Is This Patient Safety Issue Flying Under Your Radar?

The cost of a retained surgical item, commonly called RSI, is significant. The greatest potential cost, of course, is human life. Even when that most unfortunate result doesn't occur, these so-called “never events” — which actually happen 39 times a week in the U.S.¹ — cost facilities and patients prolonged care, unnecessary or unreimbursed medical expenses, penalties and lawsuits that often come with large settlements.

For hospitals, health systems and other provider organizations across the country, RSIs are a costly problem, with retained surgical sponges being responsible for 69 percent² of these incidents. The question is: are the executives leading these organizations fully prepared and taking action to avoid the most common RSI, a retained surgical sponge?

New research indicates the answer is “no.” In a recent survey of 291 healthcare professionals conducted by Modern Healthcare Custom Media, 85 percent of professionals report that their institutions are proactively avoiding these events through prevention and process.³ Yet, merely 16 percent³ use the only clinically proven 100-percent sensitive and specific detection technology—radio frequency (RF detection)—to detect retained surgical sponges, which occur approximately 27 times each week⁴ in the United States.

Leading the charge to end retained surgical sponge events, Dr. Glenn Ault, Associate Professor of Surgery at the University of Southern California Department of Surgery, has adopted RF technology (Medtronic's Situate™ Detection System) throughout his institution. Over about five years, the technology detected 11 “near missed” sponges that were about to be retained, out of 2,051 procedures.¹⁸ According to Dr. Ault, since implementing RF technology, LAC+USC Medical Center has had a 100-percent clear rate of no retained surgical sponges.¹⁸

“Current industry-standard protocols are labor intensive while leaving significant opportunity for retained surgical sponges to go undetected,” said Ault.⁵ “The industry has to do better to keep patients safe, which in turn will lessen provider costs as they reduce the risk for readmissions and additional procedures.”

The most commonly used process is pre- and post-procedure counting, which is ineffective an estimated one time out of every 64 procedures.⁶ In fact, it is estimated that 88 percent of RSIs occur when sponge counts are identified as correct.⁷ Basic human error and emergency situations greatly impact the accuracy and ability to count.¹⁸

If there is a miscount, most institutions then rely on X-ray technology, which is only effective 67 percent⁸ of the time in detecting retained sponges. This fact surprised 40 percent of C-suite executives surveyed.³ Surprisingly, 54 percent of respondents falsely believe that X-ray has a 75 percent or greater effective rate in locating a retained surgical sponge.³ Additionally, while only 19 percent of respondents trust X-ray “very much” to locate a retained surgical sponge when a procedure doesn't allow for counting, 57 percent are relying on it.³

The executives surveyed may think counting or X-ray is a proactive process, but these measures are not completely effective.^4,6 RF technology offered by Medtronic Situate™ is proven 100% sensitive and specific⁹ in detecting retained sponges, even in the most special cases and in patients with a high BMI, up to 82.¹⁵ It works by using RF-tagged sponges and a scanner to allow for quick, effective resolution of miscounts.⁸

“In our industry, it's near impossible to actually find a technology that is 100 percent effective so it's a mystery why every institution isn't using it,” continued Ault. “Change of procedure and protocol is difficult for any organization, but the improved patient outcomes and cost savings greatly outweigh any implementation education that is necessary.”

The potential savings are significant. The annual cost of retained surgical sponge prevention technology is about $191,352¹⁰ compared to less effective methods of prevention that cost more than $450,000¹¹, not considering the costs of X-ray use and OR time.

Indeed, the cost and quality outcomes of RF technology are impressive. But the most valuable part of a technology like this is more accurate prevention of adverse events, which may make for safer and healthier patient experiences.

For more information on Medtronic Situate™ and these survey results, visit medtronicsolutions.medtronic.com/situate.

Footnotes

1. Mehtsun et al. Johns Hopkins Report, 2013.
2. Gawande et al. N Engl J Med, 2003.

Medtronic/Modern Healthcare Custom Research, Nov 2016. Email Survey of 291 healthcare professionals, inclusive of clinical management, case management, senior management, financial management, materials management, operations management and general administration representatives.

3. Calculation based on occurrence of RSIs per week (39 times per Mehtsun et al. Johns Hopkins Report, 2013) and then 69% of RSIs being sponges (Gawande et al. N Engl J Med, 2003).
4. Dr. Glenn Ault was interviewed by Modern Healthcare in December 2016 to discuss the survey results.
5. Steelman et al. AORN Presentation, March 2015.
6. Gawande et al. N Engl J Med, 2003.
7. Cima et al. N Engl J Med, 2003.
8. Steelman, Amer J Surg, 2011.
9. Williams TL. et al. JACS 2014 (page 360) Total costs of RSI incident estimated at $441,534.
10. NOTE: Amounts based on data provided in below four sources and comparison to counting methodology. Calculations based on an occurrence of 1 in 7,000 procedures, assuming 10,000 procedures annually:

    • 1. Stone PW, Braccia D, Larson E. Systematic review of economic analyses of health care-associated infections. American Journal of Infection Control 2005;33(9):501–509. doi:10.1016/j.ajic.2005.04.246.
    • 2. Carroll AE, Parikh PD, Buddenbaum JL. The Impact of Defense Expenses in Medical Malpractice Claims. The Journal of Law, Medicine & Ethics, Spring 2012:135–142.
    • 3. Fact Sheet: CMS Proposes Additions to List of Hospital Acquired Conditions for Fiscal Year 2009. www.cms.gov 2008. Available at: http://www.cms.gov/newsroom/mediareleasedatabase/factsheets/ 2008factsheetsitems/ 20080414. html#_ftn3. Accessed June 2015.
    • 4. Lincoln, Taylor. Malpractice Payments Sunk to Record Low in 2011: Skyrocketing Healthcare Costs and Rampant Medical Errors Discredit the Promises Put Forth by Advocates of Tort Reform. Public Citizen, July 2012.

11. Steelman et al. AORN Journal, November 2015. (Page 498).
12. Steelman et al. AORN Presentation, March 2015.
13. NOTE: Amounts based on data provided in below four sources. Calculations based on an occurrence of 1 in 64 procedures, assuming 10,000 procedures annually.

    • 1. Steelman et al. AORN Presentation, March 2015.
    • 2. Egorova et al. Ann of Surg, 2008.
    • 3. Macario. J of Clin Anesth

14. Cima et al. N Engl J Med, 2003.
15. Steelman, Amer J Surg, 2011.
16. Williams TL. et al. JACS 2014 (page 360).
17. Inaba K, Okoye O, Aksoy H, et al. The role of radio frequency detection system embedded surgical sponges in preventing retained surgical sponges: A prospective evaluation in patients undergoing emergency surgery. Ann Surg. 2016 July 18.
18. Dr. Lottenberg was interviewed in December 2016 for commentary on the results of the Modern Healthcare survey.