Smokeout: OR nurses trying to clear the air
AORN calls for smoke evacuation
OR nurses want to clear the air in the operating room. The Association of periOperative Registered Nurses (AORN) in Denver issued a position statement in April urging hospitals and other health care providers to reduce exposure to surgical smoke and bioaerosols released in laser and electrosurgical procedures.1
About 39 noxious chemicals as well as infectious particles and viable tumor cells have been identified in smoke plumes. Exposure leads to eye and respiratory irritation, headaches, and an increased risk of asthma among OR nurses, according to health hazard evaluations conducted by the National Institute for Occupational Safety and Health (NIOSH). Researchers have determined the potential for viral or bacterial transmission from viable particles.2
Yet an online survey of 623 AORN members by Duke University researchers indicated that local exhaust ventilation is not routinely used in electrocautery or electrosurgery procedures. The regular use of local exhaust ventilation ranged from 8% to 59%, the study found.3
"On the front door of the hospital, it says 'This is a smoke-free facility.' We need that same sign on the door of the OR," says Kay Ball, RN, MSA, CNOR, FAAN, an educator and consultant who is a past president of AORN and a longtime advocate for addressing surgical smoke. Ball is conducting research on surgical smoke evacuation for a doctoral dissertation and chairs the AORN Surgical Smoke Task Force.
The AORN position statement is just the first step toward building awareness of the hazards of surgical smoke. The OR nurses plan to create a "toolkit" that will help them educate their colleagues about surgical smoke. It will include a PowerPoint presentation with a test that can be used by OR staff to obtain continuing education credits as well as sample policies, posters, a bibliography, and other information.
Too often, nurses and other OR employees suffer from headaches or respiratory problems after a shift in the OR but don't connect the symptoms with the continual exposure to surgical smoke, says Mary Ogg, RN, MSN, CNOR, perioperative nursing specialist with AORN's Center for Nursing Practice. "This will be a way to get [the message] out to all the members of the perioperative team," she says.
Toxic chemicals in OR smoke
How bad is surgical smoke? NIOSH investigators visited operating rooms in three hospitals in 2000 and 2001 to measure its impact. They detected formaldehyde, acetaldehyde and toluene, though not above recommended or permissible exposure limits.
Yet even at low levels, compounds in the surgical smoke could cause irritation of the eyes and mucous membranes, especially among sensitive individuals, the investigators concluded. They also noted that other research has shown the possible presence of "mutagenic airborne particulates" in surgical smoke.
"The smoke was definitely causing symptoms among staff," says Nancy Burton, PhD, MPH, CIH, industrial hygiene team leader with the NIOSH Division of Surveillance, Hazard Evaluations and Field Studies in Cincinnati. Even many of those employees who did not have irritant symptoms reported being annoyed by the smoke, which creates an uncomfortable work environment, she adds.
The measurements of particulates varied, probably based on the surgical procedure, the surgeon's tools and techniques, and patient characteristics, says Burton.
NIOSH plans to conduct further research and is including surgical smoke in an upcoming survey of nurses regarding their work hazards.
Meanwhile, the investigators recommended that hospitals implement local exhaust ventilation "as close as possible to the point of smoke production."
Make all smoke evacuation routine
The barrier to better evacuation of surgical smoke may simply be a matter of "standard operating procedure." Lasers were introduced along with smoke evacuation units, so local exhaust ventilation of laser-generated smoke is commonplace. For example, the Duke study found that a smoke evacuator was used in 83% of the laser procedures of condyloma or dysplasia ablation and 75% of other carbon dioxide laser procedures.
"It's just the electrosurgery plume they're not evacuating," says Ball. "We've breathed that plume in for years."
Yet not everyone simply accepts the smoke as a part of the OR environment. At Gwinnett Medical Center in Duluth, GA, removing smoke has been a part of hospital policy for many years. A sign above the scrub sink states: "There is no such thing as safe smoke. This is not a choice: Smoke evacuation is mandatory."
Every year, clinical manager Vangie Dennis, RN, CNOR, CMLSO, includes smoke evacuation as a part of inservice education. She also monitors compliance. Newcomers may have worked in other facilities that did not use smoke evacuators or long-term staff may become complacent.
"It's an ongoing challenge," she says." Education never stops."
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AORN: Filter out surgical smoke The Association of periOperative Registered Nurses recommends the following risk reduction strategies for surgical smoke:
Source: Association of periOperative Registered Nurses, Statement on Surgical Smoke and Bio-Aerosols; 2008. |
The greatest concerns about smoke evacuators focus on the noise and the impact on technique. But Dennis notes, "You can hook up smoke evacuation without interfering [with a procedure]." And quieter smoke evacuators are now available. The smoke evacuation may be controlled by a foot pedal, and the intensity of the evacuation can be adjusted based on the amount of smoke generated by a procedure.
Dennis involves physicians and nurses in the evaluation of smoke evacuation units to ensure their buy-in.
AORN also seeks to raise awareness among physicians and others about the hazards of surgical smoke. Ball encourages nurses to become more vocal about their symptoms and to report them to employee health. They need to insist upon a smoke-free workplace, she says.
"We're working to form closer relationships with physician organizations so we can educate the residents and doctors about why you have to have smoke evacuation in every room," she says.
AORN also is working with the U.S. Occupa-tional Safety and Health Administration through its alliance and hopes to initiate an informational bulletin or statement from the safety agency.
"It shocks me that hospitals are not made more aware of what we're exposing our staff to," says Dennis. "If the constituents are more carcinogenic than a cigarette, and you're smoke-free in your hospitals, why would you not set up a smoke-free environment in your operating room?"
References
1. Association of periOperative Registered Nurses. Statement on surgical smoke and bio-aerosols. Available at www.aorn.org/PracticeResources/AORNPositionStatements/SurgicalSmokeAndBioAerosols/. Accessed on April 21, 2008.
2. Ulmer BC. The hazards of surgical smoke. AORN J 2008; 87:721-734.
3. Edwards BE, Reiman RE. Results of a survey on current surgical smoke control practices. AORN J 2008; 87:739-749.
OR nurses want to clear the air in the operating room. The Association of periOperative Registered Nurses (AORN) in Denver issued a position statement in April urging hospitals and other health care providers to reduce exposure to surgical smoke and bioaerosols released in laser and electrosurgical procedures.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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