Chris Lolley stands in an inpatient operating room at UCHealth University of Colorado Hospital. He attaches a series of plastic tubes to a small device with a tip resembling a pencil lead and points to a spot on the ceiling above the surgical boom. It’s a duct designed to whisk away the risky remnants of surgery.
Lolley, an inpatient OR charge nurse, is demonstrating a system for evacuating the smoke created by the laser and electrical devices surgeons use to cut tissue and cauterize it to minimize bleeding. These tools are vital, but they generate smoke that contains toxic gases as well as microscopic particles that can elude surgical masks. These emissions have been shown to cause respiratory problems for those who inhale them. The smoke also increases the risk of pulmonary fibrosis and the transmission of viruses.
The risks decline dramatically if surgeons use smoke-evacuation systems. At UCH, they can be fitted to the laser or electrosurgical unit at the surgical table in some of the ORs. While the surgeon works, the device pulls the smoke through tubing and vents it through the ceiling ductwork. The hospital also has portable evacuators that suck the smoke through charcoal filters, cleansing it of the toxic particulates.
Clear the air
The organization’s policy on surgical smoke plume evacuation, written in 2013, is unambiguous. “The wearing of a mask is not adequate to prevent the inhalation of smoke produced from the cautery or laser during a patient procedure,” it states. “To eliminate the hazards of breathing in the smoke, a smoke evacuator unit or in-line filter should be used for any procedure in which an electrocautery or laser is used.”
To keep OR providers as safe as possible, Lolley and others want to ensure the greatest possible compliance with the policy and are taking specific steps to reach that goal. He’s leading an effort to secure a “Go Clear Award” from the AORN (Association of periOperative Registered Nurses). The hospital is seeking a Gold designation, which requires at least 90 percent compliance with standards for education, availability of evacuation equipment and use of it during surgical procedures.
To earn the award, all OR nurses and certified surgical techs will take a pretest about surgical smoke, and then will complete two online education modules and a post-test. Lolley said the results will help to identify barriers to using smoke evacuation equipment during surgery. To demonstrate compliance, the hospital also will submit three months of data gleaned from the Epic electronic health record and from observation. He’s hoping the hospital can complete the entire process in July.
Not blowing smoke
The risk that surgical smoke poses to health care workers is well established. As far back as 1989, a study concluded that the inhaled smoke produced from electrosurgery devices was equivalent to smoking six unfiltered cigarettes. The Centers for Disease Control and Prevention, the Occupational Safety and Health Administration and the National Institute for Occupational Safety and Health have all weighed in on the need to protect providers from the smoke.
“We’ve had staff report tightness in the chest and complaints of headaches,” Lolley said. “We know now that there is a reason for that.”
Technology also contributes to the problem, said Melanie Sandoval, PhD, MSN, RN, perioperative research nurse scientist at UCH, who is helping to lead the Go Clear initiative. Newer, faster laser devices increase the amount of fine particulates that “masks can’t stop,” she said.
The smoke can also be harmful to patients, Lolley noted. For example, during some laparoscopic procedures, smoke can build up in the patient’s belly. That makes it harder for the surgeon to see, but unvented smoke can also increase levels of carboxyhemoglobin – carbon monoxide molecules that bind to red blood cells – thus decreasing the patient’s oxygen absorption. That, in turn, slows healing.
The variety of threats illustrates the need to use smoke evacuation equipment consistently, Sandoval said. “We want to put a spotlight on it.”
The illumination is needed. The AORN estimates that a half-million health care workers are exposed to surgical smoke each year, Sandoval said. Yet roughly half of respondents to a NIOSH survey on laser procedures said they’d never received training that educated them about the dangers of the smoke.
That’s changing. It’s now mandatory in California to use smoke evacuators during surgery. So far it’s the only state to take that step, but it won’t be the last, predicted Richard Schulick, MD, chair of the Department of Surgery at UCH, who is serving as physician champion for the Go Clear initiative.
“Wherever California leads, the rest of the nation follows,” he said.
Schulick acknowledged that the evacuation devices can at first feel “clunky.” Surgeons may feel they have less precision and that they can’t see the surgical area as well because the evacuation device fits over the top of the cauterizing tip, he said.
He is sympathetic to those concerns, but added, “This is a safety issue. If it’s safer for me and for everyone else in the OR, then we need to take a little bit of time to learn to use the devices. We can adapt.”
Protecting providers and patients is the paramount purpose of smoke evacuators, but they may yield other benefits, Lolley added.
“We’re hoping the Go Clear Award will help us with staff retention and acquisition,” Lolley said. “We think that our use of extra safety equipment will encourage people to come work with us.”
Schulick agreed. “If a nurse has an opportunity to work at two places and one of them uses smoke evacuation equipment consistently and the other doesn’t, why would you not go to the place where they use it?” he said. “It speaks to culture: do you care about your providers and employees?”
Lolley said UCH wants to be an institutional leader in clearing the OR air, and he believes the time is right. A decade ago, skepticism, unawareness of the risks, and a lack of readily available equipment combined to hold compliance rates down. A new generation of providers is more aware of the dangers of surgical smoke and willing to speak up on their own behalf.
“It’s hard to change culture,” Lolley said, “but now we have younger nurses and other providers, and it’s easier.”