- Email: [email protected]
Smoke plume evacuation in the OR
MARCH 1997, VOL 65, NO 3 PRACTICAL INNOVATIONS
Smoke plume evacuation in the OR
T
he dangers from electrosurgical unit (ESU) smoke plume include exposure to
benzene, carbon monoxide, formaldehyde, hydrogen cyanide, methane, phenol, styrene . . . toluene . . . particulate mutter, gases, mutagens, carcinogensand sometimes, DNA components.’ Surgical team members, as well as patients, are exposed to these products.
Proper evacuation, neutralization and handling of these substances in an open situation is necessary for maintenance of a healthy operating environment for the surgeon, ancillary personnel and the patient? Perioperative nurses must be made aware of these dangers and take the responsibility of requesting that their health care facilities itlstitute recommended ESU smoke plume safety precautions. Our facility, St Jude Medical Center, Fullerton, Calif, is a 33 1bed hospital with 10 OR suites. We perform many types of surgical procedures at this facility, and we average 30 surgical procedures per day. We decided to implement ESU smoke plume evacuation precautions for all procedures using electrosurgicaldevices in accordance with AORN’s recommended practices.’ The laser
resource nurse and other perioperative staff nurses were the motivating force in coordinating and implementing ESU smoke plume evacuation policies and procedures in the OR. To assist our nurse colleagues in instituting important smoke plume evacuation policies and procedures in their facilities, we would like to share our experiences and hardlearned lessons.
llTERATUR€ REVKW Our fmt and most effective step was to conduct a thorough literature review. We referred to recent studies and to what the Occupational Safety and Health Administration (OSHA), the National Institute for Occupational Safety and Health, and the American National Standards Institute most recently had published. We compiled recommendations from AORN, government agencies, and scientists, and we used our medical library. We also used information from sales representatives of smoke evacuation system manufacturers, but we were careful to obtain unbiased information. Our literature search revealed that the contents of ESU smoke plume are similar, by spectral content, to laser plume.4 Smoke plume can cause “headaches, nausea, myalgia, rhinitis, or conjunctiviti~,”~ and it causes increased methemoglobin levels in patients JOY ANNE LANFRANCHI, RN, CNOR, is the laser resource nurse at St Jude Medical Center,Fullerton, Calif.
627 AORN JOURNAL
undergoing laparoscopicelectrosurgicalprocedures.6 Guidelines from OSHA do not mandate specifically that ESU smoke plume be evacuated; however, they do require that when practical, employers should “remove an oxygen deficient atmosphere or harmful dusts, fumes, mists, vapors or gases at their ~ource.”~ We also reviewed the AORN recommended practices regarding electrosurgery, which state:
Patients and perioperative personnel should be protectedfvom inhaling the smoke generated during electrosurgery. . . .An evacuation system should be used to remove surgical smoke.8 After reviewing the literature and establishingjustification,our next step was to review our equipment options for ESU smoke plume evacuation.
OPTlONS FOR PROT€CT/ON We considered using only high-filtration surgical masks. We already had them in stock, and they are relatively inexpensive. We decided, however, that masks were not the best choice because
ifparticulate matter less than 0.5 ,urn can penetrate an elaboratefilter system, it is unlikely that surgical masks regardless of thickness or rating wouki‘offer any substantial protection
MARCH 1997, VOL 65, NO 3
to the surgeon [or anyone present in the OR suite]. Additionally, most surgical m s k s gather moisture emanating from the surgeon's [or any other person's] breath during the operative procedure thatfurther diminishes the effectiveness of this barrier.9
In addition, masks offer no protection to patients. In-line smoke plume evacuation systems were unacceptable because the models advertised as being effective for 20 surgical procedures actually were useful for only four hours of ESU smoke plume evacuation. If the evacuation systems were used with a combination of laser and ESU procedures, that useful time decreased to approximately 2.5 hours.'O The cost of changing the filters every day proved to be prohibitive. In addition, there was the potential for our wall suction devices not having enough vacuum power to capture the ESU smoke plume at surgical procedure sites." One study identified the required flow of air to be 40 cubic feet per minute.'* We decided to use single-use, in-line filters for laparoscopicprocedures that required ESUs. As ESU smoke plume is confined, the suction devices do not need to be as powerful as in open surgical procedures. During open procedures, however, using wall suction devices requires personnel to hold suction hoses near the smoke plume production sites. This was not feasible for every open procedure in which ESU smoke plume was produced. We concluded that the only way to suction ESU smoke plume safely and effectively was to use dedicated smoke
plume evacuation systems with hands-free operation. DEPARTMENT NEED, ESTABLISHING CRITERIA To decide how many smoke plume evacuation systems were necessary, we conferred with the OR team leaders (ie, specialty resource nurses) to determine which surgical procedures would require smoke evacuation. The criterion was any procedure in which ESU smoke plume would be present, according to AORN standards.13We then looked at statistics that showed our busiest time of the year, and we averaged the number of surgical procedures being performed simultaneously that would require use of smoke plume evacuation systems. For our busy 10-room OR suite, we determined that we needed a minimum of six smoke plume evacuation systems. WRITING AND SUBMITTING A REPORT After we reviewed the information and established our criteria for smoke plume evacuation system use, we prepared a brief, factual report. This report contained information about the dangers of ESU smoke plume, recommended practices, a discussion of equipment options, and our conclusions about what needed to be done. We submitted this report to the vice president of clinical services (ie, the director of nursing) and our surgery unit-based practice committee (SUBPC). The SUBPC is a committee dedicated to improving nursing practice in our health care facility at the staff level. We gave copies of the report concurrently to the safety officer, the risk management director, and the director of materials manage628 AORN JOURNAL
ment (ie, purchasing) to inform them of the dangers of ESU smoke plume and to enlist their support. The safety officer was helpful in encouraging the creation of smoke plume evacuation policy and procedure for the OR. Risk management personnel helped with physician education and compliance issues. Materials management personnel assisted in the clinical trials by offering support in negotiation and coordination between the smoke plume evacuator manufacturer representatives. Help from personnel in these departments was necessary to set up a comprehensive smoke evacuation policy and procedure for the OR and to ensure employees' compliance. DEVELOPMENT OF EVALUATION TOOL The next phase in our project was to evaluate smoke plume evacuation systems. To do this, we created a smoke plume evacuation system evaluation tool (Table 1).First, we decided what the most important features of the smoke plume evacuation system should be, and we incorporated these into the tool. The tool was fairly simple and brief, and we were able to extract the information we needed to make an informed decision. It also was set up to involve all surgical team members. We included a brief statement in the tool to remind surgical team members of the importance of ESU smoke plume evacuation. REQUIREMENTS FOR CLINICAL TRIAL PARTICIPATION Before we contacted smoke plume evacuation system manufacturers, we determined our facility's requirements. One requirement was that we could
MARCH 1997, VOL 65, NO 3
Table 1 SAMPLE SMOKE PLUME EVACUATION SYSTEM EVALUATION
Name Date Some of the criteria that we have determined to be important in selecting an electrosurgical unit (ESU) smoke plume evacuation system are os follows. Effectiveness:To protect surgical team members, the smoke plume evacuation system must suction all visible ESU smoke plume out of the air. Ease of use: No one wants a difficult piece of equipment.
.
Noise level: It is important that the ESU smoke plume evacuation system be as quiet as possible and not affect surgical team members’ concentration.
To determine which of the trialed smoke plume evacuation systems best suits the department‘s needs, please complete #is brief questionnaire, Your input will influence our choice of equipment. 1. Manufacturer‘s name and model number of smoke plume evacuation system Please rate the fallowing on a scale of 1 to 10, with 10 being the best.
2. Ease of use 1 2 3 4 5 6 7 8 9 1 0 If lower than 5, why did you choose this score? 3. Smoke plumeevacuation system noise level 1 2 3 4 5 6 7 8 9 10 If lower than 5, why did you choose this score? 4. Efficiency of smoke evacuation 1 2 3 4 5 6 7 8 9 1 0 At what capacity did you run the device at to accomplish this? (Percent or low/medium/high) 5. Type of surgical procedure
Do you think it was appropriate to use a smoke plume evacuation system for this particular surgical procedure? If not, why? Circulating nurse: Please return this form to the front desk with your papers.
not expend capital to acquire the smoke plume evacuation systems, so we would have to acquire the devices on a consignment basis. Our department’s materials manager stated there could be. no added cost to the smoke evacuation systems’ disposable supplies in exchange for the consignment agreement. Several companies allowed us to use their smoke plume evacuation systems free of charge for a specified period of time in exchange for our commitment to use only their disposable products for the devices. We were careful, however, to avoid any consignment offer that increased the price of the evacuation system’s disposable supplies to offset the cost of providing these
machines to our OR. ed to find a smoke plume evacuaTo “allow efficient collection tion system with a filter that out to a distance of 2 inches under would withstand heavy use. all conditions of air di~turbance,”’~ We evaluated seven smoke the smoke plume evacuation sysplume evacuation systems (ie, tems need to move 40 cubic feet hand piece, suction tubing, smoke of air per minute. We were careplume evacuator). Each clinical ful, therefore, not to choose suctrial of the seven smoke plume tion tubing that restricted the evacuation systems lasted at least amount of air flow. We also need- one week. Product evaluations ed a system that would allow us to were completed by surgeons, use the smoke plume evacuation scrub personnel, and circulating system and deliver suction to the nurses. We tested each smoke surgical field at the same time in a plume evacuation system during hands-free manner. We deteras many different types of surgical mined the smoke plume evacuaprocedures as possible. It was tion system must use an ultralow important that we test each system penetration air filter to filter out carefully because advertisements particles as small as 0.lpm. As our did not always project a clear picsurgeons perform many types of ture of how the system would persurgical procedures, we also need- form in actual use. The product 629 AOFW JOURNAL
MARCH 1997, VOL 65, NO 3
Table 2 PROPOSED OR POLICY AND PROCEDURE'
Subject Smoke plume evacuation during electrosurgical unit (ESU) use. Policy:
To ensure the safeiy of patients and OR team members, a smoke plume evacuation system must be used for any surgical procedure in which an ESU is used that results in smoke plume.
Purpose: Electrosurgical units are useful tools in surgical procedures. Many studies have shown, however, that the smoke plume produced by ESUs may be a health hazard if inhaled by patients or surgical team members. To eliminate this hazard, a smoke evacuator must be used during any surgical procedure in which ESU smoke plume is produced. Points to emphasize: The circulating nurse must inspect the smoke plume evacuation system for electrical safety and filter patency before each use. A. The scrub person is responsible for ensuring proper use of the smoke plume evacuation system on the surgical field. The smoke plume evacuation system is to be used for ESU smoke evacuation only. Another means of suctioning must be used for body secretions. Smoke plume evacuation system filters are changed according to the manufacturer's recommendotions. Disposable ESU hand pieces, suction tubing, prefilters (if any), and ultrolow penetration air (ULPA) filters must be disposed of in contaminated trash bags. Procedure: 1. A smoke plume evacuation system must be used. This smoke evacuation unit contains both a charcoal and an ULPA filter to eliminate smoke and viral particles. A. A wall suction device is not adequate for smoke plume evacuation during open surgical procedures and may be used during laparascopic surgical procedures only with concurrent use of an in-line filter.
2. Sterile smoke plume evacuation tubing will be opened on the surgical field. When in use, the end of the tubing should be within 1 in of the site generating smoke to be most effective. 3. The smoke plume evacuation system must be turned on and set to the lowest level that eliminates all visible smoke particles. It is not necessary to run the smoke evacuator at 100% at all times. NOTE 1 . *The dangers of laser plume,' Health Devices 19 (January 1990) 4-1 9; Occupational Safety and Health Administration Respiratory Regulations 29 CFR, Section 1910.134; National Institute for Occupational Safety and Health, HETA 85126-1930, September 1988; 'Proposed RecommendedPractices: Electrosurgery,' AORN Joufna/ 58 (July 1993) 131; M S Eiaggish, P Baltoyannis, E Sze, 'Protection of the rat lung from the harmful effects of laser smoke," Lasers in Surgery and Medicine 8 no 3 (1 988) 248-253; Smoke hazards found with electrosurgery,' Advanced Technology in Surgicu/ Care 13 (Febnrary 1995) 20.
evaluations showed the following features to be the most important for successful use of a smoke plume evacuation system. Etrectiveness. To protect patients and surgical team members, the smoke plume evacuation system must evacuate all of the smoke plume. We discovered that if the suction tubing was too
small, there was not enough air volume being suctioned to evacuate the smoke plume. The smaller the tubing, the closer the tip had to be to the smoke plume production site. Ease Of use. We evaluated ease of use from the perspective of the scrub person, the circulating nurse, and the surgeon. Factors of 630 AORN JOURNAL
importance were setup time, maintenance, size, number of disposable items to connect, and tubing memory. If the smoke plume evacuation system was difficult to use, surgeons' and staff members' compliance to trial use of the system decreased dramatically. Noise level. Communication in the OR is of primary importance.
MARCH 1997, VOL 65, NO 3
Table 3 SAMPLE QUALITY ASSURANCE TOOL FOR SMOKE PLUME EVACUATION
Date completed Audit completed by Chart # Instructions: 1. Tool is to be completed after identified procedures in affected rooms. 2. Review is to be conducted on 20 patients per month as designated by the OR manager or designee.
3. Completed tools are to be returned to the OR manager. Goal level: 100% all criteria Threshold for action: Anything greater than 0% Major aspect of care: ESU smoke plume evacuation Standard of practice:The patient, surgeons, anesthesia care providers, and staff members can expect to function in a smoke-free environment. Indicator: Compliance with use of smoke plume evacuation equipment when smoke plume is present from ESU. Laser smoke plume evacuation is addressed separately in the policy and procedure manual. Criteria:
Not Met
Met
NIA
Comments
Smoke plume evacuation unit present in room before generation of ESU smoke Smoke plume evacuation unit inspected by nurse for electrical safety and filter patency before use Smoke plume evacuation apparatus used to eliminate all visible smoke during ESU use Disposable smoke plume evacuation accessories placed in trash bag for contaminated items after procedure
All personnel in the OR must be able to hear each other without difficulty. The noise level of the smoke plume evacuation system must be low enough not to interfere with the concentration of all personnel in the room. Versatility. The smoke plume evacuation system had to be appropriate for use with all types of surgical procedures, including coronary artery bypass grafts, total joint reconstructions, and mastectomy and radical prostatectomy procedures. It was important that it took a minimal amount of time to adapt the smoke plume evacuation system from skin surface cauterization to use in a deep abdomi-
nal or thoracic procedures. As we often use interchangeable needle, hook, or extended electrosurgical tips, we needed to consider how the tips could be used with the system we chose.
Electrosurgical hand pieces. The smoke plume evacuation systems performed best and were more accepted by surgeons if the smoke plume evacuator tubing and electrosurgical hand piece were one unit. Snap-on or slideon evacuator tubing attachments were poorly accepted. The surgeons’ complaints ranged from “It is a little bulky,” to “I cannot perform surgery with this thing!” We discovered that the single 631 AORN JOURNAL
most important compliance factor with any of the systems was the delivery of smoke plume evacuation to the surgical field. During our evaluation, most smoke plume evacuation systems were rejected because their electrosurgical hand pieces were too difficult or clumsy to use. Electrosurgical unit onloff switches. Requiring the scrub person to activate the smoke plume evacuation system by foot pedal was not feasible because of the concentration needed to perform his or her duties. The foot pedal either was too distracting or was completely forgotten. Continually running the smoke
MARCH 1997, VOL 65, NO 3
evacuation system was too noisy, even with the quietest models. For consistency of activation, the electrosurgical hand piece-activated on/off switch was an indispensable feature.
Obstruction of the surgeon’s View. Some smoke plume evacuation systems were too large to allow visualization of the electrosurgical hand piece’s electrode tip. This obstructed the surgeon’s view, and he or she could not see how much of the electrode’s tip was in contact with the patient’s tissue. The models that functioned best in this area had clear, tapered ends. Cost-effectlveness. Many manufacturers lend smoke plume evacuation systems on consignment or lease, or they give discounts on multiple purchases. The cost of the smoke plume evacuation system’s disposable items varied widely between manufacturers. The cost range we encountered was between $12 and $32 per surgical procedure. Cost is the reason many facilities have avoided the issue of ESU smoke plume evacuation systems. Our facility decided that it was prudent to consider the potential fines and future legal action, in addition to sick time paid, if no effort was made to reduce ESU smoke plume in the OR. Several smoke plume evacuation systems had added features that easily could have distracted us. One electrosurgical hand piece included a light, another could be used with existing suction tubing, and several could alert the OR personnel when the filter needed to be changed. Some of these features were helpful but did not emphasize the main purpose of smoke plume evacuation.
EVALUATION CONCLUSION After we evaluated all the available products, we concluded that ESU smoke plume evacuation systems are a new and rapidly changing technology. There are no perfect models on the market yet. We
Monitoring compliance is an effective indicator of staff members‘ education needs in smoke plume evacuation. chose what we considered to be the best system available and made a commitment to evaluate future products. We believed there were compelling reasons to begin ESU smoke plume evacuation as soon as possible to prevent any health problems among our staff members,patients, and physicians. We received a commitment from our physicians to undergo a pilot study using our chosen smoke plume evacuation system for three months to determine whether the benefits outweighed the drawbacks. DEVELOPING A WORKABLE POLICY AND PROCEDURE To implement ESU smoke plume evacuation in the OR, we developed a smoke plume evacuation policy and procedure that would be updated annually (Table 2). We collaborated with the risk management department and the safety officer when we formulated the policy. The policy first was approved by our facility’s safety
632 AORN JOURNAL
committee and then was considered by the surgery committee. The surgery committee members had serious questions about the necessity and cost of ESU smoke plume evacuation equipment, and they were concerned that the available equipment would force a change in their surgical techniques,possibly compromising patient care. We asked for and were granted a pilot time of three months to evaluate how the chosen smoke plume evacuation system would perform. If the pilot were successful, the director of nursing and hospital’s chief executive officer would sign the policy into effect. COMPLIANCE We were surprised and pleased with the level of compliance and the expressions of gratitude from physicians and staff members during the evaluation period. Many surgeons and anesthesia care providers stated they had long been concerned about the effects of ESU smoke plume inhalation. We provided information about the dangers of ESU smoke plume, and we introduced quality products available to eliminate smoke plume from the OR. Many sales representatives of smoke plume evacuation system manufacturers offer free continuing education classes to health care facility staff members regarding the hazards of ESU smoke plume. At our facility, we used inservice time and “down time” for continuing education classes. Risk management personnel and wellinformed OR staff members assisted in educating the physicians. Monitoring compliance was and is a very effective indicator of education needs in smoke plume evacuation. When our facility’s OR staff members received
MARCH 1997, VOL 65, NO 3
ongoing information about the dangers of ESU smoke plume, compliance increased dramatically. To document compliance, we developed a tool to use during our clinical trials (Table 3). We asked an available person to fill out a form (unobserved by team members) and submit it to the surgery manager or other designee, who compiled the results and focused on the areas found to be noncompliant. We based the tool on our existing quality assurance/quality improvement format.
CONCLUSION Smoke plume from ESUs is a known, documented danger. Although cost constraints will affect the means available to OR staff members to avoid this danger, health care facility administrators must be made aware of the necessity of responding to the danger. We have not succeeded entirely in implementing our ESU smoke plume evacuation policy; however, we have succeeded in raising the awareness, support,
NOTES 1. B P Giordano, “Don’t be a victim of surgical smoke,” (Editorial) AORN Journal 63 (March 1996) 520-522. 2. D Ott, “Smoke production and smoke reduction in endoscopic surgery: hliminary report,” Endoscopic Surgery 1 (August 1993) 230-232. 3. “Recommended practices for electrosurgery,” in AORN Standards and Recommended Practices (Denver: Association of Operating Room Nurses, Inc, 1996) 155161. 4. Emergency Care Research Institute, “The dangers of laser plume,” Health Devices 19 (January 1990)4-19. 5. Giordano, “Don’t be a victim of surgical smoke,” 520. 6. On, “Smoke production and smoke reduction in endoscopic surgery: Preliminary report,” 230. 7. Occupational Safety and Health Administration, Section 1530-1531,Title 8, California Code of Regulations,
and interest of staff members, surgeons, and administrators. We are confident that ESU smoke plume evacuation in our facility’s OR will become routine, rather than an exception. A The author would like to thank Bryon Miglucci, BSB, CORT, materials manager; Debbie Butler, RN, surgery department manager; Paula Heaton, RN, Ah’,staff nurse;faculty members of the nursing education department; and OR staff members and physicians at St Jude Medical Center, Fullerton, Calif.
8. “Recommended practices for electrosurgery,” 155161. 9. M S Baggish, P Baftoyannis, E Sze, “Protection of the rat lung from the harmful effects of laser smoke,” Lasers in Surgery and Medicine 8 no 3 (1988) 248253. 10. T Burke, personal communication with the author, Fullerton, Calif, 18 Jan 1996. 11. Emergency Care Research Institute, “The dangers of laser plume,” 4. 12. J P Smith, J L Topmiller, S Shulman, “Factors affecting emission collection by surgical smoke evacuators,”Lasers in Surgery and Medicine 10 no 3 (1990) 224-233. 13. “Recommended practices for electrosurgery,” 155161. 14. Smith, Topmiller, Shulman, “Factors affecting emission collection by surgical smoke evacuators,” 224233.
Campaign to Save Energy Includes Focus on Health Today, the production and use of energy causes more environmental damage than any other human activity, according to a news release from the nonprofit organization The Alliance to Save Energy. If current trends continue, this damage will worsen. Energy consumption in the United States is projected to rise 46% between 1990 and 2025, and world energy consumption will rise 50% in the next 15 years, according to the news release. Energy is a public health issue, even in developed nations like the United States. Approximately 54 million Americans live in counties that regularly
violate air quality standards. Energy efficiency is a proven way to reduce pollution created by cars, businesses, and industries. Emissions from the nation’s 190 million cars and trucks account for approximately half of all air pollution in the United States and more than 80% of air pollution in cities. The American Lung Association estimates that America spends $50 billion each year on health care directly related to air pollution.
Campaign to Save Energy (news release, Washington, DC: The Alliance to Save Energy, Sept 30, 1996).
633 AORN JOURNAL
Smoke plume evacuation in the OR
T
he dangers from electrosurgical unit (ESU) smoke plume include exposure to
benzene, carbon monoxide, formaldehyde, hydrogen cyanide, methane, phenol, styrene . . . toluene . . . particulate mutter, gases, mutagens, carcinogensand sometimes, DNA components.’ Surgical team members, as well as patients, are exposed to these products.
Proper evacuation, neutralization and handling of these substances in an open situation is necessary for maintenance of a healthy operating environment for the surgeon, ancillary personnel and the patient? Perioperative nurses must be made aware of these dangers and take the responsibility of requesting that their health care facilities itlstitute recommended ESU smoke plume safety precautions. Our facility, St Jude Medical Center, Fullerton, Calif, is a 33 1bed hospital with 10 OR suites. We perform many types of surgical procedures at this facility, and we average 30 surgical procedures per day. We decided to implement ESU smoke plume evacuation precautions for all procedures using electrosurgicaldevices in accordance with AORN’s recommended practices.’ The laser
resource nurse and other perioperative staff nurses were the motivating force in coordinating and implementing ESU smoke plume evacuation policies and procedures in the OR. To assist our nurse colleagues in instituting important smoke plume evacuation policies and procedures in their facilities, we would like to share our experiences and hardlearned lessons.
llTERATUR€ REVKW Our fmt and most effective step was to conduct a thorough literature review. We referred to recent studies and to what the Occupational Safety and Health Administration (OSHA), the National Institute for Occupational Safety and Health, and the American National Standards Institute most recently had published. We compiled recommendations from AORN, government agencies, and scientists, and we used our medical library. We also used information from sales representatives of smoke evacuation system manufacturers, but we were careful to obtain unbiased information. Our literature search revealed that the contents of ESU smoke plume are similar, by spectral content, to laser plume.4 Smoke plume can cause “headaches, nausea, myalgia, rhinitis, or conjunctiviti~,”~ and it causes increased methemoglobin levels in patients JOY ANNE LANFRANCHI, RN, CNOR, is the laser resource nurse at St Jude Medical Center,Fullerton, Calif.
627 AORN JOURNAL
undergoing laparoscopicelectrosurgicalprocedures.6 Guidelines from OSHA do not mandate specifically that ESU smoke plume be evacuated; however, they do require that when practical, employers should “remove an oxygen deficient atmosphere or harmful dusts, fumes, mists, vapors or gases at their ~ource.”~ We also reviewed the AORN recommended practices regarding electrosurgery, which state:
Patients and perioperative personnel should be protectedfvom inhaling the smoke generated during electrosurgery. . . .An evacuation system should be used to remove surgical smoke.8 After reviewing the literature and establishingjustification,our next step was to review our equipment options for ESU smoke plume evacuation.
OPTlONS FOR PROT€CT/ON We considered using only high-filtration surgical masks. We already had them in stock, and they are relatively inexpensive. We decided, however, that masks were not the best choice because
ifparticulate matter less than 0.5 ,urn can penetrate an elaboratefilter system, it is unlikely that surgical masks regardless of thickness or rating wouki‘offer any substantial protection
MARCH 1997, VOL 65, NO 3
to the surgeon [or anyone present in the OR suite]. Additionally, most surgical m s k s gather moisture emanating from the surgeon's [or any other person's] breath during the operative procedure thatfurther diminishes the effectiveness of this barrier.9
In addition, masks offer no protection to patients. In-line smoke plume evacuation systems were unacceptable because the models advertised as being effective for 20 surgical procedures actually were useful for only four hours of ESU smoke plume evacuation. If the evacuation systems were used with a combination of laser and ESU procedures, that useful time decreased to approximately 2.5 hours.'O The cost of changing the filters every day proved to be prohibitive. In addition, there was the potential for our wall suction devices not having enough vacuum power to capture the ESU smoke plume at surgical procedure sites." One study identified the required flow of air to be 40 cubic feet per minute.'* We decided to use single-use, in-line filters for laparoscopicprocedures that required ESUs. As ESU smoke plume is confined, the suction devices do not need to be as powerful as in open surgical procedures. During open procedures, however, using wall suction devices requires personnel to hold suction hoses near the smoke plume production sites. This was not feasible for every open procedure in which ESU smoke plume was produced. We concluded that the only way to suction ESU smoke plume safely and effectively was to use dedicated smoke
plume evacuation systems with hands-free operation. DEPARTMENT NEED, ESTABLISHING CRITERIA To decide how many smoke plume evacuation systems were necessary, we conferred with the OR team leaders (ie, specialty resource nurses) to determine which surgical procedures would require smoke evacuation. The criterion was any procedure in which ESU smoke plume would be present, according to AORN standards.13We then looked at statistics that showed our busiest time of the year, and we averaged the number of surgical procedures being performed simultaneously that would require use of smoke plume evacuation systems. For our busy 10-room OR suite, we determined that we needed a minimum of six smoke plume evacuation systems. WRITING AND SUBMITTING A REPORT After we reviewed the information and established our criteria for smoke plume evacuation system use, we prepared a brief, factual report. This report contained information about the dangers of ESU smoke plume, recommended practices, a discussion of equipment options, and our conclusions about what needed to be done. We submitted this report to the vice president of clinical services (ie, the director of nursing) and our surgery unit-based practice committee (SUBPC). The SUBPC is a committee dedicated to improving nursing practice in our health care facility at the staff level. We gave copies of the report concurrently to the safety officer, the risk management director, and the director of materials manage628 AORN JOURNAL
ment (ie, purchasing) to inform them of the dangers of ESU smoke plume and to enlist their support. The safety officer was helpful in encouraging the creation of smoke plume evacuation policy and procedure for the OR. Risk management personnel helped with physician education and compliance issues. Materials management personnel assisted in the clinical trials by offering support in negotiation and coordination between the smoke plume evacuator manufacturer representatives. Help from personnel in these departments was necessary to set up a comprehensive smoke evacuation policy and procedure for the OR and to ensure employees' compliance. DEVELOPMENT OF EVALUATION TOOL The next phase in our project was to evaluate smoke plume evacuation systems. To do this, we created a smoke plume evacuation system evaluation tool (Table 1).First, we decided what the most important features of the smoke plume evacuation system should be, and we incorporated these into the tool. The tool was fairly simple and brief, and we were able to extract the information we needed to make an informed decision. It also was set up to involve all surgical team members. We included a brief statement in the tool to remind surgical team members of the importance of ESU smoke plume evacuation. REQUIREMENTS FOR CLINICAL TRIAL PARTICIPATION Before we contacted smoke plume evacuation system manufacturers, we determined our facility's requirements. One requirement was that we could
MARCH 1997, VOL 65, NO 3
Table 1 SAMPLE SMOKE PLUME EVACUATION SYSTEM EVALUATION
Name Date Some of the criteria that we have determined to be important in selecting an electrosurgical unit (ESU) smoke plume evacuation system are os follows. Effectiveness:To protect surgical team members, the smoke plume evacuation system must suction all visible ESU smoke plume out of the air. Ease of use: No one wants a difficult piece of equipment.
.
Noise level: It is important that the ESU smoke plume evacuation system be as quiet as possible and not affect surgical team members’ concentration.
To determine which of the trialed smoke plume evacuation systems best suits the department‘s needs, please complete #is brief questionnaire, Your input will influence our choice of equipment. 1. Manufacturer‘s name and model number of smoke plume evacuation system Please rate the fallowing on a scale of 1 to 10, with 10 being the best.
2. Ease of use 1 2 3 4 5 6 7 8 9 1 0 If lower than 5, why did you choose this score? 3. Smoke plumeevacuation system noise level 1 2 3 4 5 6 7 8 9 10 If lower than 5, why did you choose this score? 4. Efficiency of smoke evacuation 1 2 3 4 5 6 7 8 9 1 0 At what capacity did you run the device at to accomplish this? (Percent or low/medium/high) 5. Type of surgical procedure
Do you think it was appropriate to use a smoke plume evacuation system for this particular surgical procedure? If not, why? Circulating nurse: Please return this form to the front desk with your papers.
not expend capital to acquire the smoke plume evacuation systems, so we would have to acquire the devices on a consignment basis. Our department’s materials manager stated there could be. no added cost to the smoke evacuation systems’ disposable supplies in exchange for the consignment agreement. Several companies allowed us to use their smoke plume evacuation systems free of charge for a specified period of time in exchange for our commitment to use only their disposable products for the devices. We were careful, however, to avoid any consignment offer that increased the price of the evacuation system’s disposable supplies to offset the cost of providing these
machines to our OR. ed to find a smoke plume evacuaTo “allow efficient collection tion system with a filter that out to a distance of 2 inches under would withstand heavy use. all conditions of air di~turbance,”’~ We evaluated seven smoke the smoke plume evacuation sysplume evacuation systems (ie, tems need to move 40 cubic feet hand piece, suction tubing, smoke of air per minute. We were careplume evacuator). Each clinical ful, therefore, not to choose suctrial of the seven smoke plume tion tubing that restricted the evacuation systems lasted at least amount of air flow. We also need- one week. Product evaluations ed a system that would allow us to were completed by surgeons, use the smoke plume evacuation scrub personnel, and circulating system and deliver suction to the nurses. We tested each smoke surgical field at the same time in a plume evacuation system during hands-free manner. We deteras many different types of surgical mined the smoke plume evacuaprocedures as possible. It was tion system must use an ultralow important that we test each system penetration air filter to filter out carefully because advertisements particles as small as 0.lpm. As our did not always project a clear picsurgeons perform many types of ture of how the system would persurgical procedures, we also need- form in actual use. The product 629 AOFW JOURNAL
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Table 2 PROPOSED OR POLICY AND PROCEDURE'
Subject Smoke plume evacuation during electrosurgical unit (ESU) use. Policy:
To ensure the safeiy of patients and OR team members, a smoke plume evacuation system must be used for any surgical procedure in which an ESU is used that results in smoke plume.
Purpose: Electrosurgical units are useful tools in surgical procedures. Many studies have shown, however, that the smoke plume produced by ESUs may be a health hazard if inhaled by patients or surgical team members. To eliminate this hazard, a smoke evacuator must be used during any surgical procedure in which ESU smoke plume is produced. Points to emphasize: The circulating nurse must inspect the smoke plume evacuation system for electrical safety and filter patency before each use. A. The scrub person is responsible for ensuring proper use of the smoke plume evacuation system on the surgical field. The smoke plume evacuation system is to be used for ESU smoke evacuation only. Another means of suctioning must be used for body secretions. Smoke plume evacuation system filters are changed according to the manufacturer's recommendotions. Disposable ESU hand pieces, suction tubing, prefilters (if any), and ultrolow penetration air (ULPA) filters must be disposed of in contaminated trash bags. Procedure: 1. A smoke plume evacuation system must be used. This smoke evacuation unit contains both a charcoal and an ULPA filter to eliminate smoke and viral particles. A. A wall suction device is not adequate for smoke plume evacuation during open surgical procedures and may be used during laparascopic surgical procedures only with concurrent use of an in-line filter.
2. Sterile smoke plume evacuation tubing will be opened on the surgical field. When in use, the end of the tubing should be within 1 in of the site generating smoke to be most effective. 3. The smoke plume evacuation system must be turned on and set to the lowest level that eliminates all visible smoke particles. It is not necessary to run the smoke evacuator at 100% at all times. NOTE 1 . *The dangers of laser plume,' Health Devices 19 (January 1990) 4-1 9; Occupational Safety and Health Administration Respiratory Regulations 29 CFR, Section 1910.134; National Institute for Occupational Safety and Health, HETA 85126-1930, September 1988; 'Proposed RecommendedPractices: Electrosurgery,' AORN Joufna/ 58 (July 1993) 131; M S Eiaggish, P Baltoyannis, E Sze, 'Protection of the rat lung from the harmful effects of laser smoke," Lasers in Surgery and Medicine 8 no 3 (1 988) 248-253; Smoke hazards found with electrosurgery,' Advanced Technology in Surgicu/ Care 13 (Febnrary 1995) 20.
evaluations showed the following features to be the most important for successful use of a smoke plume evacuation system. Etrectiveness. To protect patients and surgical team members, the smoke plume evacuation system must evacuate all of the smoke plume. We discovered that if the suction tubing was too
small, there was not enough air volume being suctioned to evacuate the smoke plume. The smaller the tubing, the closer the tip had to be to the smoke plume production site. Ease Of use. We evaluated ease of use from the perspective of the scrub person, the circulating nurse, and the surgeon. Factors of 630 AORN JOURNAL
importance were setup time, maintenance, size, number of disposable items to connect, and tubing memory. If the smoke plume evacuation system was difficult to use, surgeons' and staff members' compliance to trial use of the system decreased dramatically. Noise level. Communication in the OR is of primary importance.
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Table 3 SAMPLE QUALITY ASSURANCE TOOL FOR SMOKE PLUME EVACUATION
Date completed Audit completed by Chart # Instructions: 1. Tool is to be completed after identified procedures in affected rooms. 2. Review is to be conducted on 20 patients per month as designated by the OR manager or designee.
3. Completed tools are to be returned to the OR manager. Goal level: 100% all criteria Threshold for action: Anything greater than 0% Major aspect of care: ESU smoke plume evacuation Standard of practice:The patient, surgeons, anesthesia care providers, and staff members can expect to function in a smoke-free environment. Indicator: Compliance with use of smoke plume evacuation equipment when smoke plume is present from ESU. Laser smoke plume evacuation is addressed separately in the policy and procedure manual. Criteria:
Not Met
Met
NIA
Comments
Smoke plume evacuation unit present in room before generation of ESU smoke Smoke plume evacuation unit inspected by nurse for electrical safety and filter patency before use Smoke plume evacuation apparatus used to eliminate all visible smoke during ESU use Disposable smoke plume evacuation accessories placed in trash bag for contaminated items after procedure
All personnel in the OR must be able to hear each other without difficulty. The noise level of the smoke plume evacuation system must be low enough not to interfere with the concentration of all personnel in the room. Versatility. The smoke plume evacuation system had to be appropriate for use with all types of surgical procedures, including coronary artery bypass grafts, total joint reconstructions, and mastectomy and radical prostatectomy procedures. It was important that it took a minimal amount of time to adapt the smoke plume evacuation system from skin surface cauterization to use in a deep abdomi-
nal or thoracic procedures. As we often use interchangeable needle, hook, or extended electrosurgical tips, we needed to consider how the tips could be used with the system we chose.
Electrosurgical hand pieces. The smoke plume evacuation systems performed best and were more accepted by surgeons if the smoke plume evacuator tubing and electrosurgical hand piece were one unit. Snap-on or slideon evacuator tubing attachments were poorly accepted. The surgeons’ complaints ranged from “It is a little bulky,” to “I cannot perform surgery with this thing!” We discovered that the single 631 AORN JOURNAL
most important compliance factor with any of the systems was the delivery of smoke plume evacuation to the surgical field. During our evaluation, most smoke plume evacuation systems were rejected because their electrosurgical hand pieces were too difficult or clumsy to use. Electrosurgical unit onloff switches. Requiring the scrub person to activate the smoke plume evacuation system by foot pedal was not feasible because of the concentration needed to perform his or her duties. The foot pedal either was too distracting or was completely forgotten. Continually running the smoke
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evacuation system was too noisy, even with the quietest models. For consistency of activation, the electrosurgical hand piece-activated on/off switch was an indispensable feature.
Obstruction of the surgeon’s View. Some smoke plume evacuation systems were too large to allow visualization of the electrosurgical hand piece’s electrode tip. This obstructed the surgeon’s view, and he or she could not see how much of the electrode’s tip was in contact with the patient’s tissue. The models that functioned best in this area had clear, tapered ends. Cost-effectlveness. Many manufacturers lend smoke plume evacuation systems on consignment or lease, or they give discounts on multiple purchases. The cost of the smoke plume evacuation system’s disposable items varied widely between manufacturers. The cost range we encountered was between $12 and $32 per surgical procedure. Cost is the reason many facilities have avoided the issue of ESU smoke plume evacuation systems. Our facility decided that it was prudent to consider the potential fines and future legal action, in addition to sick time paid, if no effort was made to reduce ESU smoke plume in the OR. Several smoke plume evacuation systems had added features that easily could have distracted us. One electrosurgical hand piece included a light, another could be used with existing suction tubing, and several could alert the OR personnel when the filter needed to be changed. Some of these features were helpful but did not emphasize the main purpose of smoke plume evacuation.
EVALUATION CONCLUSION After we evaluated all the available products, we concluded that ESU smoke plume evacuation systems are a new and rapidly changing technology. There are no perfect models on the market yet. We
Monitoring compliance is an effective indicator of staff members‘ education needs in smoke plume evacuation. chose what we considered to be the best system available and made a commitment to evaluate future products. We believed there were compelling reasons to begin ESU smoke plume evacuation as soon as possible to prevent any health problems among our staff members,patients, and physicians. We received a commitment from our physicians to undergo a pilot study using our chosen smoke plume evacuation system for three months to determine whether the benefits outweighed the drawbacks. DEVELOPING A WORKABLE POLICY AND PROCEDURE To implement ESU smoke plume evacuation in the OR, we developed a smoke plume evacuation policy and procedure that would be updated annually (Table 2). We collaborated with the risk management department and the safety officer when we formulated the policy. The policy first was approved by our facility’s safety
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committee and then was considered by the surgery committee. The surgery committee members had serious questions about the necessity and cost of ESU smoke plume evacuation equipment, and they were concerned that the available equipment would force a change in their surgical techniques,possibly compromising patient care. We asked for and were granted a pilot time of three months to evaluate how the chosen smoke plume evacuation system would perform. If the pilot were successful, the director of nursing and hospital’s chief executive officer would sign the policy into effect. COMPLIANCE We were surprised and pleased with the level of compliance and the expressions of gratitude from physicians and staff members during the evaluation period. Many surgeons and anesthesia care providers stated they had long been concerned about the effects of ESU smoke plume inhalation. We provided information about the dangers of ESU smoke plume, and we introduced quality products available to eliminate smoke plume from the OR. Many sales representatives of smoke plume evacuation system manufacturers offer free continuing education classes to health care facility staff members regarding the hazards of ESU smoke plume. At our facility, we used inservice time and “down time” for continuing education classes. Risk management personnel and wellinformed OR staff members assisted in educating the physicians. Monitoring compliance was and is a very effective indicator of education needs in smoke plume evacuation. When our facility’s OR staff members received
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ongoing information about the dangers of ESU smoke plume, compliance increased dramatically. To document compliance, we developed a tool to use during our clinical trials (Table 3). We asked an available person to fill out a form (unobserved by team members) and submit it to the surgery manager or other designee, who compiled the results and focused on the areas found to be noncompliant. We based the tool on our existing quality assurance/quality improvement format.
CONCLUSION Smoke plume from ESUs is a known, documented danger. Although cost constraints will affect the means available to OR staff members to avoid this danger, health care facility administrators must be made aware of the necessity of responding to the danger. We have not succeeded entirely in implementing our ESU smoke plume evacuation policy; however, we have succeeded in raising the awareness, support,
NOTES 1. B P Giordano, “Don’t be a victim of surgical smoke,” (Editorial) AORN Journal 63 (March 1996) 520-522. 2. D Ott, “Smoke production and smoke reduction in endoscopic surgery: hliminary report,” Endoscopic Surgery 1 (August 1993) 230-232. 3. “Recommended practices for electrosurgery,” in AORN Standards and Recommended Practices (Denver: Association of Operating Room Nurses, Inc, 1996) 155161. 4. Emergency Care Research Institute, “The dangers of laser plume,” Health Devices 19 (January 1990)4-19. 5. Giordano, “Don’t be a victim of surgical smoke,” 520. 6. On, “Smoke production and smoke reduction in endoscopic surgery: Preliminary report,” 230. 7. Occupational Safety and Health Administration, Section 1530-1531,Title 8, California Code of Regulations,
and interest of staff members, surgeons, and administrators. We are confident that ESU smoke plume evacuation in our facility’s OR will become routine, rather than an exception. A The author would like to thank Bryon Miglucci, BSB, CORT, materials manager; Debbie Butler, RN, surgery department manager; Paula Heaton, RN, Ah’,staff nurse;faculty members of the nursing education department; and OR staff members and physicians at St Jude Medical Center, Fullerton, Calif.
8. “Recommended practices for electrosurgery,” 155161. 9. M S Baggish, P Baftoyannis, E Sze, “Protection of the rat lung from the harmful effects of laser smoke,” Lasers in Surgery and Medicine 8 no 3 (1988) 248253. 10. T Burke, personal communication with the author, Fullerton, Calif, 18 Jan 1996. 11. Emergency Care Research Institute, “The dangers of laser plume,” 4. 12. J P Smith, J L Topmiller, S Shulman, “Factors affecting emission collection by surgical smoke evacuators,”Lasers in Surgery and Medicine 10 no 3 (1990) 224-233. 13. “Recommended practices for electrosurgery,” 155161. 14. Smith, Topmiller, Shulman, “Factors affecting emission collection by surgical smoke evacuators,” 224233.
Campaign to Save Energy Includes Focus on Health Today, the production and use of energy causes more environmental damage than any other human activity, according to a news release from the nonprofit organization The Alliance to Save Energy. If current trends continue, this damage will worsen. Energy consumption in the United States is projected to rise 46% between 1990 and 2025, and world energy consumption will rise 50% in the next 15 years, according to the news release. Energy is a public health issue, even in developed nations like the United States. Approximately 54 million Americans live in counties that regularly
violate air quality standards. Energy efficiency is a proven way to reduce pollution created by cars, businesses, and industries. Emissions from the nation’s 190 million cars and trucks account for approximately half of all air pollution in the United States and more than 80% of air pollution in cities. The American Lung Association estimates that America spends $50 billion each year on health care directly related to air pollution.
Campaign to Save Energy (news release, Washington, DC: The Alliance to Save Energy, Sept 30, 1996).
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