Prevention of retained surgical sponges: A decision-analytic model predicting relative cost-effectiveness

doi:10.1016/j.surg.2009.01.011

Surgery

Volume 145, Issue 5, May 2009, Pages 527-535

https://doi.org/10.1016/j.surg.2009.01.011 Get rights and content

Background

New technologies are available to reduce or prevent retained surgical sponges (RSS), but their relative cost effectiveness are unknown. We developed an empirically calibrated decision-analytic model comparing standard counting against alternative strategies: universal or selective x-ray, bar-coded sponges (BCS), and radiofrequency-tagged (RF) sponges.

Methods

Key model parameters were obtained from field observations during a randomized-controlled BCS trial (n = 298), an observational study of RSS (n = 191,168), and clinical experience with BCS (n ∼ 60,000). Because no comparable data exist for RF, we modeled its performance under 2 alternative assumptions. Only incremental sponge-tracking costs, excluding those common to all strategies, were considered. Main outcomes were RSS incidence and cost-effectiveness ratios for each strategy, from the institutional decision maker's perspective.

Results

Standard counting detects 82% of RSS. Bar coding prevents ≥97.5% for an additional $95,000 per RSS averted. If RF were as effective as bar coding, it would cost $720,000 per additional RSS averted (versus standard counting). Universal and selective x-rays for high-risk operations are more costly, but less effective than BCS—$1.1 to 1.4 million per RSS event prevented. In sensitivity analyses, results were robust over the plausible range of effectiveness assumptions, but sensitive to cost.

Conclusion

Using currently available data, this analysis provides a useful model for comparing the relative cost effectiveness of existing sponge-tracking strategies. Selecting the best method for an institution depends on its priorities: ease of use, cost reduction, or ensuring RSS are truly “never events.” Given medical and liability costs of >$200,000 per incident, novel technologies can substantially reduce the incidence of RSS at an acceptable cost.

Section snippets

Methods

We used standard decision trees to model the predicted incidence of RSS and incremental costs for each prevention strategy. All analyses were conducted in TreeAge Pro 2007 (TreeAge Software, Williamstown, MA).

A schematic model of key OR sponge-tracking events is shown in the Figure. Strategies incur incremental costs both from the cost of sponges (relative to standard radio-opaque sponges) and other equipment (such as bar-code readers for the BCS system and detection wands and console for the

Base case

The expected costs, number of RSS events prevented, RCER and ICER for each of the 8 strategies are presented in Table III. If no active tracking were performed, the incidence of RSS would be approximately 67 per 100,000 operations. Standard counting protocols alone are predicted to prevent 82% of these, resulting in a baseline estimated incidence rate of 12 per 100,000, which calibrates well with published epidemiologic data.10, 29 All strategies that included mandatory radiographs—whether

Discussion

Retained sponges remain a persistent and dreaded occurrence in surgery. Unfortunately, more than just diligence of highly sensitized surgical personnel will be required if they are ever truly to be a “never event.” Standard counting protocols already detect >80% of RSS that would otherwise occur. Still, sponges are left behind in approximately 12 per 100,000 operations,¹⁰ stimulating increasing interest in strategies to ameliorate the sponge count. Because RSS are already rare, however, the

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Retained surgical items are a serious human error. Surgical sponges account for 70% of retained surgical items. To prevent retained surgical sponges, it is important to establish a system that can identify errors and avoid the occurrence of adverse events. To date, no computer-aided diagnosis software specialized for detecting retained surgical sponges has been reported. We developed a software program that enables easy and effective computer-aided diagnosis of retained surgical sponges with high sensitivity and specificity using the technique of deep learning, a subfield of artificial intelligence.
In this study, we developed the software by training it through deep learning using a dataset and then validating the software. The dataset consisted of a training set and validation set. We created composite x-rays consisting of normal postoperative x-rays and surgical sponge x-rays for a training set (n = 4,554) and a validation set (n = 470). Phantom x-rays (n = 12) were prepared for software validation. X-rays obtained with surgical sponges inserted into cadavers were used for validation purposes (formalin: Thiel's method = 252:117). In addition, postoperative x-rays without retained surgical sponges were used for the validation of software performance to determine false-positive rates. Sensitivity, specificity, and false positives per image were calculated.
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Citation Excerpt :
Unfortunately, few studies have been performed examining the costs of quality improvement efforts, and even fewer examining the cost-effectiveness of these efforts in comparison to the cost of never events.34 One rare example of literature investigating the cost effectiveness of a quality intervention is a study published by Regenbogen and colleagues,18 which compares the cost effectiveness of 3 alternatives to the standard counting process to address retained surgical sponges. This complex decision analysis incorporated information on the frequency of retained surgical sponges and the cost estimates for various strategies to identify a retained sponge: (1) no sponge counting, (2) standard sponge counting, (3) universal x-ray films without counting, (4) universal x-ray films with counting, (5) selective x-ray films for high-risk operations, (6) bar-coded sponges, and (7) radiofrequency sponge systems.
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All dual dye coated needles searched utilizing the near infrared camera (n = 26) or ultraviolet light (n = 26) were located within 300 seconds. Conversely, 9 needles in both control settings (no dye usage) were not located within 300 seconds. Mean time to locate control needles in open surgery and laparoscopic surgery was statistically 2-3× greater than time to localization with the use of dye as an adjunct (P = .0027 open, P < .001 laparoscopic).
Incorporation of a dual-dye fluorescent coating on surgical needles improved the efficiency of locating needles, may minimize the need to convert minimally invasive surgeries procedures to open, and may decrease the consequences of a missed RFO.
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: S.E.R. was supported by Kirschstein National Research Service Award T32-HS000020 from the Agency for Healthcare Research and Quality. Drs Greenberg and Gawande have received research grant support from SurgiCount Medical, Temecula, CA. The funding agencies were not involved in the conduct, analysis, or composition of this study, and were not given the opportunity to approve or edit the manuscript before submission.

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Original CommunicationPrevention of retained surgical sponges: A decision-analytic model predicting relative cost-effectiveness

Background

Methods

Results

Conclusion

Section snippets

Methods

Base case

Discussion

Curr Probl Surg

Asian Journal of Surgery/Asian Surgical Association

Surgery

J Am Coll Surg

J Surg Res

J Am Coll Surg

J Surg Res

AORN J

AORN J

Surgery

Surgery

Surgery

J Surg Res

J Am Coll Surg

Serious reportable events in healthcare: a consensus report

Sentinel event policy and procedures

changes to the hospital inpatient prospective payment systems and fiscal year 2008 Rates

Fed Reg

Recommended practices for sponge, sharp and instrument counts

Diagnosis of retained abdominal gauze swabs

Br J Surg

Original Communication
Prevention of retained surgical sponges: A decision-analytic model predicting relative cost-effectiveness