patient safety & quality
By J . Hudson Garrett Jr ., PhD , MSN , MPH , MBA , FNP-BC , IP-BC , PLNC , CFER , AS-BC , VA-BC , BC-MSLcert™ , NCEE , NREMT , MSL-BC , DICO-C , TR-C , CPPS , CPHQ , CPXP , FACDONA , FAAPM , FNAP , FSHEA , FIDSA
A New Era of Safety in the Operating Room : Truly Treating Surgical Smoke
Surgical smoke in the operating room remains a regular health and safety risk for both patients and healthcare staff . The Association of periOperative Registered Nurses ( AORN ) defines surgical smoke as “ the vaporous and gaseous by-product of the use of surgical energy devices ( e . g ., electrosurgical units , lasers , ultrasonic devices , high-speed powered instruments ).” Furthermore , the Occupational Safety and Health Administration ( OSHA ) directs that Under the General Duty Clause , Section 5 ( a )( 1 ) of the Occupational Safety and Health Act of 1970 , employers are required to provide their employees with a place of employment that is “ free from recognizable hazards that are causing or likely to cause death or serious harm to employees .” Even though OSHA ’ s General Duty Clause can be leveraged as a catch-all standard for healthcare surgical smoke initiatives , there is not a specific OSHA regulatory standard that addresses surgical smoke in the perioperative setting .
Surgical smoke is sometimes referred to as smoke plume , surgical plume , bio-aerosols , lung-damaging dust , and laser-generating airborne contaminants . Surgical smoke is known to contain particles and can contain certain substances including aromatic hydrocarbons , volatile organic compounds ( VOCs ), polycyclic aromatic hydrocarbons ( PAHs ), hydrogen cyanide , inorganic gases such as hydrogen monoxide , nitriles , viruses , bacteria , blood , and potentially viable cancer cells .
The need for mitigating surgical smoke is not a new recommendation , but rather one where the true consequences for patients and perioperative staff have been poorly misunderstood until recent data highlighted the widespread impacts . The overarching goal for the perioperative environment is to create a smoke-free environment . This will require a multi-modal approach consisting of the use of air purification and disinfection technologies that have multiple stages to mitigate surgical smoke . Technologies that treat contaminated air beyond traditional HEPA filtration will be more effective in reducing the negative consequences of surgical smoke when used according to the device ’ s instructions for use .
The hierarchy of controls can be used as a systematic approach to identify the most effective method of risk reduction :
● Eliminating the hazard ( e . g ., avoiding use of smoke-generating surgical devices )
● Substituting the hazard ( e . g ., using alternative devices )
● Using engineering controls ( e . g ., surgical smoke evacuation and filtration , room ventilation of 20 total air exchanges per hour , work practices )
● Using administrative controls ( e . g ., policies and procedures , education and training )
● Wearing personal protective equipment ( PPE ) ( i . e ., respiratory protection )
When managing the risks associated with surgical smoke , healthcare facilities should utilize a variety of methods to mitigate the potential impacts and evaluate effectiveness . As part of the surgical plan , if surgical smoke is anticipated , the team should discuss mitigation steps to be taken during the case .
Current AORN Guidelines for Surgical Smoke recommend that healthcare facilities use smoke evacuation and filtration ( i . e ., local exhaust ventilation ) in addition to room ventilation . This combination approach will most effectively treat the contaminated air and remove harmful particles from the operating room . Additionally , AORN has revised its guidelines to recommend healthcare facilities “ Use a smoke evacuator system that contains an ultra-low particulate air ( ULPA ) filter with an activated carbon filter when surgical smoke is anticipated . When using a medical-surgical vacuum system , place an in-line ULPA filter with an activated carbon filter between the suction wall connection and the suction cannister . An ULPA filter demonstrates an efficiency of no less than 99.999 percent at a most penetrating particle size ( MPPS ) ( e . g ., 0.12 μm ). An activated carbon filter adsorbs odors and gases ( e . g ., volatile organic compounds ) in surgical smoke .”
In addition to the need for air filtration technologies to mitigate surgical smoke , perioperative departments must also establish policies and procedures regarding surgical smoke and communicate these policies to all impacted team members . Perioperative team members , including surgeons , should receive training on surgical smoke mitigation strategies at the time of initial hire , annually , and anytime a process or procedure changes . This training should be role-specific and competency-driven . In addition to training , perioperative leaders should engage with the facility quality , safety , engineering , and infection prevention teams on surgical smoke initiatives .
Surgical smoke in the perioperative setting continues to be a true safety concern , but luckily some technologies will mechanically treat the contaminated air and render it safe through multi-modal filtration . This safety threat requires constant attention from perioperative leadership and healthcare facility leadership . The time for action is now as our patients and healthcare team members deserve a safe healthcare environment that is free of these preventable airborne risks . For more information on surgical smoke prevention , visit the AORN website at www . aorn . org .
J . Hudson Garrett Jr ., PhD , MSN , MPH , MBA , FNP-BC , IP-BC , PLNC , CFER , AS-BC , VA-BC , BC-MSLcert™ , NCEE , NREMT , MSL-BC , DICO-C , TR-C , CPPS , CPHQ , CPXP , FACDONA , FAAPM , FNAP , FSHEA , FIDSA , is president and CEO of Community Health Associates , LLC . He also serves as an adjunct assistant professor of medicine in the Division of Infectious Diseases at the University of Louisville School of Medicine , is a fellow with the Institute for Healthcare Improvement , and has earned designation as a fellow with the Society for Healthcare Epidemiology of America and the Infectious Diseases Society of America . Garrett is a frequent lecturer globally on patient safety , infectious diseases , and medical device reprocessing and safety . He may be reached at : Hudson . garrett @ chaassociates . com