Standing Up Against Surgical Smoke

Qing Zhou, RN, BSN, CNOR, grew concerned about her surgical team’s exposure to surgical smoke back in 2008 when AORN began raising awareness of the dangers to its members. It took several years of talking about the issue with her colleagues at Kaiser Permanente Irvine (Calif.) Medical Center to make change happen. “Our hospital is a tobacco-free campus — you have to leave the campus to smoke a cigarette,” says Ms. Zhou. “We began to question the effects of surgical smoke in the OR and decided the campus should be free from that, too.

“I’ve been an OR nurse more than 25 years and always felt like being exposed to surgical smoke was just part of the job,” continues Ms. Zhou. “But after learning about the negative side effects, we took it upon ourselves to create a smoke-free environment.”

To make change happen, first find out how much your staff knows about the dangers of surgical smoke. Ms. Prince used the online polling tool SurveyMonkey to quiz her staff and found out only 1 in 3 had a basic understanding of the associated health hazards or were familiar with the contaminants that surgical smoke contains.

Lack of knowledge about the dangers of surgical smoke appears to be a common issue. “When we first presented to our staff about surgical smoke, they began to realize maybe that’s why they had headaches, burning eyes or other symptoms,” says Lauren McNulty, BA, BSN, RN, an OR nurse at Penn Presbyterian Medical Center in Philadelphia, Pa. “We didn’t have to convince anyone of the importance of smoke evacuation after our presentation, which inspired us to push for change.”

Hand out questionnaires during staff meetings to gauge how much your staff already knows about the dangers of surgical smoke, suggests Ms. McNulty. Keep a tally of how many evacuators are used before your educational efforts, a month later and 3 months out to understand how well your message gets across and how sustainable it is.

She believes the facts speak for themselves when it comes to eliminating exposure to surgical smoke, and more surgical professionals need to be informed of the risks involved. “I honestly believe one of the main reasons smoke evacuation is not being used is due to a lack of knowledge,” says Ms. McNulty. “Constantly talking about the subject is a way to keep it fresh in everyone’s minds.”

After multiple educational sessions at Littleton Adventist Hospital, 94% of the staff knew about the dangers of what they were breathing in during surgery, a significantly higher percentage than before the information was disseminated. “Our team recognized what they were being exposed to on a daily basis,” says Ms. Prince, “and they wanted to take action.”

Going smoke-free in the OR takes plenty of hard work and internal campaigning, especially when trying to convince surgeons, some of whom don’t fully believe surgical smoke causes long-term side effects or illnesses — perhaps because they spend only a fraction of the time around smoke compared with the nurses and the rest of the surgical team members who work long days in the OR. That’s partly why much of the push for mandatory smoke evacuation across the country is coming from other members of the surgical team.

Ms. Prince suggests creating PowerPoint presentations and handing out scientific research on the topic. Email team members reputable research papers — studies not sponsored by the manufacturers of smoke evacuators — that show overwhelming evidence of the hazards of surgical plume (here’s one: osmag.net/Rnj6ZW).

Most surgical professionals, surgeons primarily, want to see clear clinical evidence before they agree to change how they operate. “I provided our team with Level 1a evidence, because it’s hard to argue with empirical research,” says Ms. Prince.

She also conducted educational in-services and invited guest speakers to present to the surgical team about the importance of smoke evacuation. Her persistence and prodding paid off. “Staff began to do their own research,” says Ms. Prince. “They were empowered by their knowledge of the facts and were inspired to speak up.”

Don’t hesitate to lean on vendors to support your efforts to get evacuators into your ORs. They of course want to sell you their products, but they’re also experts on how their devices work and advocates for creating smoke-free work environments. “We worked closely with the makers of smoke evacuation devices to find cost-effective options,” says Ms. Zhou. “They gave us really good products to trial and conducted educational sessions.”

Alexandra Muehlbronner, RN, BSN, BS, an OR nurse at Penn Presbyterian Medical Center, says implementing smoke evacuators into everyday use is a much bigger process than you might realize, one that includes presenting to and gaining approval from different committees or administrators and finding cost-effective products.

She shared a PowerPoint presentation on the dangers of surgical smoke with her staff, and emailed the presentation to the chief of anesthesia in an effort to inform leadership in all departments that are impacted by surgical smoke.

“With so many factors involved,” she says, “you have to push to make sure your cause is seen and taken seriously by everyone involved.”

Ms. McNulty suggests looking ahead on the surgical schedule for cases that will involve electrocautery or laser devices and conferring with circulating nurses to see if they plan on having discussions about using smoke evacuators with the surgeons, who must be comfortable with devices before they agree to implement them.

That’s why a key part of smoke exposure prevention is having staff and surgeons trial the different types of evacuators available to see which ones they like best and, just as importantly, which ones they don’t feel comfortable using. Ease of set-up between cases is important, but it’s often the surgeons who decide which product ultimately gets used, according to Ms. Zhou. “Their concerns often center on the ergonomics of the device — how easy it is to use without impacting how they operate — and that it effectively evacuates smoke,” she says.

I've always felt like being exposed to surgical smoke was just part of the job.
— Qing Zhou, RN, BSN, CNOR

Smoke evacuators were already on hand at Penn Presbyterian Medical Center, so the trialing process involved renewing staff interest in using the devices rather than finding the right fit. Still, Ms. Muehlbronner hopes to conduct another trial that will let the team find a product that better fits their clinical needs and preferences. “We got a lot of feedback from surgeons, and one of the things they didn’t like was how bulky and loud the evacuator was,” she says.

Ms. Prince heard similar feedback from her surgeons, who trialed 4 evacuators before deciding which ones they wanted to use. “Each surgeon filled out an evaluation form to rate the products,” she explains. “Whichever one they rated the highest was added to their preference cards.”

Her surgeons preferred the smallest, most lightweight electrosurgery pencils with integrated evacuators that had the same feel as the standard pencils they had been using and pushed back against using noisy, bulky pencils that blocked visualization of the surgical field. “It’s important to give surgeons a choice,” says Ms. Prince. “Smoke evacuation efforts have to involve the end users to be successful.”