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What’s New in the
Patient Safety World
March 2023
New York Mandates
Smoke Evacuation
Our January 12, 2021 Patient Safety Tip of the Week “Surgical
Smoke” discussed in detail the hazards of surgical smoke in the OR and
recommendations for implementation of smoke evacuation programs. Surgical
“smoke” is produced by electrosurgical units, lasers, ultrasonic devices, and
high-speed electrical devices like bone saws, drills, and other high-speed
electrical devices used to dissect and resect tissue. It consists of chemical compounds
in the gaseous phase along with particles of cells, bacteria, and viruses.
Viable bacteriophage has been found in surgical smoke, and transmission of
human papillomavirus from the patient to operating personnel has occurred, even
leading to laryngeal papillomatosis in an operating room nurse. Volatile
organic compounds (VOC’s) may also be found in surgical smoke and may be
impacted by medications the patient had been receiving. There is even concern
about the possibility of viable cancer cells in surgical smoke.
New York is now the 10th state to enact legislation that
requires all licensed hospitals and freestanding ambulatory surgery facilities
to adopt policies to use a smoke evacuation system for surgical procedures that
generate smoke (AORN
2023). The law takes effect on June 14, 2023.
The AORN press release notes that, according to OSHA, each year “an estimated
500,000 workers, including surgeons, nurses, anesthesiologists, and surgical
technologists, are exposed to laser or electrosurgical smoke.” This smoke, also
known as plume, includes carbon monoxide, polyaromatic hydrocarbons and a
variety of trace toxic gases. Prolonged exposure can potentially lead to
various respiratory diseases.
The January 2023 issue of Outpatient Surgery Magazine has a
nice article on “The Secrets of a Successful Surgical Smoke Evacuation Program”
(Bouchat-Friedman
2023). It describes how Memorial Sloan Kettering addressed concerns
of some surgeons in implementing a surgical smoke evacuation program. Some
compromises were needed when surgeons were working in deep and small cavities.
Growing statewide legislation has certainly increased the
number of smoke-free OR’s throughout the country, but an unlikely catalyst has
also helped in recent years: COVID-19 (McDonald
2022), a point we also made in our January 12, 2021 Patient Safety Tip of
the Week “Surgical
Smoke”. In 2020, the Joint Commission (TJC
2020) released a paper about alleviating the dangers of surgical smoke. The
American College of Surgeons released a statement during the early months of
the pandemic acknowledging potential transmission of COVID-19 to surgical staff
during aerosol-generating procedures, including laparoscopic surgery (ACS
2020). The Society of American Gastrointestinal and Endoscopic Surgeons (Pryor
2020) also urged surgeons to use precautions to reduce the risk of exposing
OR personnel to COVID-19 from surgical plume and to use smoke evacuators. And
an article in the British Journal of Surgery discussed potential viral
transmission in surgical smoke (Mowbray 2020).
The McDonald article cites OSHA’s eight important steps
toward going smoke free:
1.
Use portable local smoke evacuators and room suction
systems with in-line filters.
2.
Keep the smoke evacuator or room suction hose nozzle
inlet within two inches of the surgical site to effectively capture airborne
contaminants.
3.
Have a smoke evacuator available for every operating
room where plume is generated.
4.
Evacuate all smoke, no matter how much is generated.
5.
Keep the smoke evacuator activated at
all times when airborne particles are produced during surgical
procedures.
6.
Consider all tubing, filters and absorbers as
infectious waste and dispose of them appropriately.
7.
Use new tubing before each procedure and replace the
smoke evacuator filter as recommended by the manufacturer.
8.
Inspect smoke evacuator systems regularly to ensure
proper functioning.
McDonald further notes that today’s technological solutions are capable of capturing up to 99% of smoke when placed near
the source.
The Joint Commission Quick Safety Issue “Alleviating the
dangers of surgical smoke” (TJC
2020) had the following recommendations:
·
Health care organizations that conduct surgery
and other procedures using lasers and other devices that produce surgical smoke
should take the following actions to help protect patients and especially staff
from the dangers of surgical smoke.
·
Implement standard procedures for the removal of
surgical smoke and plume through the use of
engineering controls, such as smoke evacuators and high filtration masks. Use
specific insufflators for patients undergoing laparoscopic procedures that
lessen the accumulation of methemoglobin buildup in the intra-abdominal cavity.
(Surgical smoke is cytotoxic if absorbed into the blood and can cause elevated
methemoglobin.) For example, a lapro-shield smoke
evacuation device — a filter that attaches to a trocar — helps clear the field
inside the abdomen.
·
During laser procedures, use standard
precautions, such as those promulgated by the Blood-Borne Pathogen Standard
(29CFR1910.1030) and the CDC’s Core Infection Prevention and Control Practices
for Safe Healthcare Delivery in All Settings, to prevent exposure to the
aerosolized blood, blood by-products and pathogens contained in surgical smoke
plumes.
·
Establish and periodically review policies and
procedures for surgical smoke safety and control. Make these policies and
procedures available to staff in all areas where surgical smoke is generated.
·
Provide surgical team members with initial and
ongoing education and competency verification on surgical smoke safety,
including the organization’s policies and procedures.
·
Conduct periodic training exercises to assess
surgical smoke precautions and consistent evacuation for the surgical suite or
procedural area.
Don’t wait for your state to mandate surgical smoke
evacuation. There are plenty of reasons for you to implement such programs to
protect both your staff and your patients.
See our previous columns discussing surgical smoke:
·
July 28, 2020 “Electrosurgical Safety”
·
January 12, 2021 “Surgical
Smoke”
References:
AORN (Association of periOperative
Registered Nurses). New Legislation Makes New York’s ORs Smoke-Free. OR
Management News 2023; January 10, 2023
Bouchat-Friedman D. The Secrets of
a Successful Surgical Smoke Evacuation Program. Outpatient Surgery Magazine
2023; January 2023 pp. 49-51
https://digital.outpatientsurgery.net/view/254235774/49/
McDonald NH. Fighting for Smoke-Free OR’s. Outpatient
Surgery 2022; October 18, 2022
TJC (The Joint Commission). Quick Safety Issue 56:
Alleviating the dangers of surgical smoke. TJC 2020; December 2020
ACS (American College of Surgeons). Covid-19: Considerations
for Optimum Surgeon Protection Before, During, and After Operation. ACS 2020;
April 1, 2020
https://www.facs.org/covid-19/clinical-guidance/surgeon-protection
Pryor A. SAGES and EAES Recommendations Regarding Surgical
Response to COVID-19 Crisis. SAGES 2020; March 29, 2020
https://www.sages.org/recommendations-surgical-response-covid-19/
Mowbray NG, Ansell J, Horwood J, Cornish J, Rizkallah P, Parker A, Wall P, Spinelli A, Torkington J. Safe management of surgical smoke in the age
of COVID-19. Br J Surg 2020; 107(11): 1406-1413
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7267397/
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