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Joint Commission makes it perfectly clear: Get the surgical smoke out of OR
Breathing difficulties, 'viable bacteria, and viral particles'
The air is clearing in the nation's operating rooms, as The Joint Commission places a greater emphasis on evacuating smoke from electrocautery procedures.
In the accrediting process, hospitals have long been required to manage "risk related to hazardous material and waste." In the 2009 Environment of Care standard, The Joint Commission added a note for clarification: "Hazardous gases and vapors include, but are not limited to, glutaraldehyde, ethylene oxide, vapors generated while using cauterizing equipment and lasers, and gases such as nitrous oxide."
This is the first specific mention of surgical smoke in Joint Commission standards, although the National Fire Protection Association (NFPA) code addresses smoke detectors and scavenging of waste anesthetic gases. The Joint Commission requires hospitals to comply with NFPA codes.
"We have always interpreted the smoke that's generated from these procedures [as a hazard]," says Jerry Gervais, CHFM, CHSP, BSME, associate director-engineer of the Standards Interpretation Group of The Joint Commission, which is based in Oakbrook Terrace, IL. "Organizations didn't make that connection, so we wanted to be very, very clear about it.
"The hospital should have a written policy on how they're handling this issue," he adds. "By having a written policy, they can require compliance by all employees. They can write in the required safety precautions and hold them accountable."
The "clarification" by The Joint Commission comes on the heels of a 2008 position statement by the Association of periOperative Registered Nurses (AORN), urging hospitals and surgery centers to reduce exposure to surgical smoke and bioaerosols released in laser and electrosurgical procedures.
In March 2009, the Canada Standards Association issued a voluntary "Plume Scavenging Standard," which provides guidance on systems that evacuate surgical smoke from electrosurgery procedures.
Hospitals frequently tout their "smoke-free" campus. Now, the "no-smoking" rule will include the pungent smoke produced when tissue is burned, say OR nurses who have advocated for greater attention to the issue.
"I think the biggest challenge we have is getting the message across to the surgical team that what they're doing has cumulative long-term effects, just as second-hand cigarette smoke does," says Vangie Dennis, RN, CNOR, CMLSO, clinical manager of procedural nursing at Gwinnett Medical Center in Duluth, GA, and a member of the AORN Surgical Smoke Evacuation Task Force. "If you take a look at the constituents of cigarette smoke, it's identical to surgical smoke; only we have additional components," including viable bacteria and viral particles," she adds.
Equipment lacking, nurses report
Surgical smoke is causing irritation, discomfort, and breathing difficulties for OR nurses. About one in four OR nurses (24%) report having allergies and one in 10 (11%) have asthma. About 12% said smoke from electrosurgical procedures caused breathing difficulties, and 25% said it led to more frequent coughing, according to a survey of AORN members by Kay Ball, RN, PhD, CNOR, FAAN, a nurse consultant/educator in Columbus, OH, and chair of the AORN Surgical Smoke Evacuation Task Force. Ball received 777 responses from a randomly selected group of OR nurses.
Those symptoms parallel the findings of "health hazard evaluations" conducted at three hospitals by researchers from the National Institute for Occupational Safety and Health. They detected formaldehyde, acetaldehyde, and toluene in the smoke, though not above recommended or permissible exposure limits. OR employees complained of irritant symptoms.
Yet too often, hospitals don't have adequate smoke evacuation equipment, says Ball. Lack of equipment was the No. 1 barrier cited by nurses in the survey, she adds. "Hospitals need to get smoke evacuation devices for every surgical suite," Ball urges. "There are still a lot of people who are not evacuating surgical smoke."
Other barriers included the noise of the equipment, lack of support from physicians, and complacency of the staff. Freestanding ambulatory surgery centers are more likely to evacuate smoke than hospitals, as are larger or urban facilities, she found.
Start with needs assessment
To implement smoke evacuation, begin with a committee that includes OR leaders or "champions," advises Dennis. The committee can conduct an assessment and determine the needs and concerns of OR staff and physicians, she adds.
For example, if surgeons are concerned about noise or interference with their procedures, investigate products that are insulated and can be easily incorporated into the OR, Dennis points out. "We addressed the loudness. We made sure the staff understood you didn't have to turn it up to 100%," she says. "On a small smoke-generating procedure, 20% [power on the smoke evacuator] is enough."
Conduct a trial of the new products and educate staff about how to use them and why evacuating surgical smoke is important, says Dennis. She conducts education annually. AORN has released a new surgical smoke toolkit, with a sample policy and procedure, competency skill checklist, tips for compliance, and a link to vendors (www.aorn.org).
After implementing a new policy, hospitals should follow up with observations to check for compliance, Dennis suggests.
Changing habits can be difficult. While hospitals typically implemented smoke evacuation along with new laser technology, they have been slow to make smoke evacuation routine in electrosurgical procedures. But hospitals are getting the message, says Ball.
"I want to make 2009 the year of smoke evacuation," she says. "I want everyone to realize you can't breathe this in. We need to protect the air of the surgical nurses."