The hazards that surgical smoke present to your employees and the importance of evacuating plume from your procedure areas have been made abundantly clear by clinical researchers and workplace health advocates. But implementing a solution can require a change of practice, which might pose an obstacle to its adoption. How does a plan become action? A few safety-minded managers recounted how they outfitted their facilities with smoke evacuation systems and how they make sure they're put to use.

CLEAR VIEW Electrosurgery without the offensive odor or health hazard of surgical smoke.

Smoke and suffering
As the by-product of electrosurgical, laser or other energy-based device usage, surgical smoke permeates OR and procedure room environments with the offensive odor of ablated human tissue. "From the first time I set foot in an OR, I knew that surgical smoke was a problem," says Rob Scroggins, RN, BSN, CMLSO, the clinical technology resource nurse at St. Elizabeth Healthcare in Edgewood, Ky. "The smell was bad. My eyes were watering. It was just really bad."

The plume isn't just objectionable; it is by many accounts potentially hazardous to employees' health. Surgical smoke contains toxic, carcinogenic and non-carcinogenic chemicals and gases, including some that are also found in cigarette smoke. It also aerosolizes patients' tissue and body fluids, including viral DNA. "It's been out there for many, many years that surgical smoke is harmful," says Terri Link, RN, BSN, MPH, perioperative patient safety specialist at the University of Colorado Hospital in Aurora.

Anyone who's suffered prolonged exposure to surgical smoke, though, doesn't need a scientific analysis to tell them that. Electrosurgical or laser plume can irritate the eyes and upper respiratory tract, induce nausea and lingering breathing difficulties, and cause visibility difficulties for the surgeon. "You can totally tell it has an effect," says Barbara Getlan, RN, BSN, administrator and director of nursing at the Bellona Surgery Center in Towson, Md. "Your chest gets tight. There is something there."

The worst part of surgical smoke? For a long time, says Mr. Scroggins, a surgery veteran with more than 2 decades of experience, "it was just accepted. If you worked in the OR, you knew you were going to get the smoke."

Motivation to action
That's not the case anymore. Increased awareness has brought the issue to the forefront, health and safety standards have made it imperative, and technological advances have made surgical smoke exposure a largely avoidable hazard. The combination of these factors has motivated many facilities to take steps toward routine and efficient smoke evacuation.

"Twenty years ago, the technology didn't exist," says Mr. Scroggins. "We used room suction, which wasn't particularly effective. About 10 years ago, articles started to emerge that showed the hazards of smoke. We had some smoke evacuation devices, for use in laser cases." At that time, he explains, many clinicians mistakenly believed that laser plume was worse than other kinds of surgical smoke. (Now, however, "research shows that Bovie plume may actually be worse than laser.")

The year 2010 saw stronger statements on workplace air quality and chemical hazard mitigation from the Occupational Safety and Health Administration, the CDC's National Institute of Occupational Safety and Health, and the American National Standards Institute. These joined OSHA's long-standing General Duty Clause, which states that employers are obligated to mitigate any recognized hazards that employees face in the course of their jobs. "Smoke is a recognized hazard, there it sits," says Mr. Scroggins. "It's an environmental issue. You can fit everyone for respirators, or you can evacuate the smoke." With that, it became incumbent upon OR managers to take a serious look at the issue, he notes.

At Ms. Link's hospital, 21 of the 25 ORs had equipment booms with integrated smoke evacuators. They'd been in place for a few years in anticipation of the 2010 regulatory requirements, but their use wasn't mandatory, so they weren't routinely used. Once the criteria for handling surgical smoke became "if you see it or smell it, it needs to be evacuated," the hospital re-evaluated its existing system and considered the freestanding suction units and devices it would need to supplement its centralized evacuators.

For other facilities, the decision to take smoke seriously wasn't driven by policy, but by personal experience. In the Bellona Surgery Center's single OR, the smoke evacuator tube that attached to the electrocautery handpiece was used only for longer cases, such as abdominoplasty or breast reconstruction, says Ms. Getlan. When high-volume surgeon Michael Cohen, MD, returned to the OR after a month away, it only took a couple of cases before he noticed a sore throat and cough from the smoke. "He said, we should be using smoke evacuation for all cases, and asked me to see if we could find a solution, preferably one that wasn't too expensive."

TOTALLY TUBULAR If your smoke evacuation method is unintrusive enough, it can easily become a routine step in every procedure.

Making the case
Dr. Cohen's backing meant that smoke evacuation success was virtually assured at Bellona. "We were lucky because the medical director, the owner, the one who pays the bills, was the one pushing for it," says Ms. Getlan. "He's a very health-conscious person, and wants his employees to be healthy."

If your centers' chiefs haven't noticed a cough that doesn't go away or a rash of employee absences, how can you bring this issue to the attention of those who make the decisions? Researching the literature can help you make converts, says Mr. Scroggins, who has unearthed warnings on the dangers of plume dating back to the 1980s.

A few years ago, as more regulatory agencies and healthcare organizations addressed the issue of surgical smoke, he took his research to his nursing manager, who took it to the director of nursing, who took it to the health system's administrator and safety director. Their response? "They said, 'We've got to do something about this. Can you make it happen?'"

Making the case "went easier with administration than I'd expected," he recalls. "I was expecting resistance. Not because of costs — ?they're very big on safety, and 'do what you have to do' to ensure it — but because of rocking the boat of routine practice." But they didn't challenge the validity of the research he'd compiled.

Ms. Link was part of a task force that conducted a review of each procedural area and any department that used surgical energies. Their findings, which the group presented as a poster at a recent AORN Congress, toted up the changes that needed to be implemented in the clinical environment and among the staff in order to attain compliance with the Joint Commission's standards on smoke evacuation.

Evacuation options
You've got plenty of options for smoke evacuation equipment. The range of freestanding evacuation devices and electrosurgery instruments with integrated suction might be the chief hurdle in deciding what best serves your needs.

"We went looking in the midst of changing technology," says Ms. Link, "just as smaller units were becoming available." Her hospital's task force reviewed each product's effectiveness and noise level. On some, the tip of an electrosurgical pencil's evacuator proved obstructive to the physician's view or tubing tangled up his technique.

If the details of trialing and selection bog you down, enlist your facility's technology whiz. "My job as a resource nurse is to look at healthcare technology for the OR," notes Mr. Scroggins. "My boss calls me a geek, and I am one." His knowledge of energy-based devices (a subject he's taught peers about) and his network of clinical and commercial electrosurgical and laser contacts let him sidestep hands-on trials entirely. Instead, he scoured the products' literature for such technical specifications as cubic feet per minute of air displacement and peripheral attachments; called manufacturers to determine pricing; and checked references to ascertain the reliability of local service and support. That's how his system settled on electrocautery pencils with built-in smoke evacuators, and evacuator hoses at the surgical site for laser and other cases.

One big advantage of the range of options is the range of pricing. If the reason you're hesitating to implement smoke evacuation is the cost, says Ms. Getlan, "look at all the alternatives. There are ways to do it safely and still cost-effectively." Her center went from using wall suction to a freestanding smoke evacuator with tubing at the site or clipped to energy devices. The eagerness of manufacturers to get their products in use and contract purchasing can also put safer practices within the reach of nearly every budget.

Putting it into practice
Changes in practice can meet resistance from staff, but the extra steps involved in smoke evacuation are usually readily accepted. "It may not be quite so simple as, 'Here it is, we're going to use it,'" says Ms. Link. "But nursing staff are a little more understanding as to why it's necessary. They do not want to be exposed to the smoke."

Education is key to ensuring routine use of evacuation devices and complete compliance with employee safety guidelines, says Mr. Scroggins. "It's all about getting the information in front of staff nurses." When his ORs were first outfitted with the devices, he worked with facility educators to create bulletin board posters warning of the hazards of surgical smoke, and encouraged nurses to research the subject themselves, which built solid support for routine evacuator use. As a result, "anecdotally, we've noticed less of that little cough that OR nurses and techs have at the end of the day."

As with any new equipment, nurses and techs may need to scale a learning curve at first to operate smoke evacuation devices. Standardizing products and practices throughout your ORs and procedure rooms can help to smooth training and adoption, says Ms. Link. Practice makes proficiency, adds Ms. Getlan, whose staff has learned that longer cases are usually best served by evacuator tubes attached to electrosurgical instruments, which free up nursing and tech hands to hold other items.

Does the doctor know?
"I think there are people who still don't believe smoke is that bad," says Ms. Link. "Surgeons who have limited exposure to it may not recognize its hazards." Her hospital's choice of evacuation equipment makes it as easy as possible for them to act, though. A Bovie pencil with built-in suction automatically evacuates smoke without them having to hit a switch or pedal every time they're cauterizing. It also means they don't have to continuously listen to the sound of suction, and intermittent use increases the life of the suction filter. If a surgeon doesn't use the device — and he has to provide a solid reason why not, she says, such as it obstructs his view of the site — another smoke removal method is set up and noted on his preference cards.

"I'm a firm believer that education and communication solve any problem," says Mr. Scroggins, who estimates evacuation device use in his health system's cases is at 70% to 80%. "Find your champion nurses and physicians. Do your research: Doctors are scientists, they want to see proof."

And to those who, for whatever reason, don't want to use the smoke evacuation equipment on hand, he extends an offer. "If something isn't meeting your needs, I have the equipment catalog in my office. If there's something that works for you, we'll get it. We have the full support of administration to do so," he says. "Then they can't say they didn't use it because they didn't have it. That wouldn't be true."