Since body piercing is an increasingly popular form of self-expression, you're likely faced with patients presenting for surgery with jewelry in places other than in their ears or on their fingers. A survey of surgery center patients 18 to 50 years old published in the Journal of the American Academy of Dermatology found that 14% have body piercings. The survey notes piercings are equally common among men and women. So what should you do when a patient shows up with a piercing? Cancel the surgery? Put tape on it and go ahead with the procedure? In my opinion, there's only one sensible option: Remove it for safety and liability reasons.

Understand the risks
The most common reason for removing metal accessories is fear of the patient suffering a burn during electrosurgery. To reduce the likelihood of current straying from its intended course, electrosurgical unit manufacturers have developed isolated generator technology. This "isolated" technology means the internal "hot" parts of the ESU are not in contact with another ground source and cannot act as an alternate pathway. I made a call to a leading ESU manufacturer and was told a majority of the newer ESU units employ an isolated design. However, older models may not. This is a very important consideration if you're inclined to buy older, less-expensive equipment. Have a biomedical technician examine the ESU generator's inner workings to be sure.

Even though newer isolated generators have definitely reduced the risk of electrosurgery burn, don't ignore the potential danger of the current's total flow. The wires that run between the ESU, handpiece and return pad still carry significant current that can leak through the wire's insulated cover. If the metal adornment touching the patient becomes grounded, the electricity may jump from the intended return route to the patient-grounding pad. While taping body jewelry flat to the patient minimizes burn risks by lessening the current's concentration on the jewelry, removing accessories is the surest way to keep your patients safe.

In addition to burn risks, an article published in the February 2004 issue of the Journal of PeriAnesthesia Nursing notes jewelry or piercings can get caught on surgical drapes or wires, which can cause unwanted pressure on surrounding tissue, accidental tearing of the pierced site or loss of the valuable during the procedure. In addition, tongue piercings can create problems during intubations and should be removed in the name of patient safety, according to the article. Also be aware that tongue piercings that constantly clack around in the mouth can weaken teeth and increase risk of dental damage during intubation. Your anesthesia providers need to take extra care with patients that have a tongue piercing, even if it has been removed.

Develop a policy
Non-ear body piercings are easily seen in the lateral brow or the crease of the nasal fold. Tongue piercings can be obvious, especially when patients speak, but navel, nipple and genital piercings usually remain hidden. For that reason, be sure to include general jewelry and piercings instructions in your pre-op phone calls.

Ask patients to remove jewelry or piercings before they arrive at your facility. Despite your request, some patients will ignore your instructions due to their hesitancy or inability to remove the accessories. Wedding rings sometimes become difficult to slide over knuckles thickened by arthritis. Other patients may refuse to remove piercings for fear the hole will close up before the stud can be reinserted. For example, the tongue is very vascular and a hole in it may quickly close if the piercing is removed. Even parents of children with fresh ear piercings are resistant to removing the studs before surgery.

Certainly your staff can remove jewelry or piercings at your center, but this typically entails using a ring cutter or some sort of lubrication. While cutting a ring may be necessary as a last resort, doing so can cause damage. A jeweler can more effectively remove the ring before the patient presents for surgery, will likely cause less damage during the removal and can simultaneously repair the ring so that it is the correct size afterward.

In addition to patient safety concerns, having patients (or their jewelers) remove valuables before surgery helps keep you out of legal trouble. What happens if you damage a piece of jewelry while removing it or it accidentally falls into a floor drain upon removal? By not bringing jewelry into your center, the patient retains possession of the valuable and responsibility for its care.

Believe it or not, asking a patient to sign a waiver that absolves you from responsibility for lost or damaged property may not keep you out of legal hot water. We consulted with an attorney before creating a jewelry policy for our ASC. To our surprise, waivers in the state of Wisconsin do not necessarily protect us from legal responsibility for lost or damaged personal property. Patients can bring legal action against our center even if they waived the right to do so before surgery. The theory is that procedures done on an outpatient basis are elective and can be cancelled if jewelry or piercings jeopardize patient safety. A signed waiver simply shows that you discussed the risks and considered the issue, but proceeded outside your normal course of care.

A growing trend
Patients need to understand that jewelry should be left at home. Today's electrosurgical units are much safer, but unusual circumstances can still result in a patient burn. Even if risks to the patient are small, taking care of an unconscious patient's jewelry can open up your center to unnecessary legal liability if the expensive piece is lost. The best practice is to have your patients leave their accessories at home or visit their own trusted jewelers to remove them. Body jewelry is more common now than it was 10 years ago. Your staff should be familiar with the latest piercing trends, screen patients for hidden jewelry and know how to remove the pieces if called upon to do so.