Introduction:

Within each operating room (OR) suite, there are many instruments used by the surgical team members. And then the falling of instrument seems to be a common incident and also a deterrent to most of the surgery. This issue is very important, which can have short and long-term effects, leading to surgical flow disruption, the imposition of additional time and costs, and the shortening the longevity of instruments. Surgical instrument fall as an interruption factor may affect negatively the surgical team’s ability to remain fully engaged mentally during a case. Also, the noise caused by the moving or falling of the surgical instrument leads to distraction of the surgical team. Surgical team members should give their full attention to carrying out duties performed during critical phases². As mentioned by Wiegmann, surgical flow disruptions related to resource accessibility accounted for the remaining 8% of the observed events during 31 nonemergency cardiovascular operation³. Joshi and colleagues reported an average delay of 5.7 min after the fall of the surgical instrument⁴. As a result of prolonging the procedure, the patient is placed at a higher risk of infection or other serious complications. In addition, other surgeries may be subsequently delayed, and time wasted on the part of the surgeon and other hospital staff. Harders and colleagues found that the second most commonly recorded reason for delay in the operating room, after patient clinical condition, was the availability of instruments⁶. During surgery, contaminated instruments should be properly and completely removed from blood or tissue in the sterile field. On the other hand, the instrument dropped to the floor remains there until the completion of the surgery. Blood and foreign matter that are not removed or are allowed to dry and harden may become trapped in jaw serrations, between scissor blades, or in box locks, making final cleaning more difficult and the sterilization or disinfection process ineffective. It can cause instruments to become stiff and eventually break. Surgical instruments are a major financial investment in every surgical facility, and processes should be in place to protect this investment. The life of a surgical instrument is dependent upon the way it is used and the care it receives. It is a responsibility for the surgical team and the operating room staff. Instruments should be handled carefully and gently to avoid possible damage caused by their becoming tangled, dented, and misaligned. During and after surgery they should be placed in an appropriate place to prevent them from falling⁷. Surgeons, assistants and scrub nurses work very closely together handling the same instruments in a confined space during surgery⁸. Consequently, one of the factors influencing the incidence of instruments fall is communication in the operating room. In recent research, verbal and non-verbal exchanges in the operating room (OR) have been evaluated; commands are delayed, incomplete, or not received at all, and frequently left unresolved⁹. Firth-Cozens found that 31% of all communications in the operative procedures represent failures, a third of which had a negative impact on the patient¹⁰. Halverson and colleagues claimed that 36% of communication errors were related to instrument utilization¹¹. Generally, there are three phases related to the use of the instruments. First, the request for a tool has to be handled, then the tool is used, and finally it is disposed of^1,2. An error in any of these phases can be considered as a disruption to the surgical flow.

In other words, the tool request was not properly interpreted or holding the required tool was not conducted properly e.g., it was mishandled or dropped on ground¹². Because the most fallen surgical instruments include Hemostats, needle holders, Scissors and Forceps, also the majority of surgical instruments are stainless steel and stainless steel can be magnetically absorbent, therefore, the use of magnetic instrument holder will improve the efficiency and safety of the transfer of tools to the surgeon when they are needed. Thus, this study was undertaken to investigate the effect of magnetic drapes on the falling of instruments during neurosurgical, general, gynecological, orthopedic and urological operations^3,4.

Materials and methods:

This experimental paper is divided into two section. Firstly, Intra-operative observation of operative procedures was performed by first author over two week periods. Surgical cases were distributed across all days of the week, times within the day, surgical specialty, and surgeon within each specialty. A similar sampling scheme was used for observation in order to make a main checklist and record data sheet for two control and intervention group during study. A combination of recorded observations was used to introduce the basic checklist and categorize falling events. The topics of the self-administered checklist were classified into 6 categories: Demographic information of the surgical team, surgical position, type of instrument, stage of falling, condition followed falling of instrument during surgery, number of falls per surgical operation. In the second section, we designed and examined the particular magnetic drape for this investigation. All 20 operating rooms committed to full- time surgery in academic hospitals of Alzahra, affiliated to Isfahan University of Medical Sciences were selected by the convenience sampling method. After applying the criteria of entry and approval of participation in the study, 200 operations such as general surgeries, neurosurgeries and urology, orthopedic, obstetrics and gynaecologic surgeries were randomly assigned to two groups (control and Intervention) of 100 cases were recorded. We excluded emergency and after-hours cases. Entry criteria included being the first surgical operation of day and performing open surgery. The first author entered all falls into the database immediately after each case in both groups and the magnetic drape was successfully used during surgeries in an intervention group. The checklist validity was confirmed through a survey of 10 members of the faculty. The data were analyzed by SPSS ver.16 using descriptive and analytical statistics (Chi-square, Pearson, Fisher’s exact test, and Kolmogorov-Smirnov tests) at a significance of 0.05.

Results:

A 2-week-long pilot project was initiated to introduce and test the new checklist. After revisions were made, the process was introduced into the first surgical case of the day. A total of 200 neurosurgical, general, gynecological, orthopedic and urological cases were observed during the study. The surgeries were divided into control and intervention groups. There were 512 surgeons and 200 scrub technicians who participated in the project. Surgical residents participated in all cases. There was no significant difference between the two groups in terms of age, gender, and work experience (P-value>0.05). The frequency distribution of the demographic characteristics of the population under investigation in two groups of control and Intervention is shown in (Table 1) & (Table 2). There were 55 falls (55%) during control and 19 (19%) during intervention surgeries. The results of this study showed that the frequency of instruments fall in the intervention group significantly decreased (P<0.05) (Table 3).

In control group 40 falls (52.6%) in supine position, 6 falls (66.7%) in lateral position, 2 falls (28.6%) in prone position and 7 falls (87.5%) in lithotomy position occurred, while in intervention group 14 falls (19.4%) in supine position, 2 falls (20%) in prone position and 3 falls (21.4%) in lithotomy position were noted.The results also showed that there was a significant difference between frequency of instruments fall in supine(P-value=0.001 <0.05) and lithotomy(P-value=0.006 <0.05) position. The type of the falling surgical instruments was also noted. Out of a total of 55 instruments falling on the floor in control group, there were 53 falls involving instruments set like forceps, scissors, clamp, needle holders and 2 implants. And all of instruments falling on the floor in intervention group were involved instruments set. There were no significant difference in the types of instruments falling observed (P-value>0.05). During the observation period, the causes of instruments’ fall in control (49.1%) and intervention (57.9%) group was related most commonly to time that the tools were left on the side of the patient body, at a reachable region, but outside the opening incision, and reused later by surgeon (Table 4). Ignoring instruments dropped on the floor was the most common condition after falling surgical instruments in both groups (Table 5). Seven surgeries had two or more falls. The results are based on Chi-square and Fisher’s exact test non-parametric tests at a significance of 5% (due to the fact that the distribution of satisfactory score is not normal based on Kolmogorov-Smirnov results (P-value=0.001 <0.05)).

Discussion:

To our knowledge, no scientific data evaluating the effect of instrument holders and magnetic drapes on preventing instruments fall during surgeries. The studies evaluating the incidence of accidental fall of instruments during elective and emergency caesarean section and orthopaedic procedures have led to analyse and compare statistically the occurrence instrument fall, which can be applied in a modified manner to studies similar to ours.

In the study by Joshi et al⁴., which was conducted at V. C. S. G. G. Medical Sciences and Research Institute) Srinagar, Pauri Garhwal, India, 362 randomly chosen emergency and elective caesarean sections was observed. The results showed that gynaecological instruments fall in one-sixth of elective caesarean sections and in approximately every second emergency caesarean sections. The operating surgeon and his/her first assistant were responsible for 83.64% of instrument falls in the operating room. This is practicaly the same as the study performed on accidentally falling instruments during orthopedic surgery in 2008 by khan et al. Their analysis reveals that orthopedic instruments fall in one third of elective procedures and in approximately every second trauma orthopedic one. Also, more than 80% of instrument/implant falls in the operating room occurred as a result of the operating surgeon and his/her first assistant¹³. In both previous studies, the nature of instrument falling during surgery indicates that falls are more common with smaller instruments (like forceps) and with instruments having a steel handle.

Our study concluded that to prevent instruments from falling from the surgical field, the scrub person may place a magnetic pad on the drapes below the incision site when the patient is placed in especially supine and lithotomy position. However, the scrub nurse has also created a small area on drape with the magnetic drape dedicated for the 4-5 most frequently and currently used tools (Figure 1). These instruments are placed in a particular order. In this example the scrub nurse places the instrument anticipated to be used next, nearest to the surgeon.

Figure 1.
Use of the magnetic drape during surgery with lithotomy position

After use, the items are placed back in the magnetic zone, and the scrub person retrieves them. This technique eliminates hand-to-hand passing of sharps between the surgeon and the scrub person, so that no two individuals touch the same sharp at the same time and prevents instruments lying on the surgical field from sliding to the floor. Rahmati and colleagues confirmed that the use of needle magnet within surgical field may reduce the chances of sharps injury during surgery¹⁴. The evidence from our study suggests that it’s better to remove instruments from the surgical field after use, and return them to the Mayo stand or instrument table promptly. But according to Svensson and colleagues’ findings, the use and handling of instruments is embedded in a complex weave of multiple interrelated activities and responsibilities. For example, the passing is done in relation to other distinct and parallel activities¹⁵. Because the scrub nurse does not just respond to a request by quickly removing and passing the correct instrument, he/she can define a location on the surgical field where instruments are placed on a magnetic drape, from which the surgeon or assistant can retrieve them. The findings of our study illustrate conditions underlying the causes of falling instruments during surgeries in general. Finally, we suggest that further investigations are needed to estimate the association between falling of instruments and perioperative delay, additional subsequent delays, errors, system deficiencies, longevity of instruments and cost-effectiveness^6,7. We aware that our research may have limitations. First, all surgical team members, type of surgeries, duration of surgeries are different between two groups. Another important limitation is the way in which falling of instruments were recorded. There is no established classification in the literature^8,9,10; thus, we developed our own checklist. We hope that the data from this study can be used to show that falling of instruments does happen frequently and to elevate awareness about them so that appropriate surgical instrument holders like magnetic drapes can be used to prevent them.

Conclusion:

Surgical operations where nurses and surgeons routinely pass instruments to one another. The key to the successful accomplishment of a surgical intervention is the timely availability and efficiency of tools. Surgical instruments not working properly or not immediately available may delay procedures, interrupt other activities or sometimes even endanger the safety of the patient. The handling and exchange of instruments during the surgical operation raises issues that may bear upon the development of technologies. A magnetic drape is one of new surgical technology that it is necessary to position a magnetic instrument pad over the top drape to serve as a neutral zone, and also to retain any instruments that are placed on the drape. In conclusion, the use of the magnetic drape will make the surgical procedures more proficient, decrease loss and improve the transfer of instruments to the surgeon by keeping them in a safe but reachable distance maximizing the organization of the surgery.

Acknowledgement: The present paper is drawn from one of the parts of the master's thesis of the operating room approved by the code 396872 at Isfahan University of Medical Sciences. Hereby, I express gratitude to the entire staff working in operating room and the officials of Isfahan’s Alzahra Hospital. Also, I greatly thank the Isfahan University of Medical Sciences and the research office for cooperating and their funding the project.

References

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Author notes

Bagherisep1993@gmail.com