June 5, 2024

Staff Safety Patient Safety

By: Outpatient Surgery Editors

Published: 6/4/2024

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THIS WEEK'S ARTICLES

Protecting the Youngest Patients in the OR

Thinking Inside the Box

The Regulatory Landscape for Surgical Smoke - Sponsored Content

Land of 10,000 Lakes Becomes 18th Surgical Smoke-Free State

A Team Approach to OR Fire Safety Is Crucial

 

Protecting the Youngest Patients in the OR

Three nurses perform a study to better understand and mitigate surgical smoke exposure among pediatric patients.

Pediatric smokeMEASURING POLLUTANTS During the study, the nurses placed calibrated monitors near the surgical field, as shown here, and other areas to gather data on contaminant levels during smoke-generating pediatric procedures. | Nancy Do, Andrea Dyer, Megan Nolan

We’ve long heard about the dangers of surgical smoke exposure and how it can threaten the long-term health of staff and patients in the OR, but what about its impact on the youngest patients — those undergoing pediatric surgeries?

Three nurses affiliated with Boston Children’s Hospital and Harvard Medical School Teaching Hospital — Nancy Do, BSN, RN; Andrea Dyer, MSN, RN, CNOR; and Megan Nolan, MSN, RN, CNOR, NEA-B — performed a pilot study to investigate the issue, the results of which they submitted as a poster at the 2024 Association of periOperative Registered Nurses (AORN) Global Surgical Conference & Expo in Nashville. "By evaluating the efficacy of smoke evacuation systems in pediatric surgical settings, we aim to enhance safety measures for both patients and healthcare providers," wrote the nurses. "Despite growing awareness of this issue, effective mitigation strategies specifically tailored to pediatric cases are lacking."

The nurses’ pilot study assessed the effectiveness of a smoke evacuation unit attached to an electrocautery device in reducing levels of hazardous pollutants during pediatric spinal and hip procedures. The nurses measured carbon monoxide (CO), formaldehyde, total volatile organic compounds (VOCs) and particle counts during pediatric spinal and hip procedures using calibrated monitors placed near the surgical field and the anesthesia station. Regular suction was employed in both arms of the study to remove additional smoke, and data from the first hour of each case was included in a statistical analysis.

The nurses then compared pollutant levels between procedures with and without the use of a smoke evacuation unit attached to the electrocautery device. The differences were stark, with contaminant levels significantly reduced when smoke evacuation was employed:

  • CO was measured 27 parts per million without smoke evacuation, but just 2.5 parts per million with smoke evacuation — a 90.7% decrease.
  • Formaldehyde was measured at 0.698 milligrams per cubic meter without smoke evacuation, but just 0.151 milligrams per cubic meter with smoke evacuation — a 78.4% decrease.
  • Total VOCs were measured at 0.515 milligrams per cubic meter without smoke evacuation but just 0.0175 milligrams per cubic meter with smoke evacuation — a 96.6% decrease.
  • Particle counts were measured at 362 micrograms per cubic meter without smoke evacuation, but just 160.5 micrograms per cubic meter with smoke evacuation — a 55.7% decrease.

Beyond the obvious conclusion given those numbers that smoke evacuation systems should be present and activated during smoke-generating pediatric surgeries, the nurses identified additional areas for improvement. They encourage perioperative nurses to advocate for patient safety, especially by promoting the adoption of best practices in smoke evacuation. They also call for greater awareness and more training among perioperative nurses about the risks associated with surgical smoke exposure to empower them to help create safer perioperative environments for pediatric patients.

The nurses concluded that their pilot study "highlights the need for ongoing research and innovation to further optimize smoke evacuation strategies and improve patient outcomes in pediatric surgery."

Thinking Inside the Box

When many legislators witness this in-person surgical smoke evacuation demonstration, the nature of the problem becomes clearer to them.

Arkansas smokeBRINGING IT HOME Nurses Tiffany Spivey and Kenneth Worley demonstrate smoke evacuation to Arkansas Rep. Mary Bentley (right). | AORN

Reading about surgical smoke and its potential health effects is helpful for those who are learning about it for the first time, but it doesn’t truly click for a lot of people until they see a visual representation of the phenomenon. That seems to be particularly true for government officials, many of whom have never even heard of surgical smoke before, let alone the need to evacuate it to protect the health of OR staff and patients.

The Association of periOperative Registered Nurses (AORN) and its members, who have been visiting statehouses across the country to encourage legislators to pass smoke evacuation legislation, often employ a simple demonstration tool that accomplishes just that.

The demonstration is both visual and interactive, as it invites the legislator or staffer to actively participate in a straightforward experiment. A chicken breast is placed inside a transparent box. Legislators and staff put their hands into a glove that is embedded in the box and are then encouraged to use electrocautery to dissect the meat. Their surgical technique (or lack thereof) doesn’t really matter. It’s the smoke the electrocautery produces that catches their attention because it rapidly fills up the box.

After that, it’s easy to see what an active smoke evacuation system can do to improve staff and patient safety. An evacuation system that is connected to the box is activated, and as the government official once again performs electrocautery, the smoke it produces no longer rapidly collects in the box.

In February, Kenneth Worley, RN, BSN, CNOR, director of value analysis at University of Arkansas for Medical Sciences in Little Rock, attended the Arkansas Nurses’ Association’s Nurses Day at the Capitol. He made the case for statewide smoke evacuation requirements to the nurses and student nurses in attendance. Then Mr. Worley and his colleague Tiffany Spivey, RN, MAT, MBA, BSN, CNOR, used the box to provide hands-on demonstrations of surgical smoke evacuation to legislators and other interested parties at the Capitol.

"Seeing really is believing," says Mr. Worley. "The legislators who were able to participate in the demonstration were immediately supportive of smoke evacuation legislation in Arkansas." Mr. Worley, Ms. Spivey, AORN and others are spending this year laying the groundwork to introduce what they hope will become a successful smoke evacuation bill for Arkansas in 2025.

There are still 32 states that have not passed smoke evacuation mandates. If you work in one of them and are interested in providing this demonstration to legislators and stakeholders in your state, email AORN Associate Director of Government Affairs Jennifer Pennock using the subject line "Smoke Evacuation Demonstration" to learn more about how to coordinate such an event.

 

The Regulatory Landscape for Surgical Smoke
Sponsored Content

Following guidelines and regulatory policies can aid in protecting healthcare workers from surgical smoke in OR environments.

150 ChemicalsSteris

The healthcare community is paying more and more attention to the hazards of surgical smoke as almost one-third of the nation has enacted legislative action on the state level to mandate safe smoke evacuation in the OR. Minnesota (See ‘Land of 10,000 Lakes Becomes 18th Surgical Smoke-Free State’ for legislation update) just joined 17 other states in passing legislation designed to protect the health of healthcare workers and the patients they serve during surgical procedures.

The danger of surgical smoke is not in question as surgeons and their teams can encounter biological and electrical hazards as they work cases. These can have both short-term and long-term effects on the individuals who are working on these procedures. The hazardous surgical smoke plumes come from the use of equipment that is used to cauterize or burn vessels and destroy tissue during a surgical procedure. The different types of smoke produced in the operating room include electrocautery smoke, laser smoke, ultrasonic scalpel smoke, harmonic scalpel smoke and suction irrigation smoke – all hazards that can create gaseous material.

In a case study that illustrates the dangers of surgical smoke, samples were collected that were generated by electrocautery during colorectal surgery. The sampling tube was attached near the end of the electrocautery pencil or held in the plume above the pencil. Once analyzed, the electrocautery smoke was found to contain significant benzene, ethyl benzene, styrene, carbon disulfide and toluene. Benzene, a known carcinogen, was detected in significant quantities. The substances detected can cause eye irritation, dermatitis, central nervous system effects, and hepatic and renal toxicity.

Researchers have concluded that surgical smoke should be evacuated to protect the OR team from the toxic, possibly carcinogenic, mutagenic and genotoxic effects. Due to the toxic chemical components found in surgical smoke, the respiratory system can also be negatively affected, especially for individuals with more severe conditions such as asthma or pneumonia.

The way all parties can be protected is through legislative action, as some states have done, and regulatory policies that spell out the guidelines for controlling surgical smoke. Today, the most recent version of the American National Standards Institute Z136.3 (2011) specifically states that airborne contaminants from laser surgery "SHALL" be controlled. Also, it notes that electrosurgical devices produce the same type of airborne contaminants as lasers. Many organizations and agencies are making their recommendations more powerful by changing the verb from "should" to the more powerful word "shall" to help encourage compliance.

Additionally, several national and international organizations address standards concerning patients' and healthcare workers’ exposure to hazardous materials and surgical smoke. According to the National Institute of Occupational Safety and Health /Centers for Disease Control, ventilation techniques include a combination of general room and local exhaust ventilation (LEV) including portable smoke evacuators and room suction systems.

Specifically, the NIOSH/CDC recommends that the smoke evacuator or room suction hose nozzle inlet must be kept within two inches of the surgical site and the smoke evacuator should always be "ON" (or activated) when a plume is present. They also recommend that healthcare workers follow standard precautions.

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 to guard the health and safety of the surgical staff as well as the patients as they go on their surgical journey.

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

 

Land of 10,000 Lakes Becomes 18th Surgical Smoke-Free State

Minnesota’s governor last month signed a bill into law that will require compliance in all of the state’s ORs by Jan. 1, 2025.

On May 17, Minnesota’s Democratic governor, Tim Walz, signed an omnibus labor and industry policy bill named SF 3852 into law. The law addresses many pressing issues, such as enhancing worker protections, strengthening the minimum wage and increasing pay transparency.

One of those enhanced worker protections is a new requirement for healthcare facilities to adopt and implement policies to evacuate surgical smoke from Minnesota’s operating rooms.

As a result, when that requirement goes into effect on Jan. 1, 2025, Minnesota will become the 18th U.S. state to require smoke evacuation systems to be present and activated in its ORs during all procedures that produce the toxic plume.

As has been the case in other states where this type of legislation has been signed by governors from both major parties, the successful passing of the smoke evacuation law in the North Star State was a result of a combination of lobbying by groups like the Association of periOperative Registered Nurses (AORN) and grassroots advocacy from workers in the field. In the last issue of eNews Briefs, we reported on powerful testimony delivered to the Minnesota House of Representatives’ Labor and Industry Finance and Policy Committee in February by John Zender, RN, a retired firefighter and current perioperative circulating nurse from Crosby, Minn., who works at University of Minnesota Medical Center in Minneapolis.

Plainspoken but persuasive comments like Mr. Zender’s play a crucial role in bringing home the realities of the dangers of inhaling surgical smoke to legislators. Once a nurse or other OR team member describes the issue through real-life experiences, it becomes even more difficult to ignore or overstate the problem — particularly in terms of the real and potential health effects that surgical teams face when working in clouds of hazardous smoke that can contain bacteria, viruses and chemicals day after day.

AORN is offering resources to nurses in Minnesota as well as other states such as West Virginia and Virginia whose smoke evacuation laws go into effect in 2025 on how to ready their facilities for compliance, including the next steps that imminently impacted facilities should take in preparation, as well as how best to navigate implementation and compliance issues that may arise during the transition to mandatory smoke-free ORs.

The 2024 legislative landscape still holds promise that additional states, particularly Massachusetts, North Carolina and Pennsylvania, could pass similar surgical smoke evacuation laws to the 18 that already have. Stay tuned for an update on the status of bills in those states in an upcoming issue of eNews Briefs.

 

A Team Approach to OR Fire Safety Is Crucial

Evidence supports collective development of a prevention protocol.

Guidelines from the Association of periOperative Registered Nurses (AORN) are based fully on evidence-based approaches. The recent update to its Safe Environment of Care guideline, which includes new recommendations for fire safety prevention in the OR, is no exception.

The updated guideline provides new and revised recommendations for the development of OR fire safety plans, performance of fire risk assessments, fire safety training guidance, the establishment of latex safety programs and chemical safety plans and more. It now states that evidence supports a team approach to fire safety and prevention in the OR.

The new AORN Fire Risk Assessment and Prevention Algorithm included in the guidelines focuses on the development of OR fire prevention interventions that address specific risks identified by the perioperative team during an initial risk assessment.

"OR teams that may have previously assessed fire risk using a score or a low/medium/high risk rating will find some differences when they're using our new fire risk assessment and prevention algorithm," said Renae Wright, DNP, RN, CNOR, AORN Guideline author as well as a perioperative practice specialist for the association, of the changes during a recent episode of AORN’s Periop Talk vlog.

Both Dr. Wright and co-host Lisa Spruce, DNP, RN, CNS-CP, CNOR, ACNS, ACNP, FAAN, AORN’s senior director of evidence-based perioperative practice, said they had experienced OR fires while in perioperative practice. The scenarios were varied. Dr. Spruce witnessed four OR fires that all involved patients; Dr. Wright experienced a couple, recalling that one involved an open oxygen source that should have been addressed beforehand, while the other involved electrical equipment.

These varied scenarios exemplify that fire prevention interventions should be contextual, immediate and collaborative. "It all goes back to making sure that the interventions that you're putting in place to prevent fires match the fire risks that are present in the OR right in front of you," said Dr. Wright. "Fire risk assessment should not be based on a risk score or rating because you can't really intervene appropriately unless you know exactly what the risks are that you're seeing in front of you.

"Say a team determines a case to be low risk," added Dr. Wright. "That alone doesn't tell us: Is there an open oxygen source present that we need to address? Is there an electrosurgical device that could ignite something? This new algorithm will guide teams in intervening based on the presence of specific oxidizers, fuels and ignition sources."

The algorithm centers on four "yes"/"no" questions that OR teams can answer to identify the presence of the three different fire triangle components. "If they answer ‘yes’ to a question, they get some examples of interventions that they could implement to address that risk," said Dr. Wright. "Once you have addressed the risk, or answer ‘no’ to any of the questions, you proceed down the line to the next question. It's pretty easy."

Order the 2024 AORN Guidelines for Perioperative Practice, which includes the updated Safe Environment of Care guideline. OSM

 

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