Electrosurgery Safety Made Easy

Sound electrosurgical safety practices often come down to preventing complacency from setting in among the staff who use these high-powered devices to cut and coagulate tissue during countless surgical procedures. Unfortunately, the most powerful weapon available to prevent a false sense of comfort and laxity is usually what’s lacking most: A fundamental understanding of how electrosurgery technology works.

While most surgeons have a cursory knowledge of the safety components of electrosurgery, they often reach a level of complacency where risks are underestimated, says Julie Miller, MS, principal project engineer 1 at ECRI, a non-profit organization in Plymouth Meeting, Pa., that provides independent medical device evaluation. 

Thomas Robinson, MD, MS, FACS, puts it a bit more bluntly. “The number one issue when it comes to electrosurgery is that there’s no curriculum for the usage of the technology,” he says, adding that surgeons learn from their mentors, who generally only pass along the bare minimum knowledge necessary to operate the devices safely. “Surgeons are taught to set the Bovie to 30/30 and go,” says Dr. Robinson, who is a professor of surgery at the University of Colorado School of Medicine in Aurora and the committee chair of the Society of American Gastrointestinal and Endoscopic Surgeons’ Fundamental Use of Surgical Energy (FUSE) program.

If a lack of fundamental awareness is the problem regarding electrosurgery, education is the answer. To that end, Dr. Robinson is a big believer in the FUSE program. The traditional FUSE program is a bear. The 10-hour long class, which includes online didactic materials and an exam — consisting of multiple-choice questions on the basic principles of electrosurgery — is designed to inform and promote best practices for the use of electrosurgical, ultrasonic and other energy sources that are used during surgery. As good as the program is, Dr. Robinson acknowledges there are certain issues with the robust, 10-hour long curriculum — with the main obstacle being the amount of time it takes to complete it. That’s why the FUSE Hospital Compliance Module was created and piloted among 380 staff, including 198 surgeons, 139 nurses, 28 surgical technicians and 15 house staff, in 2020. A team took a close look at the traditional FUSE program, stripped out material that’s good to know but not necessarily essential for staff (the physics behind electrosurgery, for example) and created a significantly abbreviated education module. “You can finish the module in 25 minutes. In fact, I’ve heard some people have completed it in just 20 minutes,” says Dr. Robinson. 

The module eliminated service line-specific education to instead focused the three major areas everyone in the OR should know about electrosurgical safety: the fundamentals of electrosurgery; an essential look at the rare but catastrophic risks of OR fires and how to avoid them; and the ways in which electrosurgical instruments can disrupt the function of patients’ pacemakers. 

Even if your OR staff isn’t enrolled in a formal education program like FUSE, there are simple and practical ways to bolster electrosurgical safety. One of those ways is to provide regular reminders on the most common safety mistakes — and the types of injuries and incidents that are most likely to occur as a result, such as patient burns. For instance, one of the most common incident reports that comes across Ms. Miller’s desk involves burns from electrosurgical unit (ESU) pencils accidentally activating on the patient. “A lot of times this happens when the ESU isn’t in use and it’s resting on the patient, instead of being properly placed in its non-conductive safety holster,” she says. “If the tip is hot due to buildup of eschar or it accidentally activates, patients can wind up with some nasty burns.”

What’s more, many of these incidents Ms. Miller comes across are mistakenly reported as misfiring devices. “The report comes in and says that the device misfired or was activated by itself, but through investigation we find out that somebody accidentally leaned on it or stepped on the foot switch while the pencil was resting on the patient,” she says. “With this technology, patient harm is very commonly caused by user error.” When staff are fully aware of the risks of accidentally activating the ESU and potentially burning the patient in the process, they’re more likely to use safety holsters whenever the devices aren’t in use. 

In addition to patient — and even staff — burns from the misuse of energy instruments, be aware that ESUs create a fire risk in the OR where the energy devices serve as a common ignition source in the fire triangle that already has an oxidizer (oxygen) and fuel (prepping agents soaked into drapes). “If you’re working on the face during head and neck procedures, that’s where the risk is at its highest because the ignition source is working where there is open oxygen,” says Ms. Miller. “If you’re placing a jugular catheter and a fire starts, it can be catastrophic.” Again, awareness of the risks and a basic understanding of the role electrosurgical instruments play in creating OR fires is worth its weight in gold here.

The FUSE Hospital Compliance Module was created to provide an easier way for time-pressed staff to gain the understanding they need about electrosurgical safety, but for a sizeable number of participants it went beyond simply providing basic education and fundamentally altered how they use energy devices. Nearly a third (27%) of the participants in the module’s pilot program said they were “extremely likely” to change how they set up and used energy devices, according to a survey on the effectiveness of the program.

A better understanding of electrosurgery and the safety risks it poses is something all facility leaders should be able to get behind because, as Ms. Miller points out, the more you know about how the energy devices work, the safer electrosurgery will ultimately be for patients and staff alike. “An ESU is a universal device that’s involved in high-stakes functions,” she says. “Understanding the physics of it, the electricity, the circuit behind it, and all that’s going on, can help you improve patient safety and lead to better outcomes for your surgeries.” OSM