RFO PREVENTION

An RFO event refers to an iatrogenic event in which a sponge or surgical instrument is deliberately or unintentionally left behind while the wound proceeds to definitive management. Both surgical and traumatic open wounds are at risk for RFOs. Several features unique to the deployed environment place patients at increased risk of this complication. Among these risk factors are multiple surgical teams performing procedures on multiple wounds simultaneously, multiple surgeons performing procedures at different times, instrument and sponge counts being omitted in hemodynamically unstable patients, patients undergoing care at multiple different treatment facilities, and minimal documentation on operative records. The most obvious example of this would be definitive closure of the abdomen with a retained lap sponge. A less obvious vignette would be deliberate temporary hemostatic closure of a thigh compartment over Combat Gauze unrecognized by subsequent surgical teams at higher roles of care. Even with a slower operational tempo, RFO events continue to happen as these are two examples of true events occurring in Iraq and Afghanistan within the last 5 years. The deployed environment is high risk for RFO events because of the frequency of severe injuries requiring staged operations with temporary packing for hemostasis, multiple locations with multiple surgical teams, limited OR support for sponge and instrument counts during exigent circumstances, and communication challenges during patient hand-offs between roles of care. Strategies must be undertaken to mitigate these risks.

Best practices include:

1. The medical record must reflect any material that has been purposefully left in the wound.
2. Physician-to-physician communication (preferably surgeon-to-surgeon) should occur if foreign bodies remain in the wound.
3. There should be a low threshold to obtain radiographs to confirm removal of all foreign bodies. This is particularly important for cases in which a sponge and instrument count were omitted due to hemodynamic instability, discrepancies during the closing or final sponge an instrument count, or when a wound is being closed by a different surgeon at a subsequent treatment facility. Ideally, the images should be reviewed by both the surgeon and radiologist before closing the wound and leaving the operating room. The use of radiofrequency-labeled sponges and detectors is an adjunct to improve detection of retained sponges, but does not remove the need to use x-rays to definitively clear a cavity of sponges. Not only is it possible that a forward role of care used non-RFID lap sponges, but combat gauze can be used to control challenging intracavitary bleeding and will only be detected on x-ray.