Health Care Costs and Financing

X-ray of patients undergoing emergency surgery is cost-effective in preventing retained surgical sponges

For patients undergoing emergency open-cavity surgery, it is cost-effective for the hospital to require routine x-rays before the patient leaves the surgical suite to detect retained surgical sponges, rather than relying on sponge counts by operating room staff, concludes a new study. Authors of the study simulated decision analysis to compare radiography with surgical sponge counts while the patient is still in the surgical suite. They took into account the cost of the radiologist, as well as legal and other costs relevant to a hospital being sued for a retained surgical sponge. The analysis was not extended to patients undergoing elective open-cavity surgery, because the working conditions for elective surgery are less harried and quite different, the researchers noted.

A few studies have reported that emergency surgery is associated with a 5- to 9-fold higher risk of retained instruments or foreign bodies than are elective operations. Other factors that increase the risk of retained sponges, such as massive blood loss (that requires use of many sponges) or hurried sponge counts, are commonly present during emergency surgery. Retained sponges have been associated with a variety of clinical problems and, over time, mortality as high as 11 to 35 percent.

To develop a model that would compare surgical sponge counts and radiography, the researchers surveyed 34 trauma and emergency department surgeons anonymously for estimates of the sensitivity and specificity of surgical sponge counts and intra-operative radiography (IOR). Institutional estimates were obtained for the cost of the radiograph, the extra operating room time to permit IOR, and the institutional cost of an undiscovered, retained surgical sponge. The sensitivity and specificity of x-rays were higher than for a sponge count, and sponge counts suffer from the possibility of false-negative results (miscounting that misses a retained sponge). The researchers calculated a cost-effectiveness ratio for IOR of $705 per emergency operation compared to $1,155 for the sponge count strategy.

The researchers conclude that, in the use of IOR, hospitals must spend money to save money. The cost of implementing the IOR strategy is incurred immediately, but the cost savings of prevented retained surgical sponges are realized over time. The study was funded in part by the Agency for Healthcare Research and Quality (T32 HS13833).

More details are in "Cost-effectiveness of routine radiographs after emergent open cavity operations," by Lesly A. Dossett, M.D., Robert S. Dittus, M.D., M.P.H., Theodore Speroff, Ph.D., and others in the August 2008 Surgery 144, pp. 317-321.

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