy? Can we just take an x-ray at the end of the procedure? Most patients receive x-rays in the postanesthesia care unit (PACU) anyway.

Taking a postoperative x-ray of all patients exposes them to unnecessary radiation. To obviate a count, the x-ray would need to be taken before the patient left the OR. If an item is detected with x-ray when the patient is still in the OR, the incision can be opened and the item removed as part of the same surgical procedure.

If the x-ray is not taken until the patient is in the PACU and a retained item is detected, the patient must return to the OR for resolution. This results in an “unplanned return to the OR” incident, which skews your facility’s quality measures. Performing a count, as opposed to taking an x-ray, will alert surgical team members that an item is missing before the incision is closed.

A first step to solving the counting problem is to consolidate and standardize instrument sets. Pare down and standardize the basic sets you need (eg. orthopedic, plastic, neurosurgery) so that the same instruments always are on each tray. Include the surgeons in this intrusive.

Next, determine which instruments from the various sets are needed most often, causing these sets to be opened and placed on your back table. With careful scrutiny, you will detect a pattern. For instruments be removed, packaged, and sterilized separately? For example, you may be able to add Satinsky clamps or rake retractors to your basic set, eliminating the need to open and count entire cardiac and orthopedic trays.

If the identified instruments cannot be extracted from other basic trays, consider increasing your instrument inventory to include a sufficient number of high-use instruments to allow for individual packaging and sterilization. Careful selection of correct basic trays and a few “extras” (ie, individually packaged items) will make your counting process smooth and practically seamless. After everyone learns the system, surgeons likely will be less aware that you are performing a count.

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