Fighting for Smoke-Free ORs

When Illinois Governor J.B. Pritzker signed into law last year a measure that required hospitals and ambulatory surgery centers to eliminate surgical smoke, it was a big win for the nurses and other safety professionals who had been advocating for change for more than 30 years.

“In 1981, I gave my very first lecture about the hazards of smoke plume,” says Penny Smalley, RN, CMLSO, an independent nurse consultant and director of education and regulatory affairs for the International Council on Surgical Plume (ICSP). “I was involved with one of the first laser systems installed in a medical clinic, and there was no information or educational resources at the time about the hazards.”

Ever since lasers and electrocautery devices became mainstream surgical tools, the question of how the resulting surgical plume impacted people would be debated. Advocates like Ms. Smalley have been working toward educating both healthcare administrators and state legislators about why the issue is as important as ever. “The noxious smoke that results from surgery is disgusting and uncomfortable,” she says. It’s also considered one of the top five hazards in the OR today, prompting eight states — Georgia, Rhode Island, Colorado, Kentucky, Oregon, Washington, Arizona and Illinois — to pass laws requiring surgical teams to use evacuation devices during smoke-generating cases.

The grassroots effort behind this initiative, led by the Association of periOperative Registered Nurses (AORN), is pushing to get similar legislation passed in all 50 states — and momentum seems to be growing. According to AORN, the average daily impact of surgical smoke to a surgical team is the equivalent of inhaling up to 30 unfiltered cigarettes. In the U.S. alone, an estimated 500,000 healthcare workers are exposed to surgical smoke each year, and perioperative nurses report twice as many respiratory issues compared to the general population. 

Rebecca Vortman, DNP, RN, CNOR, an assistant clinical professor at the University of Illinois Chicago College of Nursing, has been instrumental in conducting important research into surgical plume. Dr. Vortman calls on healthcare providers and state leaders to require mitigation of hazardous smoke plume, which can contain E.coli, MRSA, HPV, hepatitis viruses and HIV. Other potential hazards, including COVID-19 variants, as well as gases such as benzene, toluene, carbon monoxide, formaldehyde and hydrogen cyanide, can pose serious health risks.

While growing statewide legislation is certainly increasing the number of smoke-free ORs throughout the country, an unlikely catalyst has also helped in recent years: COVID-19. During the early stages of the pandemic, there were reports of surgeons at hospitals and outpatient centers around the country asking for plume evacuation devices for protections against the virus. Many professional organizations and regulatory agencies also started taking positions on the issue for the first time publicly. In 2020, the Joint Commission released a paper about alleviating the dangers of surgical smoke, stoking a bigger conversation about the dangers and solutions for surgical smoke evacuation. Additionally, the American College of Surgeons released a statement during the early months of the pandemic acknowledging potential transmission of COVID-19 to surgical staff during aerosol-generating procedures, including laparoscopic surgery. The Society of American Gastrointestinal and Endoscopic Surgeons urged surgeons to use precautions to reduce the risk of exposing OR personnel to COVID-19 from surgical plume, and to use smoke evacuators.

Many facilities have taken this message to heart. For instance, the Cleveland Clinic set a goal during the pandemic that all its surgical sites would go smoke-free. To date, 90% of the health system’s ORs have adopted effective evacuation methods. The same happened at Northwestern Medicine Palos Hospital in Palos Heights, Ill. As the second-largest hospital in the Northwestern Medicine HealthCare system with more than 600 affiliated physicians, the hospital took a comprehensive approach to eliminating surgical smoke in the past two years. With built-in compliance monitoring, the hospital was able to go smoke-free even before Illinois passed legislation requiring all hospitals and ambulatory centers to do so.

“When a facility chooses to avoid implementing plume evacuation policies, it sends the message that they may not care about the health of the nurse, the patient and the entire surgical team. I personally consider it a red flag to work somewhere that doesn’t evacuate surgical plume,” says Dr. Vortman.

She now advises nurses to ask during the interview process whether the facility uses surgical smoke plume evacuation devices. “COVID-19 and the Great Resignation have taught us that nurses and healthcare workers demand safe working conditions,” she says. 

In 2020, Dr. Vortman and her team conducted a study to determine how perioperative nurses are being exposed to surgical smoke plume, the most common health concerns and complaints due to that exposure as well as the best mitigation practices. Dr. Vortman concluded that while nurses are aware of the health hazards from exposure to surgical smoke plume, not enough of their employers were implementing mitigation practices. As she puts it, “Recommended practices and standards are not always used in the perioperative environment despite the proven risks.” Ms. Smalley can relate to this. When she was still working as an OR nurse, her team struggled with surgical plume, so much so that they came up with a way to evacuate the smoke using a DIY approach. They purchased a Shop Vac from the hardware store, and outfitted it with activated charcoal and fiberglass filters and hid the contraption in a closet with plastic tubing sticking out. “We built it because there was nothing on the market,” she says.

Luckily, today’s technology has caught up with the demand, producing devices capable of capturing up to 99% of smoke when placed near the source. While wall suction and surgical masks may not always remove or filter the substances of concern from surgical smoke, there are newer, more effective options.

According to the CDC, the most recommended ventilation techniques include a combination of general room and local exhaust ventilation (LEV). While general room ventilation alone is not sufficient to capture contaminants, the two major LEV approaches include portable smoke evacuators and room suction systems.

The first, smoke evacuators, contain a suction unit (vacuum pump), filter, hose and an inlet nozzle that offers high efficiency in reducing the number of airborne particles. Choosing the best filter is an important part of the process. A High Efficiency Particulate Air (HEPA) filter, for example, is recommended for trapping most particulates.

The second, a room suction system, can pull air at a much lower rate and is designed primarily to capture liquids rather than particulates or gases. If these systems are used to capture smoke, it’s important to install appropriate filters, make sure that the line is cleared and that filters are disposed of properly. The use of smoke evacuators tends to be more effective than room suction systems to control the smoke generated from non-endoscopic laser or electrosurgical procedures.

“When facilities implement plume evacuation devices, it sends the message that they care for the health and well-being of their staff,” says Dr. Vortman. “When healthcare facilities choose to invest in their staff by requiring the use of plume evacuation devices, this could lead to staff retention and a decrease in sick days.”

All facility leaders should heed this evidence and join the grassroots movement to make ORs everywhere smoke-free. OSM