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May 12, 2021
OSD Staff
Publish Date: May 11, 2021   |  Tags:   Staff Safety
eNews Briefs May 12, 2021


Nurse Drives Smoke Evacuation Buy-in at Surgery Center

Kentucky Becomes Third State to Mandate Smoke Evacuation

OSHA and Surgical Staff Safety

Tips for Evangelizing Surgical Smoke Safety

Addressing Barriers to Surgical Smoke Evacuation


Nurse Drives Smoke Evacuation Buy-in at Surgery Center

The effort demanded determination, hard work and passionate selling of the health-related benefits.

Smoke Education CREDIT: MedCenter Mebane Surgery Center
FRESH AIR Tabitha Turner, RN, MSN, CNOR, CGRN, educates staff on the dangers of surgical smoke.

The dangers of inhaling surgical smoke seem obvious, but affecting change at a facility to ensure smoke evacuators are installed and used is much less straightforward. Tabitha Turner, RN, MSN, CNOR, CGRN, assistant director at the Cone Health MedCenter Mebane (N.C.) Surgery Center, and the driving force behind its implementation of a surgical smoke evacuation program, understands that quandary very well.

After attending a medical conference where she learned about the Association of periOperative Register Nurses' (AORN) Go Clear program, Ms. Turner dove deeply into the issue, spending two months on research she presented to her leadership, which voiced its support. She then collected every study and article she could find about surgical smoke and bound it into a book she passed out to staff and surgeons. Each week, she posted new information about smoke evacuation on bulletin boards throughout the center. She placed packets of research in locker rooms and lounges, and even gave the surgical team candy cigarettes to get across the point that surgical smoke, like cigarette smoke, is dangerous to your health.

It didn't take long to convince staff and surgeons to join the smoke-free movement. "I spent many months gathering data to support what I was talking about," says Ms. Turner. "It's really important to present surgeons with clinical evidence when asking them to change how they operate."

In just over a year, Ms. Turner established a smoke evacuation program. She walked away with these valuable lessons:

  • Show the newest models. Ms. Turner brought in sales reps to introduce the latest smoke evacuators and set up trials. When her health system's ENT surgeons expressed concern about the potential negative impact of a smoke evacuation pencil close to the surgical site, she worked closely with them to gain their support. She then proceeded to win over the orthopedic and general surgeons. Much of the opposition came from experiences surgeons and staff had with earlier smoke evacuation products, so the design and functional improvements in the new devices, such as slimmer profiles, incorporation into electrosurgery devices and quieter operation, bolstered her case.
  • Choose the correct filters. After staff and surgeons began to use smoke evacuators during procedures, Ms. Turner continued educational efforts to ensure the devices were being used properly. She discovered many facilities don't use the correct filters, so she referred to the evacuators' instructions for use and ensured surgical teams understood the importance of using the correct filters.
  • Wear proper PPE. For added protection, ASTM level 3 masks should be used during smoke-producing cases. Higher-grade surgical laser masks should be used for procedures expected to generate heavy amounts of plume.

Ms. Turner has expanded her smoke evacuation program to facilities throughout the Cone Health system. With mandatory smoke evacuation laws now in place in three states, with more potentially on the way, Ms. Turner says the time for facilities to act is now. "It's going to be managed for you at some point, so get ahead of it," she says. "Pick out the products you want and make your own path. Don't wait for somebody to tell you what to do."

Kentucky Becomes Third State to Mandate Smoke Evacuation

The Bluegrass State's ORs will go smoke-free next year.

Smoke Evacuation Credit: Pamela Bevelhymer
EVACUATING AMBIGUITY Surgeon preferences will no longer apply to the use of smoke evacuation systems in Kentucky.

Kentucky has become the third state to mandate smoke evacuation in its operating rooms. Following nearly three years of advocacy efforts that overcame a pandemic-shortened legislative session, Governor Andy Beshear signed Kentucky SB 38 into law on March 22, requiring hospitals and outpatient surgery centers to use a surgical smoke evacuation system during any procedure that generates smoke. The law will take effect Jan. 1, 2022.

Kentucky joins Colorado and Rhode Island in passing surgical smoke-free legislation. "While it took some time to work through the legislative system, AORN is impressed that Kentucky has taken this important step toward workplace safety at a time when many other states face resistance to their smoke evacuation bills," says Jennifer Pennock, senior manager of government affairs with the Association of periOperative Registered Nurses (AORN). "Our work for similar legislation will continue across the U.S. until smoke in the operating room is as unacceptable as cigarette smoke on airplanes."

Indeed, surgical smoke evacuation bills continue to make their way through nine state legislatures this year, with AORN saying some have a strong possibility of enactment. Here's the latest on states with the best chances of enacting laws:

  • Illinois. SB 1908 has passed out of the Senate and is under consideration in the House.
  • Iowa. HF 783 generated overwhelming bipartisan support in the House, but stalled in the Senate Human Resources committee right before the April 2 deadline to advance.
  • Ohio. On April 15, SB 161 was referred to the Senate Health Committee on April 21, where it awaits a hearing.
  • Oregon. On April 13, the Oregon House Committee on Health Care passed HB 2622 unanimously, and the House of Representatives passed the bill on April 27. The bill awaits committee assignment in the Senate.
  • Texas. HB 4118 and SB 429 have been introduced and referred to committee. The TX House Public Health Committee may hear testimony on HB 4118 soon.

Click here to see all the state surgical smoke evacuation bills AORN is tracking.

OSHA and Surgical Staff Safety

Do forced-air patient warmers violate OSHA standards?

Dr Scott Augustine Credit: Augustine Surgical Inc
Dr. Scott Augustine demonstrating how surgical smoke is lifted into the breathing zone of the surgical staff by a vortex caused by forced-air patient warming (videos: http://hotdogwarming.com/stop-blowing-it/).

Operating room air quality, including surgical smoke inhalation, has OSHA's attention. OSHA has announced its enforcement position in a Standard Interpretation Letter: hospital employers can be liable for unabated exposures to air-borne pathogens.1

The dangers of surgical smoke are irrefutable. The surgical smoke produced in an operating room is the equivalent of ~30 cigarettes being smoked in a day.2 Like cigarettes, surgical smoke contains dangerous substances – carcinogens such as benzene, hydrogen cyanide and formaldehyde – but unlike cigarettes, it also may contain bioaerosols and viruses. Surgical smoke in the breathing zone is clearly a risk to the surgical staff.3

Surprising to many people, smoke evacuators remove only about 50% of surgical smoke.4,5 Even if smoke evacuation is utilized, surgeons and OR staff are still at a high risk of inhaling the viruses and carcinogens contained in the remaining surgical smoke.6 Why?

Instead of being pushed to the floor and out the side vents by the OR ventilation system, the un-evacuated smoke is sucked up into a vortex formed by the rising waste heat from forced-air patient warming devices and held in the staff's breathing zone for 2 minutes or longer each time the electro-surgical unit is used.

A vortex in the O.R.? Imagine a weather pattern forming between a hot front and a cold front. The ~950 watts of waste heat from forced-air warmers rises against the anesthesia screen before it is pulled by the low-pressure vacuum that naturally forms under the surgical light. The energy in the waste heat counteracts with the cool, downward-moving ventilation airflow, creating a substantial vortex—a literal tornado under the surgical light. Like a tornado, the vortex sucks up the smoke and holds it exactly where the surgical staff members standing by the table are breathing.

"OSHA should definitely care about this avoidable occupational hazard," says Dr. Scott Augustine, CEO of Augustine Surgical, who conducted research documenting the vortex phenomenon. "Our research shows that the only way to avoid breathing surgical smoke is to avoid forced-air patient warmers.6 This is clearly a surgical staff health and safety issue, which means that it is an OSHA issue."

The risk from forced-air warmers, however, isn't limited to surgical smoke. A Stanford University research team collected 200 air samples from forced-air devices on agar plates in 12 randomly selected ORs. The devices emitted "four times as many colony-forming units as room air," according to Justin Ward, MD, the chief resident, Department of Anesthesiology at Stanford University in California, in Anesthesiology News.7

"We can say with certainty that the [forced-air warmer] is contributing airborne microbes into the air," said Ward.7 In fact, pathogens were identified by DNA sequencing that were unique to the forced-air device and that could not be cultured from OR inlet air.

The best measures to protect surgical staff from the dangers of surgical smoke are:

  1. Use smoke evacuation to remove as much as you can.
  2. Eliminate sources of waste heat around the operating table that capture and mobilize surgical smoke and airborne pathogens.

Air-free warming systems can help maintain normothermia without generating waste heat. The HotDog® Patient Warming System, for example, is the preferred warming solution when airborne contamination is a concern and normothermia outcomes are important.

"The Association of periOperative Registered Nurses (AORN) and many other clinician groups have demanded safer operation-room air," says Dr. Augustine. "Removing the waste heat is a critical step towards that goal."

Note: For more information please go to https://hotdogwarming.com/stop-blowing-it/


1. OSHA requirements for smoke plume generated from laser and electrosurgical instruments in dental offices and hospital operating rooms https://www.osha.gov/laws-regs/standardinterpretations/2016-10-07 (2016)

2. Hill, D.S.; O'Neill, J.K.; Powell, R.J.; Oliver, D.W. Surgical smoke—A health hazard in the operating room: A study to quantify exposure and a survey of the use of smoke extractor systems in UK plastic surgery units. J. Plast. Reconstr. Aesthet. Surg. 2012, 65, 911–916

3. United States Environmental Protection Agency Criteria air pollutants https://www.epa.gov/criteria-air-pollutants (2019)

4. Liu N, Filipp N, Wood KB. The utility of local smoke evacuation in reducing surgical smoke exposure in spine surgery: a prospective self-controlled study. Spine Journal. 2020 Feb;20(2):166-173

5. Wang H, et al. Evaluation of fine particles in surgical smoke from a urologist's operating room by time and distance. Int Urol Nephrol. 2015;47(10):1671-8

6. https://www.youtube.com/watch?v=BmLu-ZIh9Rc&t=2s Published February 24, 2021

7. Vlessides, Michael, Warming Devices May Be Source of Airborne Microbial Contamination, but Fix Is Possible, Anesthesiology News, March 12, 2021, https://www.anesthesiologynews.com/Policy-and-Management/Article/03-21/Warming-Devices-Source-Airborne-Microbial-Contamination/62691

HotDog is a registered trademark of Augustine Surgical, Inc.

Tips for Evangelizing Surgical Smoke Safety

A nurse who long suffered from its effects shares her secrets for turning evacuators on for good.

Andrea Dyer, MSN, RN, CNOR, is a leading advocate for smoke evacuation across the country. Having moved smoke evacuation programs across the finish line before, she shares these tips to convince your staff and administration to install and use smoke evacuation systems:

  • Present proof. The science around surgical smoke is virtually irrefutable at this point, with its dangers well-documented in the literature, and three states have passed smoke evacuation laws. Still, some providers at your facility might remain dismissive of smoke evacuation, or not fully understand the dangers of surgical smoke. Ms. Dyer's advice is to educate holdouts with recent independent studies and research. "Make smoke evacuation an evidence-based project," she says. "Be prepared with peer-reviewed research and a cost-benefit analysis." Also stress how important smoke evacuation is for staff safety.
  • Sell it organically. Ms. Dyer partnered with a colleague to perform a "good cop, bad cop" routine. "We went from discipline to discipline in our health system, evangelizing and winning hearts and minds to our cause," she says. "Our mix of sugar and spice proved effective." Along the way, they acquired the surgeon champions they needed. "You can't just tell surgeons they need to run this machine," says Ms. Dyer. "You need frontline staff to explain it to them: 'Hey, my health is at stake here. You can choose whether or not I breathe in these chemicals.'" Don't shame surgeons who shun smoke evacuators, she says. Rather, educate them and let their understanding and advocacy grow organically.

Overall, she says, "educate from the bottom up and the top down and meet in the middle." Ms. Dyer ran continuing education in-services, shared research with anyone who asked and met with all chief nursing officers in her system. "One of the most powerful points I make is that an OR nurse breathes in the equivalent of 30 unfiltered cigarettes a day, and that over 150 chemicals have been identified in surgical smoke," she says. "That really opens eyes."

  • Make the financial case. The directors at Ms. Dyer's institution worried about cost. "My argument was that investing in smoke evacuators would be pennies on the dollar to address a known safety risk," she says. "And it's really not expensive if you work with a good vendor and negotiate effectively. Our hospital's leadership ultimately decided price was no object when it comes to protecting their employees."
  • Trial your options. "We took a focused approach on finding the best product," says Ms. Dyer. "In the process, we addressed some of the naysayers' concerns." For example, a common complaint was that electrosurgical pens with integrated smoke evacuators are bulky and heavy. Ms. Dyer presented doubters with research that revealed the diameter and weight of a typical electrosurgical pen is 1.7 inches and 21 grams, while one with smoke evacuation is 1.875 inches and 30 grams. "That's equivalent to nine paperclips," she says.

Another common concern was noise. "So we did noise studies, and found the new machines only get as loud as 55 decibels," she says. "The humming of a refrigerator is 45 decibels." She also found placing the machine closer to the ground makes its operation even quieter, and that some products run only when the electrosurgical pen is activated, eliminating the constant ambient noise some had experienced with older products.

Ms. Dyer then invited everyone in her health system of six hospitals to smoke evacuation vendor fairs. "This was another example of our organic approach: making people feel empowered to choose their own machines," she says. After the fairs, attendees completed surveys so Ms. Dyer and her team could analyze the feedback.

They trialed three products at all six hospitals for six weeks, rotating them in and out of different ORs. There was unanimous agreement among the champions on the best product.

The entire process took eight months. "Our vendor said we had the highest and quickest implementation rate in the U.S.," says Ms. Dyer. "Implementing smoke evacuation requires passion and time. Keep trying, no matter how long it takes. That's what I did, and after finally succeeding, it's become my mission to spread the word about surgical smoke safety."

Addressing Barriers to Surgical Smoke Evacuation

Study highlights the importance of partnering with surgical team members to limit their exposure risks.

Electrosurgical devices generate smoke that exposes surgical professionals to harmful chemicals, viruses and bacteria. Understanding why operating room teams don't evacuate smoke during plume-producing procedures helps to identify ways to implement protocols that effectively reduce their risk of suffering serious health conditions, according to research published in the Journal of Quality in Health Care & Economics.

The study's authors conducted a quality improvement program involving a hospital's surgeons, circulating nurses, anesthesiologists, physician assistants, surgical assistants, scrub techs and nurse anesthetists. Nearly half of the team members believed surgical smoke would have a minimal impact on their individual health before receiving education about the associated dangers. Most team members (69%) believed an evacuation system would be the most effective option for decreasing their exposure to surgical smoke.

Interestingly, circulating nurses thought surgeons did not want to use smoke evacuators when, in reality, surgeons were interested in working with unobtrusive devices that fit their comfort level and procedure type, and that did not impact their visualization of the surgical field or disrupt their focus on the procedure. Notably, surgical team members provided positive feedback of surgical smoke evacuation after using evacuators, and the study's authors report use of the devices has increased since implementation of the quality improvement project.

Individual facilities should create tailored surgical smoke safety education initiatives and evacuation policies based on their staff's perceptions of the benefits of limiting exposure risks and barriers to consistent implementation of smoke evacuators, according to the study's authors. They also suggest involving surgeons and surgical team members in choosing evacuation devices that work best for their specialties, surgical techniques, preferences and comfort levels.

The researchers say the overall success of quality improvement projects requires skilled communication, collaboration, effective decision-making and authentic leadership. "Increasing the surgical team's awareness of the harmful effects of surgical smoke leads to consistent use of evacuation devices, which reduces their exposure risks," they write.