Accounting for specialist items in neurosurgery.
This short article explores the issues surrounding the use of
certain specialist items used during some neurosurgical procedures. It
discusses the results of a benchmarking exercise that sought to
investigate how these items are accounted for since there appear to be
no nationally agreed guidelines for perioperative practice. The returns
from the exercise suggest that, while practice for patties seems to be
consistent, there is variation between neurosurgical centres in the use
of other items. It is hoped that this work may stimulate discourse and
that guidance can be produced to assist perioperative practitioners and
enhance safe practice for patients.
KEYWORDS Lintene / Lintenes / Patties / Surgical strips / Raney clips / Neurosugery
|Publication:||Name: Journal of Perioperative Practice Publisher: Association for Perioperative Practice Audience: Academic Format: Magazine/Journal Subject: Health; Health care industry Copyright: COPYRIGHT 2012 Association for Perioperative Practice ISSN: 1750-4589|
|Issue:||Date: Sept, 2012 Source Volume: 22 Source Issue: 9|
|Product:||Product Code: 8000410 Surgical Procedures NAICS Code: 62 Health Care and Social Assistance|
Lintenes (also known as surgical strips) and patties are commonly used by surgeons in neurosurgery when dissecting around fragile tissues in the brain or spinal cord and are occasionally used in ENT, orthopaedics and some laparoscopic cases (Burgu et al 2011). They are thin and made of bonded non-woven fabric and should contain an X-ray opaque strip. Patties come attached to a card for easy handling and have a thread attached for ease of identification (Figure 1), while lintenes are made of the same material but come in strip form of varying width and can be cut to a desired size and shape (Figure 2). The practice of cutting lintenes can be a problem. It makes the number of separate pieces of lintene difficult to account for as the number in the surgical field may change as the operation continues.
[FIGURE 1 OMITTED]
[FIGURE 2 OMITTED]
Another set of items used in cranial surgery are Raney clips. These are clipped into place on the edges of the incision to provide haemostasis during cranial surgery by preventing arterial bleeding from the small vessels of the skin and deeper vessels under the scalp. Raney clips were once made of surgical stainless steel and were usually included on the craniotomy instrument tray. In more recent years the metal clips have been replaced by plastic ones (Figure 3) that seem to be regarded as safe to use despite being X-ray translucent.
[FIGURE 3 OMITTED]
The issue of counting and recording of patties, lintenes and Raney clips seems to occupy something of a grey area, with variations in practice from one neurosurgical centre to another within the UK. The approach in some was that they were not counted during cranial operations as they were the surgeon's responsibility. The risk of losing a pattie or lintene was thought to be infinitesimally small, particularly as in most cases a microscope would be used by the surgeon. This was also the case in some centres for the use of surgical swabs, which were not counted in cranial surgery since they would only be used in the initial part of the operation. Once the dura was exposed swabs would be removed from the immediate surgical field and not re-introduced until required for the final closure.
A search of the literature provided very little of relevance. Most articles were written from a surgeon's perspective on how patties are utilised; some examined their adherence to dura (Menovsky et al 2009) or how retained fibres caused a local tissue reaction (Hoyland et al 1998). Thorburn (1995) seems to be the only author to have investigated the counting of patties by undertaking a small study to examine the commonality of counting practices in neurosurgical centres in the UK. Thorburn's study found that there was variation in practice between neurosurgical units in counting these items and that this in turn was at variance with accepted practice of accounting for and counting other items such as swabs and instruments. This had confirmed Thorburn's experience when working in a number of neurosurgical theatre units.
Since it appeared that no further literature was available to help inform us of the current position we turned to other organisations for further information. The AfPP Standards and Recommendations for Safe Perioperative Practice (2011) makes no specific reference to lintenes, patties or Raney clips, merely stating that all such items must be accounted for and recorded in the relevant documentation. This was also true of the guidance provided from the equivalent AORN publication Perioperative Standards and Recommended Practices (2011). Contact was made with the National Patient Safety Agency who did not have any data on retained lintenes or patties and therefore had not issued any guidelines or directives on their use.
Another issue that is prevalent is the cutting of lintenes to different shapes, according to the surgeon's preference. We are aware that some surgeons like to have their lintenes cut into long strips that they place into the wound to protect delicate tissues such as the dura. If this is done the counting of the lintenes becomes difficult as the number of lintenes increases.
We therefore decided to undertake a benchmarking exercise and asked colleagues from neurosurgical operating theatre departments from across the UK to establish the current situation in respect of accounting for patties, lintenes and Raney clips in perioperative practice. Since we were not undertaking primary research we considered that by deciding to complete and return the questionnaire, implied consent had been gained from the participants.
The questionnaire was sent to all 32 units in the UK with replies being received from 18, making a response rate of 56%. All responding units stated that they counted the patties in all neurosurgical operations.
We then asked about the cutting and counting of lintenes in neurosurgical procedures. Out of the 18 centres that use lintenes in the way previously described 11 (61%) stated that they use them. From these 11, 9 (81%) stated that they cut the lintene material to shape as required by the surgeon. One centre stated that they do not change the shape as they use a pre-cut product from one of the leading supply companies and also count them into tens for use in the surgical field. Within the group of 9 centres that cut the lintenes, 4 (44.4%) stated that they do not count them, whilst 1 stated that they count each lintene as 1 even if it is cut into smaller sizes. All other centres stated that they count the lintenes that have been cut into various different sizes. All centres stated that they count all surgical swabs for cranial surgery; however 38% stated that they do not count their Raney clips.
Within this project replies were received from just under half the centres performing neurosurgery in the UK, so we are unable to say definitively what the current state of practice actually is. However, based on this exercise it appears that neurosurgical scrub practice is not consistent across the UK in respect of the counting of lintene material, whilst the counting of Raney clips also seems to be variable. It also seems as if the issue of the counting of patties, as identified by Thornburn in 1995, has been addressed amongst those that responded to us. However, other aspects of accounting practice are now inconsistent possibly due to changes in the way that these items are used or produced by the commercial companies. This is particularly evident with the practice of cutting lintenes to a preferred size or shape for use by the surgeon.
It seems that the absence of nationally agreed standards for accounting for these items has led to the variations in local practice. It is also recognition of the difficulties of counting these items in neurosurgery since counting was not always required and surgeons developed their practice accordingly. It can therefore be problematic to change the practice with the result that some surgeons find it difficult to adapt to the new requirements when carrying out surgical procedures. What also seems at variance with accepted guidelines is the practice of cutting lintenes. One centre reports that they do not cut lintenes as they use commercial products that are already pre-cut to the desired size and shape. It may be that the companies that produce the products that are commonly used in neurosurgery might provide pre-cut lintene material that is suitable for use within neuro and other types of surgery. This would assist scrub practitioners in the counting of lintenes products and help in the standardisation of counting techniques in neurosurgical procedures, which is clearly lacking at present.
Raney clips are also counted in some centres but not in others and this may be an acceptance that since they are used on wound edges the likelihood of loss within the cranial incision is low. However that they appear to be manufactured from radiotranslucent plastic material suggests that they pose a safety issue. The non-counting of Raney clips would seem to be at variance with recommended practice from AfPP for example (2011) which states that all items used in the surgical field must be accounted for.
This benchmarking exercise has illustrated that the accounting practices of certain items in neurosurgery is not uniform within the UK and that current accepted guidelines do not cover this specialised area. Whilst the counting of surgical patties occurs in 56% of centres that responded, there is variation in the counting of lintenes and Raney clips. It would appear that there is a need for an agreed set of standards for the use of these specialist items and that manufacturers might also be involved in producing items that assist uniform and safe accounting. It is hoped that this article might stimulate discussion so that a set of nationally agreed guidelines can be produced in order to maintain the safety of our patients.
Association for Perioperative Practice 2011 Standards and Recommendations for Safe Perioperative Practice Harrogate, AfPP
Association of Perioperative Registered Nurses 2011 Perioperative Standards and Recommended Practices Colorado, AORN
Burgu B, Aydogdu O, Wilcox D 2011 Use of neurosurgical patties for dissection in laparoscopic procedures of the urinary tract Journal of Endourology 25 (5) 737-8
Hoyland JA, Freemont AJ, Denton J, Thomas AM, McMillan JJ, Jayson MI 1998 Retained surgical swab debris in post-laminectomy arachnoiditis and peridural fibrosis Journal of Bone and Joint Surgery 70-B (4) 659-62
Menovsky T, De Ridder D, de Vries J 2009 Neurosurgical patties and their intraoperative interaction with neural tissue Surgical Neurology 71 (3) 326-9
Thornburn A 1995 Safe practices in neurosurgery? British Journal of Theatre Nursing 5 15-7
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by Andy Mardell and Arsenia Davies
Correspondence address: Practice Educator, Cardiff and Vale University Health Board, Main Theatres, University Hospital of Wales, Heath Park, Cardiff CF14 4XW.
About the authors
SEN, RN, Dip N, BN (Hons), PGCE
Practice Education Nurse, Cardiff and Vale University Health Board, Main Theatres, University Hospital of Wales, Cardiff
Senior Theatre Practitioner, Neurosurgical Theatres, Cardiff and Vale University Health Board, Main Theatres, University Hospital of Wales, Cardiff
No competing interests declared
Provenance and Peer review: Unsolicited contribution; Peer reviewed; Accepted for publication May 2012.
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