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TJC makes it clear: Get surgical smoke out of OR
The air is clearing in the nation's operating rooms, as The Joint Commission (TJC) places a greater emphasis on evacuating smoke from electrocautery procedures.
In the accrediting process, hospitals have long been required to manage "risk related to hazardous material and waste." In the 2009 Environment of Care standard, The Joint Commission added a note for clarification: "Hazardous gases and vapors include, but are not limited to, glutaraldehyde, ethylene oxide, vapors generated while using cauterizing equipment and lasers, and gases such as nitrous oxide."
This is the first specific mention of surgical smoke in TJC standards, although the National Fire Protection Association (NFPA) code addresses smoke detectors and scavenging of waste anesthetic gases. TJC requires hospitals to comply with NFPA codes.
"We have always interpreted the smoke that's generated from these procedure [as a hazard]," says Jerry Gervais, CHFM, CHSP, BSME, associate director and engineer in the Standards Interpretation Group of TJC. "Organizations didn't make that connection so we wanted to be very, very clear about it. The hospital should have a written policy on how they're handling this issue," he says. "By having a written policy, they can require compliance by all employees. They can write in the required safety precautions and hold them accountable."
AORN says reduce exposure
The "clarification" by TJC comes on the heels of a 2008 position statement by the Association of periOperative Registered Nurses (AORN), urging hospitals and surgery centers to reduce exposure to surgical smoke and bioaerosols released in laser and electrosurgical procedures.
In March 2009, the Canada Standards Association issued a voluntary "Plume Scavenging Standard" that provides guidance on systems that evacuate surgical smoke from electrosurgery procedures. Hospitals frequently tout their "smoke-free" campus. Now, the "no-smoking" rule will include the pungent smoke produced when tissue is burned, say OR nurses who have advocated for greater attention to the issue.
Vangie Dennis, RN, CNOR, CMLSO, clinical manager of procedural nursing at Gwinnett Medical Center in Duluth, GA, and a member of the AORN Surgical Smoke Evacuation Task Force, says, "I think the biggest challenge we have is getting the message across to the surgical team that what they're doing has cumulative long-term effects, just as secondhand cigarette smoke does. If you take a look at the constituents of cigarette smoke, it's identical to surgical smoke, only we have additional components," including viable bacteria and viral particles, she adds.
Equipment lacking, nurses report
"Health hazard evaluations" conducted at three hospitals by researchers from the National Institute for Occupational Safety and Health (NIOSH) detected formaldehyde, acetaldehyde, and toluene in surgical smoke, though not above recommended or permissible exposure limits. OR employees complained of irritant symptoms.
Yet too often, hospitals don't have adequate smoke evacuation equipment, says Kay Ball, RN, PhD, CNOR, FAAN, a nurse consultant/ educator in Columbus, OH, and chair of the AORN Surgical Smoke Evacuation Task Force. Lack of equipment was the No. 1 barrier to complying with smoke evacuation recommendations that was cited in a survey of 777 nurses she conducted as part of her dissertation. "Hospitals need to get smoke evacuation devices for every surgical suite," she says. "There are still a lot of people who are not evacuating surgical smoke."
Other barriers included the noise of the equipment, lack of support from physicians, and complacency of the staff. Freestanding ambulatory surgery centers are more likely to evacuate smoke than hospitals, as are larger or urban facilities, Ball found.
To implement smoke evacuation, begin with a committee that includes OR leaders or "champions," advises Dennis. The committee can conduct an assessment and determine the needs and concerns of OR staff and physicians, she adds.
For example, if surgeons are concerned about noise or interference with their procedures, investigate products that are insulated and that can be easily incorporated into the OR, Dennis points out. "We addressed the loudness. We made sure the staff understood you didn't have to turn it up to 100%," she says. "On a small smoke-generating procedure, 20% [power on the smoke evacuator] is enough."
Educating your staff
Conduct a trial of the new products, and educate staff about how to use them and why evacuating surgical smoke is important, says Dennis. She conducts education annually. One resource for providers is AORN's surgical smoke toolkit, which includes a sample policy and procedure, competency skill checklist, tips for compliance, and a link to vendors.
After implementing a new policy, hospitals should follow up with observations to check for compliance, Dennis says.
Changing habits can be difficult. While facilities typically implemented smoke evacuation along with new laser technology, they have been slow to make smoke evacuation routine in electrosurgical procedures. But facilities are getting the message, says Ball.
"I want to make 2009 the year of smoke evacuation," she says. "I want everyone to realize you can't breathe this in. We need to protect the air of the surgical nurses."
For more information on smoke evacuation, contact:
To access the Surgical Smoke Evacuation Toolkit from the Association of periOperative Registered Nurses (AORN), go to www.aorn.org. Under "Practice Resources," select "Toolkits," then select "Surgical Smoke Evacuation Toolkit."
You can address problems with surgical smoke
Perioperative nurses experience respiratory symptoms at a higher rate — sometimes twice the rate — of others in the United States, based on a recent study conducted by Kay Ball, RN, PhD, CNOR, FAAN, perioperative consultant/educator with K&D Medical in Lewis Center, OH. Ball, who is chair of the Association of periOperative Registered Nurses (AORN) Surgical Smoke Evacuation Task Force, conducted the research as part of her PhD dissertation.
In her study of 777 nurses, Ball found, for example, that 22.9% nurses in the study experiences sinus infections/problems, compared to 10.3% of people nationally. Nurses in the study also reported higher rates of allergies (24.2% vs. 18.4%), asthma (10.9% vs. 6.4%), and bronchitis (9% vs. 4.5%).
"The perioperative nurses may be experiencing higher prevalence ratings because of continual inhalation of surgical smoke," Ball said. The reason? "Surgical smoke has been shown to contain toxic gases and small particulate that are hazardous when inhaled," she said. "Also the high potential for the transmission of viable organisms within the plume has been revealed."
Several professional organizations, including the Association of periOperative Registered Nurses (AORN), have supported the classification of surgical smoke as an inhalation hazard and have published recommendations for smoke evacuation that foster a clean air environment in the OR. "Toxic gases create an offensive odor, small particulate matter causes respiratory complications, and pathogens may be transmitted within the surgical smoke to the surgical team," Ball said.
However, not much emphasis has been placed on the inhalation of surgical smoke in ORs, she said. Additionally, smoke evacuation recommendations aren't being followed consistently by periop nurses, Ball said. However, a few facilities stand out, such as The Reading Hospital (TRH) Surgicenter @ Spring Ridge, Wyomissing, PA. The Surgicenter @ Spring Ridge has placed smoke evacuators in every OR.
"Now we're using them for just about everything," says Cynthia Iannelli, RN, BSN, CNOR, OR educator and chair of the facility's practice council and steering committee.
Anesthesia staff initiated the change, she says. "They were feeling the effects of sitting there, and smelling smoke, more than some of us," she says. Iannelli developed a policy and gave a poster presentation for her staff and physicians. [The policy is included.] She also wrote a letter for managers to share with surgeons that explains the reasons for wanting to enforce use of the smoke evacuator. (The letter also is included.)
When you're selling physicians and staff on the idea of using smoke evacuators, keep in mind that most don't "buy into the idea that we'll get cancer because we're taking out a tumor with electrosurgical units," Iannelli says. "I found if I told them that probably is a very small risk, however; you're still breathing lots of particle and contaminants that's an irritant to lungs and throat, causes sinus conditions and respiratory conditions, we've gotten more acceptance."
Compliance has been good at her facility, she reports. "They've gotten where they don't fight us at all, and some like it," Iannelli says.
One reason for the acceptance is that their smoke evacuator, Crystal Vision Smoke Evacuator and the handheld electrosurgery-smoke pencil PenEvac (both from I.C. Medical), is user-friendly, she says. The unit is one piece, as opposed to a clip-on evacuator that can snap off during a case. Also, their unit is set up so that it only comes on when the electrosurgery unit is activated, she says. "You don't have the constant noise from a smoke evacuator going all the time," Iannelli says.
The change has had an impact, with staff reporting less burning in their eyes and less respiratory irritation, she reports. Additionally, it smells better in the room, Iannelli says.
The cost is $35 per case. "That includes the electrosurgery pencil with a shroud, or the one-piece PenEvac that we use, plus any tubing and filters," Iannelli says. "For our facility and the type of cases we do, it is less than $20,000 per year."
For more information about the Crystal Vision Smoke Evacuator ($4,845) and the PenEvac ($550 per case of 20), contact: