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No Sponge Left Behind

December 1, 2008
by Kate Huvane Gamble
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Cutting-edge bar coding technologies are being leveraged in an attempt to make foreign bodies left in patients a thing of the past

Michael blum

Michael Blum


The use of bar coded systems to automate the administration of medications has been a growing trend in recent years; however, CIOs are now finding that the technology can prevent adverse events in a different capacity. In recent months, a handful of hospitals have begun leveraging bar coding technology to track surgical tools and supplies as well as other pieces of medical equipment — particularly those that can be left inside a patient. As a result, operation room clinicians are experiencing improvements both in patient safety and materials management.

According to a study published in the Annals of Surgery in August of 2008, discrepancies in the count of surgical instruments and sponges occur in 12.5 percent of surgeries (see sidebar for more information). While patients' lives are rarely endangered, the issue is still a concern. The incidents observed by the study's authors took an average of 13 minutes to resolve, a time lapse which can significantly impact the flow of a busy emergency or perioperative department.

It's a risk that some executives aren't willing to take, particularly when technologies exist that can produce faster and more accurate results than standard manual counting protocols. A small number of organizations, including University of California at San Francisco (UCSF) Medical Center and North Shore Medical Center (Salem, Mass.) are taking control of the problem by deploying bar coded sponge management systems that can assist in tracking the thin gauze pads that are occasionally left behind (of the retained items, sponges seem to be the most common).

“Our general philosophy is that you need to use technology where it replaces activities that human beings can't do particularly well. Computers can count and track materials much better and much more reliably,” says Michael Blum, M.D., chief medical information officer at UCSF. “No matter how well-trained they are or how much they focus on it, human beings just don't operate at 100 percent all the time. So in those spaces, we either back them up with technology or we replace the task with technology.”

UCSF implemented the Safety-Sponge System from SurgiCount Medical (Temecula, Calif.), which consists of individually bar coded surgical sponges and a portable scanner that are designed to enhance manual sponge counts.

Retained item initiatives


Mark hulse

Mark Hulse


For UCSF, the decision to deploy the sponge system came on the heels of an initiative launched by the perioperative services department to eliminate all incidents of retained items during surgical procedures.

“For years, we've been working on a concept to try to reduce anything left behind. We think it's unacceptable,” says Blum. He expects reduction campaigns to gain ground in the near future, as foreign items left behind now qualify as a “never event” that is not covered by Medicare and Medicaid.

The biggest issues weren't the counts that didn't match up; rather, it was false positive counts that were causing problems for UCSF's OR staff, according to James Bennan, director of perioperative services. “Every time we would find a sponge, we'd find that it had originally been documented that the count was correct. If we knew the count was wrong, we could find it. Our problem was we'd get a follow-up, post-surgical scan three or four days later and we'd pick up on something.”

Considering the method USCF (along with the majority of hospitals) had in place, which consisted of nurses recording counts on a board, it shouldn't have been surprising that errors occurred, says Bennan. The system, he says, was inherently flawed, but it was the only option at the time. So when the department was given an ultimatum from the administration to enact a zero tolerance policy, even if that meant taking X-rays at the end of every procedure, Bennan and his staff decided to turn to technology.

SurgiCount's system was implemented at UCSF in April 2007. Although sponges are still recorded manually by nurses, they are also passed through a scanner, allowing little — if any — room for error. The results, says Bennan, speak for themselves. “We have not had any unintended retained gauze or sponges since installing the system,” he says.

Improving the nursing experience

Similarly, at North Shore Medical Center (NSMC), which is part of the Boston-based Partners HealthCare Network, the implementation of a bar coded sponge management system is also being driven by the OR department. But while the project has been relatively “hands-off” for CIO Mark Hulse, it certainly has his full support, particularly since he once served as an OR nurse.

“It's a process that's definitely subject to interruptions and can be prone to errors,” Hulse says. “You're doing a hundred other things at the same time, and as much as you try to keep your attention on it, if the surgeon needs something, it's easy to get distracted.”

Hulse knows from experience how serious it can be when nurses discover an incorrect count and must scramble to find it. A system that would improve accuracy without involving a complicated implementation process was, to him, a no-brainer.

“With this system, all you're doing is using a hand scanner and line-of-sight scanning to collect information real-time,” Hulse says. “And through the bar code you can uniquely identify each sponge so that way the level of assurance that each sponge has been tracked is much higher.”

NSMC, which purchased the solution in June, plans to utilize the system in 12 operating rooms in two facilities — Salem Hospital and Union Hospital. The implementation is part of what Hulse calls “a fairly intensive operations improvement effort” aimed at streamlining the inventory management process while improving patient safety.

When it became clear that moving toward that goal meant piloting a new, cutting-edge technology, Hulse and his team didn't back down.

“I would say we're somewhat selective in that we really take a careful look at a technology, but when we feel the benefit is there, we are early adopters,” he says. Hulse attributes North Shore's willingness to try new technologies to its membership in the Partners HealthCare System. “The focus on technology to improve patient safety and quality of care is something that really helps us throughout the entire integrated delivery system, so it's as true at a community hospital like North Shore as it is at Mass General or Brigham and Women's Hospital,” he says.

Part of a bigger plan



While it seems to be earning high marks on its own, the sponge tracking system at North Shore and UCSF is just one part of a larger trend toward leveraging bar coding to more effectively track various types of medical equipment, supplies and tools. According to Bennan, UCSF has around 2,000 pieces of equipment tagged between the operating room and materials management, including anesthesia supplies and intubation tools.

The same holds true at North Shore, where bar coding has been deployed for patient ID bands as well as medication administration, and is being rolled out for tracking clinical laboratory samples. And there's more to come, says Hulse, as the medical center is looking to utilize RFID to track more expensive assets and equipment such as smart pumps.

“We eventually may look at it for patient and staff tracking. But for simple things like checking medications at the point of administration or sponge counts in the OR, the bar code technology seems to really work very well,” he says. “It's very tried and true. And from an infrastructure standpoint, it's less expensive than an RFID implementation.”

The sponge tracking system at UCSF was rolled out as a standalone application; however, the potential exists to tie it to other systems such as those used in supply chain management. “I think that as we start looking at these tracking technologies in general, they will absolutely be integrated,” Blum says.

One of the many bar coding technologies in place at UCSF is a system that tracks and manages blood samples. Logically, it is tied with the hospital's laboratory system. “It's on the floors and in the laboratory, and we're expanding that as we implement our new medical record to really facilitate workflow and the matching of patients and specimens, easing the burden in the laboratory,” Blum says. According to Blum, UCSF is currently rolling out GE Centricity's EMR, and is deploying provider order entry, a new pharmacy system and clinical decision support within the next year.

At North Shore, the sponge management system doesn't currently speak to any other systems, but Hulse says he'd like to integrate it with other applications to run tracking and analysis on all disposable surgical items. “Once we get to that point, then we would certainly like to interface for the materials management inventory tracking piece, as well as from a cost management piece,” he says.

But in the meantime, North Shore is focusing on completing the roll-out of the sponge system, which Hulse considers to be a “straight-forward” application that is both cost-effective and relatively hands-off for the executive team. And most importantly, Hulse says he believes that it will deliver the outcome North Shore's staff is looking for.

“We're very confident that it will absolutely improve our results,” he says. “And obviously, at the end of the day, it really is all about improving patient safety.”

Healthcare Informatics 2008 December;25(12):34-39

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