Smoke-Free Is the Way to Be

Staff Safety

By: Ashlea Blevins

Published: 10/7/2020

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Lessons learned from our facility's journey to clear the OR air.


When our chief medical officer joined our daily safety huddle one morning, I saw a golden opportunity to get our smoke-free OR program off the ground. I'd been trying to get in front of the CMO for a while and, even though I'd only been at my position for a few months at that point, I wasn't shy. More importantly, I was fiercely passionate about smoke evacuation, so I walked right up and said, "I've been trying to meet with you because we need to talk about getting smoke out of our ORs." He initially thought I was trying to sell him on a specific product, but once he saw I was approaching him purely from a safety perspective, we were off and running.

Since that memorable interaction, our facility has made great strides in going smoke-free. On September 1, 2019, our campus decided to go tobacco-free. We wanted to capitalize on the momentum and excitement the move generated at our facility and approached leadership with a simple ask: "If we're really serious about going smoke-free, shouldn't we extend our smoking ban to the OR?" After all, the vapor from smoke plume contains formaldehyde, ethanol, methane, carbon monoxide, cyanide, known-carcinogen acetaldehyde and 150 other chemicals and toxic substances. For perioperative staff, a day in surgery is essentially the same as smoking more than a pack of unfiltered cigarettes.

Of course, we just happened to be perfectly positioned to align our smoke evacuation efforts with a major campus-wide initiative to go smoke-free. Most smoke evacuation initiatives don't line up quite so well. That's OK. The key is timing your efforts and launch dates to have the maximum impact on the maximum number of stakeholders.

Buy-in from the get-go

POWER IN NUMBERS Members of the Southern Georgia AORN chapter and the Georgia Smoke Coalition gathered to discuss smoke evacuation during the chapter's very first meeting.   |  South Georgia Medical Center

Your smoke evacuation program will never go anywhere without the full support of executive leadership. The earlier in the process that you get top-level leaders onboard, the more effective your efforts will be. Not only did I go right up to our CMO, I also approached our new CEO directly with my vision for smoke-free ORs with a similar pitch: "Hey, we really need to make smoke evacuation a priority right now — especially with everything we're doing to make our campus smoke-free. This would be huge for us." Initially, I got a who-are-you? look from him, but he heard me out. If you want to get smoke-evac efforts over the hump, you really need a point person who isn't afraid to ask for things. What's the worst that could happen? You get told no?

Cost will likely be a concern. It certainly was for us in the beginning. But again, you need to be persistent and find a way to show decision-makers — in a way that resonates with them — why an upfront investment is money well-spent. For instance, finding and training good perioperative nurses is difficult and costly. Being able to say your facility truly cares about the safety of its staff and has banned smoke in the OR to prove it will certainly help you stand out from other facilities, and recruit and retain the top nurses in your area.

If you're still struggling to come up with a compelling argument for why your facility needs to go smoke-free right now, try the legal tact. Remind leadership that several states have already banned surgical smoke in the OR and that list is only going to grow in the near future. When that happens in your state, you'll be forced to comply and draft a policy on the state's timeline instead of your own.

Resistance is inevitable

If you approach a smoke-free initiative with a healthy dose of pragmatism and thick skin, you'll do just fine. You can't give up just because you get told no a bunch of times, or three surgeons yelled you. On the other hand, if you expect the change to be easy, you're in for a rude awakening. Change is never easy — especially large-scale, systemic change that requires a financial investment. Throughout our journey, we encountered resistance on a number of fronts, some expected (cost) and some a bit more surprising (staff). For instance, a surgeon came out of his OR when we were trialing evacuators and said, "Get that device out of my OR and don't ever bring it in here again."

There was also the challenge of working with materials management to bring certain smoke evacuator vendors onboard for a trial. I needed to present my research, make my case and stick to a strict cost estimate. Unbeknownst to me, one vendor I had high hopes for had burned a bridge with our materials management department and couldn't even be considered as a vendor choice.

Of course, none of these obstacles compared to the COVID-19 curveball we were thrown back in March. Due to budgetary issues, we had to push back our goal of making every OR smoke-free. But that didn't stop us. Whenever I faced resistance or encountered unexpected setbacks, I channeled my anger and frustration in my notes, which I kept in a three-ring binder. I'd write down my feelings, get them off my chest and then I'd move on.

On the other end of the spectrum, there were the positive surprises. I was able to recruit dedicated physician champions to further our cause. These surgeons read the research we painstakingly prepared and understood exactly what was at stake for our staff and patients. When we trialed vendors, they were right there asking, "So when are we getting our evacuators?"

Been there, done that

Several states have already banned surgical smoke in the OR, and that list is only going to grow in the near future.

Between garnering support from upper management, finding the right vendors and drafting an evacuation policy, it's easy to get overwhelmed with going smoke-free. The good news is you don't have to reinvent the wheel. Reach out to facilities that have gone through the process and there's a good chance you'll find lots of willing allies — and maybe even a true mentor.

That's what happened to me. I was able to lean heavily on Brenda C. Ulmer, RN, MN, CNOR, in gathering research and making sure the verbiage on our facility's smoke evacuation policy was just right. As a member of the Georgia Smoke Coalition and long-time advocate of smoke-free ORs, Brenda had no shortage of resources to help us on our journey, and she was instrumental in helping me provide the peer-reviewed articles that were most relevant and most likely to have an impact on reluctant surgeons. At around the same time we were rolling out our smoke-evacuation initiative, we created a local AORN chapter here in southern Georgia that allowed us to collaborate with other facilities that had similar initiatives in place. We even brought in outside representatives — like Kay Ball, PhD, RN, CNOR, FAAN, a renowned speaker and chairwoman of AORN's Smoke Evacuation Task Force from 2007 to 2009 — to help educate staff and drum up support for our initiative.

It's also important to lean on your vendor reps whenever possible. As surgical facility leaders, we often get close with our reps and, in many cases, these individuals can provide invaluable insight beyond the nuts and bolts of their products. Of course, you have to be careful; vendors ultimately have a responsibility to sell products. However, during our trialing process, two reps were passionate about smoke evacuation and didn't push their product on me at all. They provided neutral educational materials and research without any expectation of our facility using their product.

The ultimate reward

As we slowly move away from the survival mode we were thrust into thanks to a once-in-a-generation pandemic, we plan on pushing ahead with our smoke evacuation efforts. That's a testament to our staff's tenacity and dedication to keep our ORs as safe as possible for staff and patients alike. The buzz surrounding our efforts is certainly growing. The CMO I cornered during that morning safety huddle recently called attention to our smoke-evac efforts and gave me a personal shout-out for refusing to give up on the project.

That was certainly rewarding, but the most fulfilling part of this journey has been how it's impacted our staff and changed their perception of surgical smoke. Colleagues have reached out to me and said they didn't even realize the dangers associated with surgical plume until it was brought to their attention. One staff member even approached me and said, "Ashlea, you know smoke is why I wound up leaving the OR, right? I was using three inhalers because I couldn't breathe, and I've even been kicked out of some rooms because I couldn't stop coughing and hacking."

It's stories like these that remind me of why I'm doing this in the first place. OSM

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