If the potential for patient burn caused by electrosurgical instrumentation isn't on your radar, it should be, cautioned Vangie Dennis, RN, CNOR, CMLSO, clinical manager procedural nursing at Gwinnett Health System in Duluth, Ga. 

"Electrosurgical instrumentation is a high risk device, yet this technology is used in many surgical procedures every day," she explained. "While the need for safe electrosurgery is well known, many healthcare facilities across the United States still do not have the correct safety technologies, protocols and required competencies in place to safely operate electrosurgical devices. Without these safety practices, it's just a matter of time before a patient injury occurs," Dennis added.

Electrosurgery works by applying high-frequency, high-density electrical current to produce the desired tissue effect of cut, coagulate, desiccate or fulgurate. Achieved tissue effect depends on power output, waveform (mode), type (shape) of active electrode tip, and surgeon's technique.The fundamental rule of electricity is that it follows the path of least resistance. As tissue is desiccated, its resistance increases and the electricity seeks alternate routes.

Properties of electrosurgery are current, which is the flow of electrons during a period of time (amperes); voltage, the force pushing current through the resistance (volts); and resistance, the obstacle to the flow of current (ohms).  During electrosurgery the plasma temperature (the spark observed) reaches over 1,200 degrees Fahrenheit, the high temperature needed to cut and fulgurate tissue.

What can go wrong?
Electrosurgical equipment and accessories have long been associated with fires and patient injuries caused by human error and technology error. Patient burns incurred during electrosurgery are a serious concern because such injuries can lead to morbidity and mortality. Patient burns are also considered never-events by the Centers for Medicare & Medicaid Services, effective this October. Burns can occur in several different ways, but the most difficult of these burns to identify are internal, unintended burns that occur when electrosurgical instruments are used during minimally invasive procedures.

These burns are difficult to detect at the time of surgery because they occur beyond the surgeon's field of view, when stray electrosurgical current can unknowingly pass through an electrosurgical probe and burn through patient tissue and organs.

In fact, Dennis said the probability is that laparoscopic electrosurgical injuries are most likely underreported because the injury can go unnoticed. The majority of symptoms from such a burn present after the patient is dismissed, making the cause difficult to diagnose.

Most post-laparoscopic burn victims end up suffering from perforated colons or other internal burn injuries. When left untreated, these complications can lead to peritonitis and even death.

"While human error is always a concern when a surgical error occurs, post-laparoscopic internal burns are often caused by a failure in the technology," noted Roger Odell, co-founder, chairman, and director of Encision Inc. in Boulder, Colo. He cited two common design deficiencies of electrosurgical equipment resulting in patient burns, including a single-fault insulation failure and design defect when capacitive coupling occurs with a brand new instrument or an electrosurgical probe with intact outer insulation.
 
Insulation failure: Because laparoscopic electrosurgical instruments are commonly used in minimally invasive surgeries, these instruments undergo many wash cycles and multiple uses, which can cause tiny weak points along the probe shaft where the insulation breaks down. These breaks are often undetectable by the human eye, but energy flowing down the electrosurgical probe can easily leak through these breaks and release electrosurgical sparks measuring over 1,200 degrees Fahrenheit within the body cavity and most likely outside of the surgeon's field of view. If insulation failure occurs during a standard laparoscopic procedure, stray energy from an insulation break could burn through adjacent structures or tissue, such as the small or large bowel, stomach or intestinal wall.

Capacitive Coupling: Transfer of electrical current from the active electrode through intact insulation to adjacent structures or tissue can occur during laparoscopic procedures. This presents when two conductors are separated by an insulator. A rapidly varying electrical field attracts and repels in surrounding conductors, which can be metal and insulated instruments and body tissue. (Sixty-five percent of human body weight is saline, a conductive fluid that makes human tissue a good conductor). Movement of the electrically charged ions in the electric current passing through the surgical probe can capacitively couple or transfer and burn tissue that is in contact with the probe shaft or in close proximity to the instrument.

  
Roger Odell of Encision Inc. demonstrates insulation failure and capacitive coupling.

While many electrosurgical injuries can be the result of pilot error, setting up the potential for capacitive coupling is something perioperative staff should be aware of and there are electrosurgical units that have the ability to sense tissue response and decrease the amount of electrical voltage, but staff must be aware that capacitance will not be totally eliminated with this safety feature, said Dennis.

Safety measures
Active Electrode Monitoring (AEM) is one electrosurgical safety device. This technology is housed in a small box that can be set beneath an electrosurgical unit and connects between the unit and the electrosurgical probe, which has been redesigned to integrate a coaxial conductive shield over the primary electrosurgical probe insulated shaft. The coaxial configured electrosurgical probe shaft is then connected to the Active Electrode Monitor with a single cord. The newly designed coaxial shaft has the same outer diameter as the conventional single coated electrosurgical probes. If, during the laparoscopic procedure, insulation failure occurs or excessive capacitive coupling is detected, the AEM monitor shuts off the electrosurgical unit before a stray energy burn can injure the patient, explained Roger Odell of Encision Inc., an engineer and creator of Active Electrode Monitoring.

"With AEM, we are just trying to bring electrosurgical equipment in the OR up to code with common household electrical outlets. Homes are required to have ground fault circuit interrupt (GFCI) in wet environments such as bathrooms and kitchens," Odell said, adding "The technology is simple, but it can make the difference between life and death."

Careful monitoring of electrosurgical instruments to detect insulation failure is another safety measure AORN recommends. In Recommendation XV of AORN's Recommended Practice for Cleaning and Care of Surgical Instruments and Powered Equipment states, "technology should be used to conduct stray current leakage tests at the end of each decontamination cycle. Current can leak through insulation, even when breaks are not clearly visible . . . instruments with impaired insulation are unsafe for use" (page 435 in Perioperative Standards and Recommended Practices, 2008 Edition.)

InsulScan, distributed by Mobile Instrument Service and Repair, Inc., is a technology available to scan laparoscopic probes to detect microscopic cracks that can cause burns. More than 10,000 hospitals across the United States currently use InsulScan to monitor insulation failure in laparoscopic surgical probes, explained Kelley Hooper, a spokesperson for Mobile Instruments Service and Repair, Inc. However, Hooper cautions that facilities need to follow manufacturer instructions for limits on numbers of wash cycles and use of their electrosurgical instruments. Hooper's company also recommends that practitioners test electrosurgical instruments before and after every case. (AORN also recommends following manufacturer instructions for use and cleaning of electrosurgical units and regular testing of electrosurgical instruments).

"Testing the instrument for current leakage before use and after use can decrease the possibility of insulation failure," noted Dennis.

Both Dennis and Odell travel across the country speaking to surgeons and perioperative staff about the dangers of electrosurgery and what can be done to improve safety. Odell also helps in the forensic investigation of surgical misadventures (errors) where medico-legal action has been taken. These surgical misadventures include electrosurgical burns. "The history of litigation on these injuries shows that the risks to patients and the possibility of litigation against surgeons and nurses are very real," Odell stressed.

Perioperative nurses may be held accountable for electrosurgical injury if the injury moves to litigation. It is the perioperative nurse's responsibility to assess and monitor electrosurgical equipment, said Mary Ogg, RN, MSN, CNOR, a perioperative nursing specialist in AORN's Center for Nursing Practice. "Periop nurses know the risks associated with electrosurgery and they understand they are accountable for keeping the patient safe from injury. Electrosurgery is a basic part of surgery perioperative nurses work with everyday, and it's important that nurses do not take this technology for granted," Ogg stressed, adding, "That's why education and competency in electrosurgery is essential for all perioperative nurses."

Empowering the perioperative nurse
Dennis of Gwinnet Health System agrees. "Perioperative nurses have the power to prevent these injuries by gaining the necessary competencies, understanding the technology and working with their facilities to make safe electrosurgical instruments standard in all of their ORs," she said.

Dennis is passionate about helping her perioperative colleagues recognize and mitigate the dangerous risks associated with electrosurgery. In 2001 she led a successful campaign to improve electrosurgical safety at her facility, but she warns that such work is not easy. "The key is to make these safety steps transparent to the end-user-the instrument chosen should have the same characteristics and features of the instrumentation that the physicians are already using," Dennis said.

"I receive calls from other nurses whose facilities have purchased safety equipment, but have not found buy-in from surgeons and staff to use the equipment, making it ineffective and causing patients to remain at risk. That is why staff and physician education and support from the beginning is essential," she stressed.

A systems approach
Making AORN's Recommended Practices for Electrosurgery fit into daily safety processes at your facility requires a systems approach, Dennis stressed. To do this Dennis outlined several steps that can lead to implementing safe electrosurgical processes:

• Gather data
• Develop a multi-disciplinary team, including surgeons, perioperative nurses and administrators
• Get surgeons on board first, gather their input
• Educate all staff and require annual electrosurgical competency assessments
• Continue regular in-services and education

To implement an electrosurgical safety program at her facility, Dennis started by gathering data on reported electrosurgical injuries, including information from Physician Insurers Association of America, ECRI Institute and other associations. She also researched with industry and perioperative professionals what electrosurgical safety devices would be a good fit for her facility. She shared these data with the adhoc committee at her facility that addresses safety and technology. Once this committee of nurses, surgeons and administrators agreed to support her safety campaign and institute Active Electrode Monitoring (AEM) in every OR, she took her message to surgeons and staff, holding regular "lunch and learn" in-services to share her data and discuss her adhoc committee's plan for increased safety.

Following several months of extensive training and education for all perioperative staff, the facility established an implementation campaign to institute the electrosurgery safety procedures called "Go Green for Patient Safety" (the AEM cords and accessories are a distinct green color). AEM units were given a final test over a weekend so the safety plan could launch on a Monday morning. Today all OR's in the Gwinnet Health System practice safe electrosurgery using active electrode monitoring and requiring all perioperative staff to demonstrate competence in electrosurgery. "We had some challenges and bumps along the way during our initial implementation, but overall our initial launch was a success and seven years later, safe electrosurgery is our standard practice," Dennis said, attributing this success to a combination of continued education and a focus on electrosurgical competencies for all perioperative staff.

Required competence
Following Recommendation II in AORN's Recommended Practices for Electrosurgery, all perioperative nurses in Gwinnet Health System are required to demonstrate competence in the use of electrosurgical units and accessories.

According to this AORN Recommendation, "personnel working with electrosurgery equipment should be knowledgeable about the principles of electrosurgery, risks to patients and personnel, measures to minimize these risks, and corrective actions to employ in the event of fire or injury," (page 315-316, Perioperative Standards and Recommended Practices, 2008 Edition).

Also stated in this Recommendation, "Administrative personnel should assess and document annual competency of personnel in the safe use of electrosurgical units and accessories according to hospital and department policy  . . . regular competency assessment provides a record that personnel have a basic understanding of electrosurgery, its risks, and appropriate corrective action to take in the event of a fire or injury."

"Perioperative nurses must have a clear understanding of the basics of electrosurgery," emphasized AORN nursing specialist Ogg. "Understanding these principles in a classroom setting is important, but it is critical that perioperative nurses be able to understand these principles in the OR setting. If nurses are unsure of the differences between the cut, coag and blend settings on the electrosurgical units, request in-service training from your electrosurgical unit vendor, review the literature and AORN's Recommended Practices and assess your competency."

Additional Resources
Periop 101: A Core Curriculum: AORN's comprehensive online introduction to perioperative nursing includes a basic review of electrosurgical principles and safety practices.

Cine-med.com: Video education on Electrosurgery: Function, Practice and Safety is available through this online medical education resource.

aornbookstore.org: Perioperative Standards and Recommended Practices, 2008 Edition, Recommended Practices for Electrosurgery.

Read more news in AORN Connections.

     <sup>Insulation failure during
     laparoscopic procedures can
     cause patient injuries, such as
     intestinal perforation.
     Photo credit: Encision Inc.

ELECTROSURGERY:
BASIC TERMS</sup>

^{Active electrode: The electrosurgical unit accessory that directs current flow to the surgical site (pencils or various tips).}

^{Circuit: Pathway for the uninterrupted flow of electrons}

^{Current: Flow of electrons during a period of time, measured in amperes}

^{Dispersive electrode: The accessory that collects electrical current flow from the patient back to the electrosurgical generator (often called the patient plate, return electrode, natural electrode, inactive electrode or grounding pad).}

^{Voltage: Force pushing current through the resistance, measured in volts}

<sup>Wave form: The electrosurgical generator produces various waveforms to create desired effect, such as cutting, fulguration or desiccation (two forms of coagulating).

Cut waveform: a constant waveform the surgeon uses to vaporize or cut tissue. This waveform produces heat rapidly.

Coagulate waveform: an intermittent waveform that causes the generator to modify the waveform so that the duty cycle (on time) is reduced. This interrupted waveform will produce less heat.

Sources: AORN Recommended Practices for Electrosurgery and Principles of Electrosurgery Online from ValleyLab.com.</sup>