Br. J. Surg. 1992, Vol. 79, August, 776-777
A. W. McCombe, E. P. Bradley and M. Hairison Department of Otolaryngology, University of Liverpool, Liverpool, UK Correspondence to: Mr A. W. McCombe, Department of Otolaryngology, Head and Neck Surgery, Plymouth General Hospital, Greenbank Road, Plymouth PL4 8”. UK
Managing swabs in the operating theatre: a new method The swab count has traditionally used a swab rack. A new alternative ‘bag’ method involves placing used swabs in batches ofjive into plastic bags which are sealed and stored in a bin. A randomized prospective study was carried out to compare these two methods. Twenty consecutive ear, nose and throat cases were randomized to rack or bag collection. Swab-related activities were divided into three categories and analysed by formal time-and-motion criteria. Blood contamination of operating theatre and circulating personnel was recorded. The time involved in all three swab-related activities was significantly less using the bag technique. There was no theatre blood contamination using this method, but signiJicant contamination occurred using the rack. Circulating theatre personnel were minimally contaminated in two cases using the bag method but were grossly contaminated in all ten cases using the rack method. The bag technique is therefore safe and time eficient.
The swab count is an essential part of operating theatre procedure for patient safety and to provide medical staff with an indication of operative blood loss. The count has generally been performed using a swab rack; the circulating nurse transports used swabs to the rack where they are hung in rows of five, in full view of the scrub nurse. Periodically the swabs are counted down on to the floor in batches of five by the scrub nurse and the circulating nurse together. At the end of the procedure all the swabs are rechecked. A new ‘bag’ method has been devised, which involves the scrub nurse keeping all used swabs on a trolley and periodically counting them in batches of five, checked by the floor nurse, into plastic bags. These are sealed and placed in a designated part of the theatre, after weighing if necessary. Potential advantages of this technique include a reduced risk of blood spillage and possible contamination of the operating theatre and its personnel; with the swabs already bagged, tidying the operating theatre between cases should also be easier. A randomized controlled trial to compare the two techniques was undertaken.
personnel aware of its design and objectives was limited to the three authors. Results were analysed using Student’s t test and Fisher’s exact test; 95 per cent confidence intervals are given where appropriate3.
Materials and methods
Table 1
Twenty consecutive operations performed in a single operating suite (two theatres ) were randomly allocated to be performed using the swab rack or bag method as described by Plowes’. The suite was dedicated to ear, nose and throat surgery but a large number of major head and neck procedures were also performed. For each procedure any activities relating to the management of swabs were recorded, timed and analysed using a formal flow process method’. This involved reducing all procedures to their simplest parts and constructing a table of these. Each part was timed: the time for the composite parts when added together gave the total time involved in each procedure or activity. The timing and recording were carried out by two nurse investigators (M.H., E.P.B.). Swab-related activities were classified into three main areas: collection and transport of used swabs during the procedure, including swab counts during the operation; the final swab check and swab disposal; and the time taken to clean the theatre between cases. The theatres were tiled with 30 x 30 cm tiles and contamination was assessed by counting the number of squares around the swab rack or designated bag area marked with blood. At the end of the procedure the circulating nurse was examined for spots of blood on the clothing or exposed parts of the body and any found were recorded. Assessment of estimates of operative blood loss were made and any problems with the swab counts recorded. The study could not be performed blind, but the number of theatre
776
Results A total of 20 operations were analysed: ten in each group with six major, six intermediate and eight minor cases divided equally between the two arms of the study. In all three areas of swab-related activity the bag technique took significantly less time (Table I ). There was no contamination of the theatre using the bag technique, compared with a mean of 9.7 (95 per cent confidence interval 6.1-14.1 ) squares per case contaminated with blood using the rack technique ( t = 5.7, 18 d.f., P < 0.001). In only two cases with the bag technique was the circulating nurse contaminated with blood and this only on the hands and wrists. In all ten cases using the rack system the circulating nurse was contaminated with blood on the wrists and hands, and in nine cases there was contamination ofshoes and clothing (Table 2). Times taken for swab-related activities
Mean time ( s ) Bag method Collection and transport ( 5 swabs) Final check and disposal Cleaning of theatre
Rack method
63 (60.1-65.9)
155 (125.8-184.2)*
50 (46.1-53.9) 277 (248-296)
88 (74.1-101.9)t 480 (442-518):
Values in parentheses are 95 per cent confidence intervals. * t = 6.1, P < 0.001; t t = 5.1, P < OQO1; I t = 8.3, P i0.001 (Student’s t test, 18 d.f.)
Table 2 Contamination of staff with blood No. of cases
Site
Bag method
Rack method
Hand and wrists Other (clothing and shoes)
2 0
10* 9t
*P
= 0.0007;
tP
= 0~0001(Fisher’s
0007-1323/92/0807762
exact test)
0 1992 Butterworth-Heinemann
Ltd
Managing operating theatre swabs: A. W. McCombe et al.
Swabs were weighed in both systems and there was no apparent difference in the assessment of operative blood loss. There were no problems with the swab count using either technique.
Acknowledgements The authors are grateful to all the consultants and staff from theatres 1 and 2 of the Royal Liverpool Hospital for their permission and help in performing this study. The authors also thank Mrs J . Clinton for typing the manuscript.
Discussion Moves to abandon the swab rack have gathered momentum in recent years and alternatives, including the bag method, have been p r o p o ~ e d ' * ~Most , ~ . support for the bag method is, however, largely anecdotal, with little formal analysis of its benefits's4. This study has shown clearly that the bag technique is a useful alternative to the traditional swab rack method. It is safer, with significantly lower theatre and staff contamination. The time involved in all swab-related activities was significantly reduced with the bag technique and consequently staff exposure to blood-soaked items is reduced. With the current prevalence of human immunodeficiency virus and hepatitis B infection this should mean safer working conditions and lower risk, particularly for the circulating nurse. This is a point of theatre procedure not previously covered in relation to risks of infection6-8. Theatre cleaning time was halved with the bag method because of the reduced contamination and the prior bagging of swabs which could easily be lifted into a second bag. (Double bagging is another safety feature of this technique.) A mean time saving of 3.5 min per patient was made. Following this study the bag technique is now standard practice in this hospital.
Br. J . Surg., Vol. 79, No. 8, August 1992
References 1.
Plowes D. Life without swab racks. Br J Theatre Nursing 1990; 27: 11.
2. 3. 4. 5.
6. 7.
8.
International labour office. Introduction to Work S/udy. 4th ed. Geneva: Couleurs and Weber, 1974. Swinscow TDV. Stuti.stic.s ut Syuure One. 8th ed. Plymouth: L a t h e r Trend, 1986: 21 -4, 43-57. Mumford M . Swab racks are an old fashioned idea. Br J Theutre Nursing 1991; 1: 20- I . Wilrnot J, Maher E. Swab rack dilemma solved. Br J Theutre Nursing 1991; 1: 23-4. HMSO. Guidonce for Clinicul Health Cure Workms: Protection Aguinst HIVund Heputitis Viruses. London: HMSO, 1990: 15-24. Bessinger CD. Preventing transmission of human immunodeficiency virus during operations. Surg Gynecol Ohsret 1988; 167: 287-9. Quebbernan EJ, Telford GL, Hubbard S et (11. Risk of blood contamination and injury to operation room personnel. Ann Surg 1991: 214: 614-20.
Paper accepted 18 February 1992
777
A. W. McCombe, E. P. Bradley and M. Hairison Department of Otolaryngology, University of Liverpool, Liverpool, UK Correspondence to: Mr A. W. McCombe, Department of Otolaryngology, Head and Neck Surgery, Plymouth General Hospital, Greenbank Road, Plymouth PL4 8”. UK
Managing swabs in the operating theatre: a new method The swab count has traditionally used a swab rack. A new alternative ‘bag’ method involves placing used swabs in batches ofjive into plastic bags which are sealed and stored in a bin. A randomized prospective study was carried out to compare these two methods. Twenty consecutive ear, nose and throat cases were randomized to rack or bag collection. Swab-related activities were divided into three categories and analysed by formal time-and-motion criteria. Blood contamination of operating theatre and circulating personnel was recorded. The time involved in all three swab-related activities was significantly less using the bag technique. There was no theatre blood contamination using this method, but signiJicant contamination occurred using the rack. Circulating theatre personnel were minimally contaminated in two cases using the bag method but were grossly contaminated in all ten cases using the rack method. The bag technique is therefore safe and time eficient.
The swab count is an essential part of operating theatre procedure for patient safety and to provide medical staff with an indication of operative blood loss. The count has generally been performed using a swab rack; the circulating nurse transports used swabs to the rack where they are hung in rows of five, in full view of the scrub nurse. Periodically the swabs are counted down on to the floor in batches of five by the scrub nurse and the circulating nurse together. At the end of the procedure all the swabs are rechecked. A new ‘bag’ method has been devised, which involves the scrub nurse keeping all used swabs on a trolley and periodically counting them in batches of five, checked by the floor nurse, into plastic bags. These are sealed and placed in a designated part of the theatre, after weighing if necessary. Potential advantages of this technique include a reduced risk of blood spillage and possible contamination of the operating theatre and its personnel; with the swabs already bagged, tidying the operating theatre between cases should also be easier. A randomized controlled trial to compare the two techniques was undertaken.
personnel aware of its design and objectives was limited to the three authors. Results were analysed using Student’s t test and Fisher’s exact test; 95 per cent confidence intervals are given where appropriate3.
Materials and methods
Table 1
Twenty consecutive operations performed in a single operating suite (two theatres ) were randomly allocated to be performed using the swab rack or bag method as described by Plowes’. The suite was dedicated to ear, nose and throat surgery but a large number of major head and neck procedures were also performed. For each procedure any activities relating to the management of swabs were recorded, timed and analysed using a formal flow process method’. This involved reducing all procedures to their simplest parts and constructing a table of these. Each part was timed: the time for the composite parts when added together gave the total time involved in each procedure or activity. The timing and recording were carried out by two nurse investigators (M.H., E.P.B.). Swab-related activities were classified into three main areas: collection and transport of used swabs during the procedure, including swab counts during the operation; the final swab check and swab disposal; and the time taken to clean the theatre between cases. The theatres were tiled with 30 x 30 cm tiles and contamination was assessed by counting the number of squares around the swab rack or designated bag area marked with blood. At the end of the procedure the circulating nurse was examined for spots of blood on the clothing or exposed parts of the body and any found were recorded. Assessment of estimates of operative blood loss were made and any problems with the swab counts recorded. The study could not be performed blind, but the number of theatre
776
Results A total of 20 operations were analysed: ten in each group with six major, six intermediate and eight minor cases divided equally between the two arms of the study. In all three areas of swab-related activity the bag technique took significantly less time (Table I ). There was no contamination of the theatre using the bag technique, compared with a mean of 9.7 (95 per cent confidence interval 6.1-14.1 ) squares per case contaminated with blood using the rack technique ( t = 5.7, 18 d.f., P < 0.001). In only two cases with the bag technique was the circulating nurse contaminated with blood and this only on the hands and wrists. In all ten cases using the rack system the circulating nurse was contaminated with blood on the wrists and hands, and in nine cases there was contamination ofshoes and clothing (Table 2). Times taken for swab-related activities
Mean time ( s ) Bag method Collection and transport ( 5 swabs) Final check and disposal Cleaning of theatre
Rack method
63 (60.1-65.9)
155 (125.8-184.2)*
50 (46.1-53.9) 277 (248-296)
88 (74.1-101.9)t 480 (442-518):
Values in parentheses are 95 per cent confidence intervals. * t = 6.1, P < 0.001; t t = 5.1, P < OQO1; I t = 8.3, P i0.001 (Student’s t test, 18 d.f.)
Table 2 Contamination of staff with blood No. of cases
Site
Bag method
Rack method
Hand and wrists Other (clothing and shoes)
2 0
10* 9t
*P
= 0.0007;
tP
= 0~0001(Fisher’s
0007-1323/92/0807762
exact test)
0 1992 Butterworth-Heinemann
Ltd
Managing operating theatre swabs: A. W. McCombe et al.
Swabs were weighed in both systems and there was no apparent difference in the assessment of operative blood loss. There were no problems with the swab count using either technique.
Acknowledgements The authors are grateful to all the consultants and staff from theatres 1 and 2 of the Royal Liverpool Hospital for their permission and help in performing this study. The authors also thank Mrs J . Clinton for typing the manuscript.
Discussion Moves to abandon the swab rack have gathered momentum in recent years and alternatives, including the bag method, have been p r o p o ~ e d ' * ~Most , ~ . support for the bag method is, however, largely anecdotal, with little formal analysis of its benefits's4. This study has shown clearly that the bag technique is a useful alternative to the traditional swab rack method. It is safer, with significantly lower theatre and staff contamination. The time involved in all swab-related activities was significantly reduced with the bag technique and consequently staff exposure to blood-soaked items is reduced. With the current prevalence of human immunodeficiency virus and hepatitis B infection this should mean safer working conditions and lower risk, particularly for the circulating nurse. This is a point of theatre procedure not previously covered in relation to risks of infection6-8. Theatre cleaning time was halved with the bag method because of the reduced contamination and the prior bagging of swabs which could easily be lifted into a second bag. (Double bagging is another safety feature of this technique.) A mean time saving of 3.5 min per patient was made. Following this study the bag technique is now standard practice in this hospital.
Br. J . Surg., Vol. 79, No. 8, August 1992
References 1.
Plowes D. Life without swab racks. Br J Theatre Nursing 1990; 27: 11.
2. 3. 4. 5.
6. 7.
8.
International labour office. Introduction to Work S/udy. 4th ed. Geneva: Couleurs and Weber, 1974. Swinscow TDV. Stuti.stic.s ut Syuure One. 8th ed. Plymouth: L a t h e r Trend, 1986: 21 -4, 43-57. Mumford M . Swab racks are an old fashioned idea. Br J Theutre Nursing 1991; 1: 20- I . Wilrnot J, Maher E. Swab rack dilemma solved. Br J Theutre Nursing 1991; 1: 23-4. HMSO. Guidonce for Clinicul Health Cure Workms: Protection Aguinst HIVund Heputitis Viruses. London: HMSO, 1990: 15-24. Bessinger CD. Preventing transmission of human immunodeficiency virus during operations. Surg Gynecol Ohsret 1988; 167: 287-9. Quebbernan EJ, Telford GL, Hubbard S et (11. Risk of blood contamination and injury to operation room personnel. Ann Surg 1991: 214: 614-20.
Paper accepted 18 February 1992
777
