July 17, 2024

A perioperative nurse’s advice on how to bring smoke evacuation to your ORs — and keep it there.

TACTILE EXPERIENCE Dr. Rayan Eshaghian demonstrates laparoscopic smoke evacuation technology during an educational showcase at PIH Health Downey Hospital.

The ORs at PIH Health Downey (Calif.) Hospital have been smoke-free for three years. If you’re interested in doing the same for your own ORs, here are key learnings from Stephanie J. Jones, MSN, RN, CNOR, the facility’s clinical director of surgery, who calls the project "one of the hardest practice challenges I’ve led, but also one of the most rewarding."

• Don’t go it alone. Gather an interdisciplinary team of smoke evacuation champions. Ms. Jones brought together nurses, surgical technologists, educators, surgeons and anesthesia providers to work on and bring their unique perspectives to the initiative. Later, a materials coordinator was added for insight on smoke evacuation equipment, supplies and purchasing. "Having a solid project team really helped during implementation once we identified our challenge areas so we could delegate team members to divide and conquer," she says.
• Educate yourself and your team. Collect, understand and distribute evidence about the dangers of surgical smoke exposure to your team and other stakeholders. "We found team members knew smoke was bad for them but didn’t know just how bad," says Ms. Jones. "Seeing peer-reviewed research demonstrating the reality of virus transfer, such as HPV released in surgical smoke infecting the respiratory tract of surgeons, was eye-opening."
• Activate equipment already in-house. Capital expense approval to purchase smoke evacuation equipment can be difficult to secure. The good news is many facilities already have equipment that can be used for this purpose. For example, Ms. Jones’ hospital had recently purchased waste management systems for every OR that included smoke evacuation functionality. "We brought the vendor in for additional training, our materials coordinator took the lead on purchasing additional smoke evacuation supplies, and our OR educator led training on how to safely use and dispose of biohazard items such as smoke evacuation tubing and manifolds," says Ms. Jones.
• Trial different systems. Ms. Jones says some surgeons were hesitant to embrace smoke evacuation based on years-old experiences with noisy systems and evacuation pencils they had found bulky and challenging to use. Today’s systems address those concerns, so have your surgeons experience the latest smoke evacuation systems. "We connected with vendors to bring in different smoke evacuator pencils and gave surgeons the chance to test and vote for their favorites," says Ms. Jones. "This helped secure surgeon buy-in by engaging them in the process and respecting their preferences."
• Educate post-purchase. Once the equipment is in-house and ready to use, tailor education to specific teams to achieve buy-in. "We wanted our RNs and surgical technicians comfortable with how to open, use and discard smoke evacuation disposables," says Ms. Jones. "We also wanted them to be the experts in the room to troubleshoot device use. Then we went to each individual group committee meeting, including anesthesiologists and surgeons, to explain our project and timeline, and address any concerns."
• Establish your smoke-free policy. Create a specific policy dedicated to the detailed practices of smoke evacuation. "First, it standardizes the ‘how’ to help teams get it right every time," says Ms. Jones. "Second, a policy is something everybody can reference to empower practice while making it clear that compliance isn’t optional."
• Gamify compliance. Auditing compliance is crucial, but changing behaviors can be challenging. "Our auditing identified individual surgeons who weren’t evacuating smoke consistently, so we posted compliance rates in our community lounge for all to see," says Ms. Jones. "No one wanted to be at the bottom of the leaderboard. Our weekly compliance updates soon leveled out with everyone at the top."

These steps helped the hospital not only to go smoke-free, but to stay that way for three years running.

A pregnant nurse’s concerns led this facility to go smoke-free.

TIME OUT Working in smoke-filled ORs can seem "normal" for teams that have done so for years, but one strong and concerned voice often can cut through the complacency.

Surgical smoke can be harmful to the long-term health of perioperative professionals. Janelle Casanave, RN, circulating nurse at Kaiser Permanente in San Jose, Calif., had an additional reason to advocate for smoke evacuation: her soon-to-be-born child.

"I learned about the dangerous effects of surgical smoke when I became a nurse in 2012, and I found it very conflicting that nothing was being done about it," says Ms. Casanave, who had shied away from speaking up at first. "I thought, ‘Well, no one else is complaining, so I don’t want to be the person questioning things. I’m a new nurse.’ I told myself it can’t be that bad if the surgeons aren’t complaining about it."

That changed five years later when Ms. Casanave’s pregnancy inspired her to speak up in favor of permanent change. "I decided I couldn’t expect the surgeons to lead the charge, because they aren’t in the operating room nearly as often as nurses and techs," she says.

Her single but powerful voice made a difference, and it kicked off a successful effort to rid the facility’s ORs of surgical smoke for good. Ms. Casanave’s concerns were met with understanding ears and very little resistance, and within four months, the facility’s ORs were completely smoke-free. Conveniently enough, the ORs were already equipped with mobile fluid waste management units that connected to smoke bovies included with the systems. "The equipment was already accessible," she says. "It was just a matter of using it. We really tried to help the surgeons with ways around whatever problems they were having. Fortunately, the pencils we already had were great, so it made the transition easier."

The facility has since earned Gold Status from the Association of periOperative Registered Nurses’ Go Clear Program, and Ms. Casanave became the West Coast representative for Nurses Against Surgical Smoke, even speaking in support of a statewide surgical smoke evacuation mandate during a Senate hearing at the California State Capitol in Sacramento.

Ms. Casanave’s story exemplifies that, in the fight to evacuate surgical smoke from our nation’s ORs, sometimes it just takes one concerned but committed voice to set off a chain of positive events.

Meeting safety concerns for patients and staff takes a step-by-step approach and the right equipment.

STERIS

The issue of smoke in the OR is a long-term problem that has been a focus of healthcare professionals for decades. Now, as more states are embracing and passing regulations that protect healthcare workers from the dangerous plumes of smoke created by surgeries, the momentum is growing for additional legislation to take hold. Strong advocacy on the part of the Association of perioperative Registered Nurses (AORN) and others have kept this safety concern in the forefront.

AORN is leading the efforts to make smoke evacuation policies the law across the country and ensure that all operating rooms are surgical smoke-free. To date, 18 states have enacted surgical smoke evacuation legislation. These include Arizona, California, Colorado, Connecticut, Georgia, Illinois, Kentucky, Louisiana, Minnesota, Missouri, New Jersey, New York, Ohio, Oregon, Rhode Island, Virginia, Washington and West Virginia.

According to AORN, the commitment to evacuate all surgical smoke is best implemented with interdisciplinary support and buy-in at a health care facility. These teams are the backbone of technological development for their organizations, executing and monitoring pilot projects based on emerging trends and needs. The National Fire Protection Association (NFPA) has required capture of surgical smoke plume since the 2012 edition of NFPA 99, Health Care Facilities Code. In the 2024 edition, however, Section 9.3.8, Medical Plume (Surgical Smoke) Evacuation and Filtration, now requires health care facilities to capture surgical smoke as close as possible to the point of generation in ORs nationwide.

In a recent article in Health Facilities Management, Erin Kyle, R.N., DNP, CNOR, NEA-BC, editor-in-chief of the Guidelines for Perioperative Practice, and Amy L. Young, JD, general counsel and director of government affairs for AORN, outlined a step-by-step process for facilities to take action on smoke advocacy.

It states, "Facilities seeking to fulfill the updated requirements of the National Fire Protection Association’s NFPA 99, Health Care Facilities Code, can do so by following a step-by-step process: 1) Securing commitment of facility executives, leaders and teams working in clinical care environments where medical plume/surgical smoke is generated; 2) Identifying an interdisciplinary team that will hold the responsibility and authority to develop and implement policies and procedures requiring evacuation of all medical plume/surgical smoke; 3) Developing an action plan, including adopting a facility wide policy and procedure for medical plume/surgical smoke evacuation; determining resources needed (e.g., point-of-generation surgical smoke evacuation equipment and supplies); identifying barriers and planning for overcoming them during implementation; agreeing on a timeline for implementation; and determining how success will be measured and maintained (e.g., compliance metrics and an audit strategy); 4) Implementing the action plan by identifying and including all members of the affected teams (e.g., perioperative health care workers and teams working in other departments where medical plume/surgical smoke is generated) and providing education about the dangers of medical plume/surgical smoke and details about the facility’s action plan and what each team member’s role is for implementation; and 5) Auditing and monitoring compliance and celebrating successes."

There is agreement that surgical smoke plume is a dangerous hazard that poses a health risk to all OR occupants during almost all surgical procedures. We know that surgical smoke is released into the air when energy-based surgical equipment, such as lasers, electrocautery and ultrasonic devices, are used on surgical patients.

Products on the market can help stem the tide of smoke plume hazards while fitting into the workflow and budget considerations of an outpatient facility. One of the most effective ways of removing the hazards of surgical smoke plumes is using Smoke Evacuation Systems. These can remove the plume at its surgical site source by using a tube attached to the accessory or device creating the plume. The system usually contains a series of filters allowing filtration down to the micron size to ensure that even the smallest particulates can be captured. The goal is to ensure the safe elimination of any smoke plume during a surgical procedure.

The Steris Smoke Evacuation device works with all cutting devices for automatic activation. This surgical smoke evacuator employs a unique design that pulls air through a narrow opening at very high speeds causing the air to spin and form a powerful air vortex around the ESU blade.

Smoke particles expelled from the surgical site in any direction are captured in the air barrier created by the vortex before they escape. It stops automatically if tissue is accidentally suctioned and can be used to deflate pneumoperitoneum at the end of the case. The rotary vein pump motor provides a longer service life and creates less noise compared to brush motors. Additionally, the ULPA Filter offers efficiency greater than 99.99% and captures 0.03Microns size particles without blowing bioburden back out to OR. The charcoal filter provides the highest airborne particle reduction capacity.

Overall, this system provides unique advantages during laparoscopic procedures with a patented automatic built-in valve that allows for hands-free smoke evacuation and a feature that helps maintain pneumoperitoneal pressure and allows the surgeon to concentrate fully on the procedure.

Researchers have concluded that surgical smoke should be evacuated to protect the OR team and the patient from the toxic, possibly carcinogenic, mutagenic and genotoxic effects – and with the Steris Smoke Evacuation device these safety concerns can be met.

Note: For More information visit Surgical Smoke Evacuator | Surgical Smoke Evacuation Systems | STERIS