How to Stay Laser Safety Compliant

If representatives from your credentialing organization pay you a surprise visit tomorrow, will your laser safety program pass muster? For many laser safety officers, this question is difficult to answer. Outpatient surgery facilities' policies are often ambiguous, because it is difficult to determine exactly how much effort is needed to adequately protect your patients, personnel, and facility without over-investing your time and energy. When you are armed with good information and guidance, however, a laser safety program does not have to be a source of anxiety. In this article, we'll outline what you need to do to stay laser-safety compliant.

Update Policies & Procedures
When creating or revamping a laser safety program, the first step is to be sure your facility's policies and procedures reflect current ANSI Z136.3 standards, and then be sure your current practice reflects these policies and procedures. OSHA, JCAHO, and other credentialing organizations follow these standards, which apply to all outpatient surgery facilities-including hospital-based facilities, freestanding centers, and office-based surgical suites. Your credentialing representatives may very well turn to your policies and procedures manual when assessing your laser safety compliance.

Train
It is incumbent on the laser safety officer to know the ANSI Z136.3 standards and understand their rationale. Otherwise, it is nearly impossible to enforce the standards. A basic knowledge of laser technology is mandatory, but an in-depth physics course is not warranted. Essentially, the laser safety officer and all other staff members involved in laser cases should know what happens when the laser is turned on. (ANSI Z136.3 standards recommend that all healthcare practitioners who will be in the room during laser procedures receive "proper education in laser science and safety.") For example, how is the laser producing the particular wavelength, and how does it interact with tissue to produce the desired result? (See Understanding Laser Technology sidebar.)

It is also important for the laser safety officer and other involved personnel to know how to run the laser. Without question, the hardest part of laser operation is working the control panel, so I recommend hands-on training. In my training sessions, I give participants laser parameters and ask them to do mock surgery on practice specimens (chickens and livers) until they feel comfortable with the laser.

The laser safety officer can meet these training requirements through self-education or by attending a course, and then conducting in-house training using teaching tapes or presentations by staff members. Alternately, the staff members who are involved in laser cases can attend a laser course together. I recommend a group training course if the facility can afford it, and there are ways keep costs down. For example, you may want to ask your laser representative for suggestions and possible sponsorship. You can also arrange a joint training conference with other outpatient surgery facilities. By offering continuing education credits and charging other attendees for the course, you can help defray the cost of the trainer or even make the venture profitable. Page 54 offers a list of training firms, as well as resources for conducting your own training.

Credential
JCAHO and other credentialing organizations require "competency-based evaluations," although it is up to the facility to determine just how to meet this requirement. The hands-on training sessions are a terrific way to demonstrate compliance. Some also recommend proctoring all staff members in three separate cases, but I simply recommend proctoring until the individual feels comfortable with the laser.

Enforce Safety Standards
Foremost, the ANSI Z136.3 standards aim to protect the patient, but it is also incumbent on the laser safety officer to protect the healthcare staff. To do so, it is important to create a laser safety checklist and review it before every case. The checklist should cover everything from door signs to draping to laser-safe endotracheal tubes (see page 56). The checklist is generic to all lasers, although the CO2 laser also needs to be test-fired before surgery (see page 57).

Some important parts of the safety checklist include:

• Eye protection.
  Eye injuries can occur when there is a break in the fiber or laser energy reflects off a shiny surface. The fluid in the eye readily absorbs excimer, CO2, and holmium laser energies, and this can cause a corneal burn. Other wavelengths can pass through the anterior chamber and cause a debilitating retinal burn. To protect the patient when the eyes are in the sterile field, the anesthesiologist should use a water-based lubricant, tape the eyes, cover them with wet eye pads, tape the pads, and then cover them with a wet sterile towel if possible. Otherwise, I recommend soft goggles appropriate to the laser wavelength, as regular laser glasses allow too many gaps.
  To protect healthcare practitioners in the ANSI-specified "nominal hazard zone," which I consider to be the entire room, protective glasses with an optical density specific to the laser's wavelength are necessary. Different wavelengths require glasses of different optical densities, although some specialized glasses will work for several wavelengths if your facility uses more than one type of laser. The laser safety officer should also inspect all glasses before each procedure, as a significant scratch can alter the optical density and leave the wearer vulnerable to injury. All glasses must also be labeled or marked with the laser wavelength and optical density.

• Smoke evacuation.
  The laser plume contains dead and live cellular material and may contain viruses. I prefer a triple filtration system, although the efficiency of any filtration system is highly dependent on the proximity of the suction device to the tissue surface.

• Laser log.
  The ANSI Z136.3 standards suggest documenting each use of the laser, and the laser safety officer can record this information on a laser log or a dedicated component of the patient record. I recommend recording the following information: Laser settings and mode; serial number (if your facility has more than one laser); adherence to the checklist; name of the laser safety officer; and the name of anyone who refuses to wear eye protection. In the latter case, the log should state that "laser glasses were offered and refused by Dr. _______." This may also trigger an incident report if it deviates from your facility's policy, although facilities do not have much influence over independent, licensed practitioners.

• Fire prevention.
  Alcohol-containing solutions such as Hibiclens and Duraprep are flammable, and great care is required when using them during laser procedures. Duraprep needs to dry completely before firing the laser; rinsing or blotting can destroy the bacteriostatic properties. Hibiclens can be safely rinsed or blotted dry before firing the laser. When using a CO2 laser, methane gas is a concern when the patient is in the lithotomy position. In this case, drape the rectum with a wet towel and insert a wet Raytek into the rectum to prevent release of gas. In all cases, the OR team needs to drape the surgical area with wet towels to prevent fire and have water available on the field at all times. The water should be in an open basin on the Mayo stand and fully accessible to the surgical team.

• Laser-safe endotracheal tube.
  When performing laser surgery in an airway, it is important to use a laser-compatible (non-PVC) endotracheal tube. PVC is highly flammable and toxic. In the event of an endotracheal tube fire, the scrub should dump the water down the tube while the anesthesiologist shuts off the oxygen. This will prevent removal of the tube while it is still burning. The anesthesiologist then needs to reintubate the patient and perform a bronchoscopy when feasible to assess the damage. In some cases, tracheotomy may be needed, and postoperative antibiotic and steroid treatment is warranted.

Maintain Compliance
In many facilities, lasers sit unused part of the time, and it can be challenging to keep your laser skills fresh. To maintain compliance, I recommend setting up a "skill day" every three to six months, during which the laser safety officer performs a repeat, hands-on training session. I also recommend addressing the issue of laser safety about every six months as part of your usual safety or performance improvement committee meeting to determine if there are any problems.

The laser safety officer can also include the topic of safety in the facility's performance improvement program. For example, you may want to conduct a retrospective chart review to ensure that the laser log is filled out properly. Or, you may do a prospective evaluation of the OR to ensure proper laser set-up and adherence to the safety checklist.

Make it Fun!
In my experience, many staffers don't like lasers because they represent just one more piece of equipment to worry about. For this reason, I feel it's imperative to make the laser safety program at your facility as much fun as you possibly can. With a well thought-out training program and a touch of levity, lasers can actually be fun!

Karen Andersen has provided laser science and safety training programs to OR staffers for the past ten years. She is the administrator of the Surgery Center of Melbourne in Melbourne, Florida, and president of Med-Ed Seminars. She is a licensed health care risk manager in the state of Florida.