Spread the Word About Surgical Smoke Safety

Staff Safety

By: Andrea Dyer

Published: 9/27/2019

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My evacuation success story could guide efforts to clear the OR air in your facility.


I had been suffering for a long time, and wasn't sure why. I was using my asthma inhaler 4 times a week. I had skin rashes dermatologists couldn't make go away. I thought it was just a byproduct of the different places I'd lived, but the common thread finally became clear. When I stopped working in ORs during smoke-producing procedures, I went from using my inhaler 4 times a week to 4 times a year. The skin rashes went away.

People who've never set foot in an OR have no idea what's it's like to work in a room filled with smoke. I've explained what burning flesh smells like, how it brings tears to your eyes. How you can't escape it, how you breathe it in and choke immediately no matter where you go in the room. Your surgical mask is not a barrier. You're a healthcare professional protecting the lives of your patients, but with exposure to smoke, you're risking your own life every single day.

What can you do to convince your staff and administration to install smoke evacuation systems? Perhaps our hard-won success story can give you some ideas.

1. Present the proof

The science around surgical smoke is virtually irrefutable at this point: It's bad for everyone in the OR, and the more time people spend there, the more harmful it can be. The dangers of surgical smoke are well-documented in the literature, and AORN has made a huge push to raise awareness and get legislation passed in statehouses across the country to mandate the use of smoke evacuation systems in ORs. Rhode Island and Colorado have passed such laws. Several more states are studying the issue, and AORN is throwing serious weight behind those efforts. Chances are, however, that smoke evacuation systems aren't mandatory in your state yet. Even worse, there might be many people at your facility who are dismissive of the idea, or who really don't fully understand the dangers of surgical smoke.

Make smoke evacuation an evidence-based project. Be prepared with peer-reviewed research and a cost-benefit analysis. At the end of the day, though, this is about staff safety, which should be a high priority. I myself didn't know how important smoke evacuation was until a vendor held an in-service years ago.

Hospital executives would say my research was outdated, but I was really strict about not having research older than 5 years. None of my articles were biased, and I didn't take any research from vendors. My advice: Do your research, avoid bias, and be prepared to back up your assertions with recent peer-reviewed science.

2. Sell it organically
END USERS Surgeons need to be convinced that evacuation systems won't interfere with their preferred methods of operating.   |  Pamela Bevelhymer, RN, BSN, CNOR

In our situation, it was a PR effort of sorts to get smoke evacuation over the goal line. My partner in our smoke evacuation push, assistant nurse manager Jim Wade, RN, BSN, CN, and I often teamed up in a sort of "good cop, bad cop" routine (I was the bad cop) to get our message across. We went from discipline to discipline in our health system, evangelizing and winning hearts and minds to our cause. Our mix of sugar and spice proved effective.

We focused on finding surgeons to champion smoke evacuation. I tried to understand how a surgeon wouldn't want to protect their staff. People think surgeons are in the OR 40 hours a week; they aren't. Usually, it's once a week, so they aren't as affected by smoke as much as other surgical staff are.

My philosophy is to take an organic approach. You can't just tell surgeons they need to run this machine. You need frontline staff to explain it to them: "Hey, this is my health here. You can choose whether or not I breathe in these chemicals." It wasn't me going into ORs and shaming surgeons. It wasn't me putting a policy into place immediately. It was Jim and I letting it grow organically.

Jim would tell a surgeon, "Come in my office." We had all our articles geared toward surgeons ready to go, highlighted. One doctor took the articles home overnight; he'd been refusing smoke evac for over a decade. The next day, he called Jim and said, "Where's my smoke evacuator? You don't want me to expose all these people to surgical smoke, do you?" Many younger surgeons see the research and realize this could affect them, too, so they aren't as non-compliant.

We even played up the PR and marketing angle: How great would it be if our hospital was the first in the region to say we're smoke-free in the OR and on our campus. Mandatory smoke evacuation is going to be legislation soon, so why not just be compliant before that?

My advice: Educate from the bottom up and the top down, and meet in the middle. I ran continuing education in-services. I shared my research with anyone who asked — PowerPoints, countermeasures, barriers, chemical breakdowns, signs and symptoms. I met with all of the chief nursing officers in our system. One of the most powerful points I make is that an OR nurse breathes in the equivalent of 30 unfiltered cigarettes a day, and that over 150 chemicals have been identified in surgical smoke. That really opens eyes. Everybody's jaws dropped when I presented.

3. Make the financial case

The most pushback I received was from the directors. They worried about cost (and about having to police the surgeons if they made this a policy). I took the cost issue head on. My argument was that investing in smoke evacuators would be pennies on the dollar to address a known safety risk.

The best part? It's really not expensive if you work with a good vendor and negotiate effectively. We needed 133 smoke evacuation systems, which typically cost between $1,200 and $2,000, for about 125 ORs. The vendor gave them to us for free, on consignment. They wanted us to have the machines so they could sell us the disposable electrosurgical pens. And that cost is a pittance. Electrosurgical pens had cost us about $7; with smoke evac, they increased to just $21.

Our hospital's leadership ultimately decided price was no object when it comes to protecting their employees. That's how it should be.

4. Trial the options
LEGISLATIVE ACTION AORN is spearheading efforts to make smoke evacuation mandatory in every state.

When we began evaluating smoke evacuation products, we took a focused approach on finding the best product. In the process, we addressed some of the naysayers' concerns. One of the biggest complaints was that the electrosurgical pens with integrated smoke evacuators would be bulky and heavy. But our research revealed that the diameter and weight of a typical electrosurgical pen is 1.7 inches and 21 grams, and one with smoke evac is 1.875 inches and 30 grams. That's equivalent to 9 paperclips.

The naysayers also expressed concern about noise, so we did noise studies, and found the new machines only get as loud as 55 decibels. The humming of a refrigerator is 45 decibels. And we found if you place the machine closer to the ground, it's even quieter. Some products run only when the electrosurgical pen is activated, so you don't have to worry about that constant ambient noise.

Then we held a vendor fair. I invited everyone in the hospital, and people could drop in all day. If the surgeons couldn't be there, their frontline staff were; they knew what their surgeons would use and like. This was another example of our organic approach: making people feel empowered to choose their own machines. After the fair, everyone filled out surveys so we could collect and analyze feedback.

We trialed 3 products at all 6 of our hospitals for 6 weeks, rotating them in and out of different ORs. Then we assembled our champions and, happily, we agreed unanimously on the best product. The whole process took just 8 months; our vendor said we had the highest and quickest implementation rate in the U.S.

Persistence pays off

Implementing smoke evacuation requires passion and time. It's not easy, but don't take no for an answer. The biggest thing is believing your facility wants to do right by you, that you're important, that your health is important. Educate everyone in your facility about the dangers of surgical smoke until you find someone as passionate as you are about evacuating it. Sometimes all it takes is one person to be on your side, and it snowballs from there.

Keep trying, no matter how long it takes. That's what I did, and after finally succeeding, it's become my mission to spread the word about surgical smoke safety. If you'd like to talk with me about how to get smoke evacuation in place at your facility, email me! I'll be thrilled to discuss it with you. OSM

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