May 17, 2024

Staff Safety Patient Safety

By: Outpatient Surgery Editors

Published: 5/17/2024

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THIS WEEK'S ARTICLES

Two More States Pass Surgical Smoke Evacuation Laws

This OR Nurse Has Extra Experience With Harmful Smoke

Surgical Smoke Poses a Risk to Staff and Patients Alike - Sponsored Content

Fighting for Smoke Evacuation on a Federal Level

Where There’s Smoke, There Can Also Be Fire

 

Two More States Pass Surgical Smoke Evacuation Laws

West Virginia and Virginia clear the air in their ORs.

AORN smoke mapGOING GREEN As of May 2024, the 17 states in green have passed surgical smoke evacuation laws, while the four states in yellow remain in play for possible votes this year. | AORN

More than a third of U.S. states have now mandated the use of smoke evacuation systems in ORs, as West Virginia became the 16th state and Virginia the 17th to enact such legislation.

On Mar. 22, the Mountain State’s Republican governor, Jim Justice, signed HB 4376 into law. The Association of periOperative Registered Nurses (AORN), which has worked tirelessly in all 50 states to help advance smoke evacuation legislation, reports the new law will require West Virginia’s Office of the Inspector General to propose rules for legislative approval that will require a healthcare facility to utilize a smoke evacuation system during any procedure likely to generate surgical smoke. Any health facility subsequently in violation will be subject to a fine of $1,000 to $5,000 per violation. The law goes into effect on Jan. 1, 2025.

Surgical smoke evacuation advocates credit the efforts of W.Va. Delegate Phil Mallow (R-Marion) in getting HB 4376 over the finish line. "Delegate Mallow has championed the issue of surgical smoke evacuation since he first introduced legislation in 2022," says Dawn Yost, MSN, RN, CNOR, CSSM, manager of surgical support services at WVU Medicine in Morgantown and AORN’s West Virginia State Council Chair. "We are grateful for his advocacy and persistence and look forward to January 1, 2025, when all facilities will need to evacuate surgical smoke."

In Virginia, the commonwealth’s House and Senate passed identical bills: HB 763 and SB 537, respectively. Both were signed into law by Republican Gov. Glenn Youngkin on Mar. 28. Virginia’s law goes into effect on July 1, 2025, which gives surgical facilities in the state more than a year to prepare.

The development of the law was a grassroots effort. Janet Shortt, MHSA, BS, RN, CNOR, president of AORN Chapter 4702 in Richmond, engaged the Virginia Nurses Association about the importance of surgical smoke evacuation. The organization agreed and added surgical smoke evacuation legislation to its 2024 policy agenda.

Ms. Shortt offered a public comment on HB 763. "After 20 years in the OR, after three bouts of bronchitis and multiple upper respiratory infections, I was diagnosed with asthma," she said. "I thought this odd as I was living a healthy lifestyle, working out five days a week and eating a healthy diet. I now have chronic asthma that requires inhalers." She said surgical smoke aggravates her asthma and makes her eyes water.

In fall 2023, AORN surveyed its members in Virginia to gauge the availability and usage of surgical smoke evacuation equipment in the state. The good news: 94% of respondents said their facility had smoke evacuation equipment. The bad news: Only 26% said that surgical smoke was always evacuated during smoke-generating procedures. These results helped drive home to legislators the necessity of a mandate to ensure that surgical smoke evacuation systems are not just present at facilities but actually used for every smoke-generating surgery.

West Virginia and Virginia join the ranks of 15 other states that have passed similar laws to date: Arizona, California, Colorado, Connecticut, Georgia, Illinois, Kentucky, Louisiana, Missouri, New Jersey, New York, Ohio, Oregon, Rhode Island and Washington. According to AORN, bills for the 2024 session currently remain under consideration by legislators in four states: Massachusetts, Minnesota, North Carolina and Pennsylvania.

To get involved in surgical smoke evacuation advocacy in your state — or to arm yourself with resources to develop and promote smoke evacuation policies at your own individual facility — visit AORN Government Affairs for more information.

This OR Nurse Has Extra Experience With Harmful Smoke

A retired firefighter who is an OR circulator tells Minnesota legislators he felt more protected from the harmful effects of smoke when entering a burning building than he does in the OR.

TestimonyDOUBLE DUTY Former firefighter and current perioperative circulating nurse John Zender testifies to a Minnesota House committee about the dangers of surgical smoke and the importance of evacuating it. | YouTube/MNHouseInfo

Are you having difficulty convincing one or more of your surgeons to turn on that smoke evacuation system during smoke-producing procedures? Are they ignoring the ample literature and case studies you’ve shown them, the firsthand accounts of the health problems some OR workers have possibly suffered due to decades of inhaling surgical plume, the educational materials you’ve shared with them from organizations like the Association of periOperative Registered Nurses that lay out the health risks of working in a cloud of toxic smoke filled with chemical and biological materials all day, every day?

Perhaps the words of a firefighter might break through their dismissiveness.

John Zender, RN, a perioperative circulating nurse from Crosby, Minn., who works at University of Minnesota Medical Center in Minneapolis, is also a retired firefighter. He testified to the Minnesota House of Representatives’ Labor and Industry Finance and Policy Committee on Feb. 29 on behalf of HF4011, a bill sponsored by Rep. Kaela Berg (DFL-Burnsville) that would require all Minnesota healthcare facilities to use a smoke evacuation system during any surgical procedure likely to generate surgical smoke.

Mr. Zender described to the committee how surgical smoke is full of carcinogenic and mutagenic materials, including benzine, hydrogen cyanide, formaldehyde, bioaerosols, dead and live cells, viruses and blood fragments. "In a house fire, believe it or not, many of these hazardous chemicals are similar," he testified. "Thankfully, in my 20 years as a firefighter, I did not have to experience smoke from burning flesh. Only in the operating room, where we’re all expected to be clean and sterile, do I experience burning flesh smoke.

"As a firefighter, smoke is an obvious risk of the job," he testified. "But every big fire I walked into, I was never worried about exposure to fire or smoke. Why? My equipment protected me. Smoke inhalation was never a worry because I carried an air tank that delivered clean, filtered air. In my career as a circulating nurse, I’m often surrounded by smoke with little or no protection." He noted that OSHA states that surgical masks are not certified for respiratory protection for medical employees.

Mr. Zender’s son is also studying to be a circulating nurse, and his dad wants him and his fellow nursing students to work in safer smoke-free ORs. "For me, the current generation has a duty to the next generation to pass on our knowledge of what we know and have learned that make our professions better and safer for them," he testified. "This bill is not just the right thing to do, it’s personal."

Rep. Berg characterized HF4011 to the committee as "the easiest bill that you’ll ever vote on. This was something that I’d bet most of us are not aware of, but once you become aware, it is a horror. For surgical nurses and for the patients, they can breathe in up to 150 hazardous chemicals. You can breathe in the HPV virus, portions of human flesh. This is like a really bad movie, except it’s real."

You can watch the entire hearing on YouTube. Mr. Zender’s testimony begins at the six-minute mark.

According to the Minnesota House of Representatives website, the committee approved HF4011 and sent it to the House Health Finance and Policy Committee. A companion bill, SF3948, is moving through the Minnesota Senate. The Minnesota 2024 legislative session runs until May 21, and advocates hope the North Star State will join the growing ranks of U.S. states that have mandated surgical smoke evacuation.

 

Surgical Smoke Poses a Risk to Staff and Patients Alike
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Ensuring that surgical smoke is evacuated safely will lead to better health.

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The hazards of surgical smoke on the wellbeing and ultimate health of healthcare workers – as well as patients – has been a concern for decades, but the current landscape indicates that a momentum of legislative efforts is growing to curb this critical concern. To date, 17 states have passed smoke legislation that will make the OR safer for both the professionals who work there every day in hospitals and ambulatory surgery centers across the country.

The dangers of surgical smoke are clear. While patient care in the operating room is the number one priority of the surgical staff, the safety and care of the staff are equally important. Surgeons and their supporting staff can encounter biological and electrical hazards in each case they attend. If not managed properly, surgical smoke can have short-term and long-term effects on surgeons and their staff.

Exactly what is surgical smoke? Found in most ORs today, the patient and OR team are regularly subjected to a surgical smoke plume – a potentially dangerous by-product generated from the use of lasers, electro-surgical pencils, ultrasonic devices and other surgical energy-based devices. As these instruments cauterize or burn vessels and destroy tissue, vaporized fluids, including blood, create this gaseous material and the individuals present in the room can be subjected to it.

While most people are aware of this hazard, not everyone is aware of just how dangerous the surgical smoke plume can be to the people present. The composition or the chemical makeup of this smoke plume is what makes the smoke so dangerous. The plume comprises 95% water and 5% additional matter and that other 5% matter is potentially what is most hazardous to the surgical staff and patients.

The biological matter of the plume can include blood with potential infectious viruses and bacteria. Since surgical smoke comprises approximately 95% water vapor, it creates a viable carrier for bacteria and viruses, which can transfer infectious diseases. Evidence of an airborne virus transmitted within a surgical smoke plume has been documented.1 Viable bacteria exist within the laser smoke plume generated during laser resurfacing. However, additional research is needed to define the exposure risk associated with patients who have hepatitis, HIV and antibiotic-resistant bacteria.

Additionally, the chemical component of surgical smoke plumes contains more than 80 different toxic chemicals and by-products and some of these components have documented harmful health effects. In fact, OR staff members and patients have for years been exposed to surgical smoke without knowledge of the potential side effects. While the synergistic and antagonistic interactions of aldehydes, benzene, toluene, ethylbenzene, xylene, ozone and dioxins present in the OR have not been studied and are difficult to predict, researchers have concluded that surgical smoke should be evacuated to protect the OR team from the toxic, possibly carcinogenic, mutagenic and genotoxic effects.

Ensuring the safe elimination of the always present smoke plume during a surgical procedure – and taking the appropriate protective measures – can guard the health and safety of both the surgical staff and patients.

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

References:
1. AORN Government Affairs, Policy Agenda. Everyone Deserves a Smoke-Free OR; 2022. https://www.aorn.org/get-involved/government-affairs/policy-agenda/surgical-smoke-free-or

 

Fighting for Smoke Evacuation on a Federal Level

While advocates try to refocus OSHA’s attention, the National Fire Protection Association codifies smoke evacuation for all new builds and remodels.

While 17 states have now passed surgical smoke evacuation mandates, the ultimate goal is to require the use of smoke evacuation systems nationwide. To that end, advocates have worked since the mid-1990s to secure a national mandate for the use of surgical smoke evacuators. While nothing is imminent in Washington, these efforts continue.

AORN Associate Director of Government Affairs Jennifer Pennock says AORN recently met with the U.S. Occupational Safety and Health Administration (OSHA) to request an updated hazard information bulletin on surgical smoke. Incredibly, OSHA last issued a hazard information bulletin on surgical smoke in 1988 — 36 years ago. Ms. Pennock says AORN is hopeful an updated bulletin will be issued this year.

That’s not all that’s happening on the national level in the fight to evacuate surgical smoke. The movement recently gained another influential ally in the National Fire Protection Association (NFPA), which has included a new requirement in the 2024 edition of the NFPA 99, Health Care Facilities Code (payment required to access).

Section 9.3.8 of the code, entitled "Medical Plume (Surgical Smoke) Evacuation and Filtration," requires healthcare facilities to capture surgical smoke as close as possible to its source. Among the capture options presented to facilities:

  • a dedicated local exhaust ventilation system
  • a connection to a return or exhaust duct after air cleaning through ultra-low particulate air (ULPA) and gas phase filtration (activated carbon, for example)
  • a surgical smoke evacuation tool at the point of use
  • a medical-surgical vacuum system with an in-line filter with ULPA and gas filtration (this option is applicable only for procedures that generate small amounts of plume)

When hospitals are built or remodeled, they are required by their state and local jurisdictions to comply with current building codes, which will now include the NFPA’s smoke evacuation requirement. AORN recommends surgical facilities communicate the new NFPA smoke capture requirement to their risk management personnel, administration, surgical services department leads, medical staff committees and purchasing departments.

"We are pleased to see the NFPA join OSHA and The Joint Commission in recognizing the harms to operating room personnel that ongoing exposure to surgical smoke causes," states Ms. Pennock. "This 2024 Code is one more tool in our arsenal to move all healthcare facilities toward 100% compliance and to truly be smoke-free facilities."

AORN, along with the American Society of Healthcare Engineers and the American Hospital Association, has requested that CMS update its Conditions of Participation and Conditions for Coverage to reference the newest edition of NFPA 99, including the smoke evacuation and filtration section.

 

Where There’s Smoke, There Can Also Be Fire

The Joint Commission reminds facilities of the dangers of surgical fires, with risk particularly present during head and neck surgeries.

Surgical smoke is a silent and gradual health hazard in ORs where smoke evacuation systems are not present or in use. Surgical fire, on the other hand, is an all-hands-on-deck emergency that presents an immediate danger to everyone and everything in the OR — and possibly beyond.

Last fall, The Joint Commission issued a Sentinel Event Alert on surgical fire prevention that both warns of the danger and provides recommendations for prevention. The accreditation organization says most surgical fires are associated with the use of electrosurgical devices during head and neck surgeries.

The Joint Commission cites available estimates that suggest less than 100 surgical fires occur each year in the U.S. While that number may sound low, it doesn’t matter when a fire has actually ignited in the OR, putting surgical teams, patients and facilities alike at risk for significant damage.

The Sentinel Alert informs surgical teams about surgical fire risk factors and identifies prevention strategies and actions. The Joint Commission says numerous factors contribute to surgical fires, particularly in terms of teamwork and communication, work design, staff and equipment.

With those shortcomings in mind, the Sentinel Alert advises the following:

  • Staff should understand and monitor the three elements of the "fire triangle": oxygen, ignition sources and fuel.
  • The preoperative time out should include a robust fire risk assessment regarding the surgical or endoscopic procedure about to take place.
  • The anesthesia provider should maintain the local oxygen concentration at less than 30% whenever possible.
  • OR staff should carefully manage electrosurgical devices, light sources and cables, surgical draping and other risks during every procedure.
  • OR staff should receive training on how to avoid and manage fires and conduct fire drills as well as education about the risks that surgical fires present.
  • Every surgical fire should be entered into your facility’s incident reporting system.

"Care must be taken, especially when using electrosurgical tools, to reduce the risk of fires," says Herman A. McKenzie, MBA, CHSP, director, Physical Environment Department, Standards Interpretation Group, The Joint Commission. He says these new recommendations, along with The Joint Commission’s relevant requirements on fire prevention within the surgical environment, can support healthcare organizations as they develop fire prevention policies and procedures.

Click here to read The Joint Commission’s Sentinel Event Alert 68, "Updating surgical fire prevention for the 21st century," in full. The Alert also reviews related Joint Commission requirements and provides resources and references. OSM

 

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