September 27, 2023



Fourteen States Have Now Mandated Smoke Evacuation in ORs

How to Sell a Smoke-Free OR to Anyone

Why is Surgical Smoke Evacuation in the OR So Important? - Sponsored Content

Smoke-Free in Stages

Mississippi VA Site Recognized for Smoke-Free OR Efforts


Fourteen States Have Now Mandated Smoke Evacuation in ORs

Could yours be the 15th?

Smoke mapAORN
ONE BY ONE States in green have now passed smoke evacuation laws, while bills are pending this year in the states in gold.

At the beginning of 2021, only two U.S. states had enacted legislation mandating the use of smoke evacuation systems in every OR for every smoke-producing procedure. The addition of a dozen additional states over the last two years exemplifies the huge impact that concerned perioperative nurses and other staff are making in statehouses across the country, buttressed by a strong educational and advocacy push from members of the Association of periOperative Registered Nurses (AORN).

The 14 states that have enacted surgical smoke evacuation legislation are Arizona, Colorado, Connecticut, Georgia, Illinois, Kentucky, Louisiana, Missouri, New Jersey, New York, Ohio, Oregon, Rhode Island and Washington. However, bills remain pending this year in seven additional states: California, Florida, Massachusetts, Pennsylvania, North Carolina, Texas and West Virginia, says AORN Associate Director of Government Affairs Jennifer Pennock, who has worked tirelessly to get smoke evacuation bills over the finish line in every state.

Why all of this effort? Simply put, inhaling surgical smoke, which is full of toxic materials, is dangerous to OR staff and patients and can produce long-term health problems, including respiratory issues. The good news is that the voices of everyone who works at surgical facilities are being heard. If you work in a state that still hasn’t passed a surgical smoke evacuation bill, you can help make a difference.

“For years, AORN has worked on the issue of surgical smoke at the policy and facility levels,” says AORN CEO and Executive Director Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN. “AORN members across the country are working to enact state laws to ensure harmful surgical smoke is evacuated from every operating room to protect their health and safety.”

While laws that mandate surgical smoke evacuation are obviously helpful, individual facilities in all states can take their own initiative to make their ORs smoke-free. Ms. Groah and Ms. Pennock say that hundreds of facilities nationwide have done just that through AORN’s Go Clear Program.

“I urge AORN members to focus on this issue locally,” says Ms. Groah. “Get involved in AORN’s advocacy efforts to go surgical smoke-free, and join the hundreds of facilities nationwide working toward their own Go Clear Awards.”

How to Sell a Smoke-Free OR to Anyone

Safety, ROI and efficiency are three talking points to get the job done.

SmokeSTOP SMOKING The cumulative effects of surgical smoke exposure can eventually cause respiratory difficulties and other negative health impacts for perioperative providers.

Currently, 14 states have mandated smoke-free ORs. If you’re in one of the 36 states that still hasn’t and are getting tired of waiting for legislative change, you need to make the case for clearing the air at your facility to executive leadership. Fortunately, creating a pitch-perfect deck to sell your C-suite on the use of smoke evacuation systems and mandatory smoke-free ORs generally comes down to these three basic talking points.

Surgical smoke is toxic to your staff. The first place to go when answering the inevitable question of “why” is to share the facts. For example, a well-cited study by Hill et al quantified the mutagenicity of surgical smoke to be as harmful as smoking 27 to 30 unfiltered cigarettes per day, which increases the risk of cancer and neurodegenerative diseases. Need more? A 2019 review by Liu et al discussed cases of the same types of HPV lesions excised during surgery as the cause of surgeons and nurses in the room developing laryngeal cancers. The truth about surgical smoke hazards can win buy-in from OR team representatives to support the broader effort.

Beyond safety, it’s a worthwhile investment. Once you’ve covered the facts, convincing executives that the upfront investment in smoke evacuation is well worth it in the long run requires a data-driven approach. Engaging in collaborative product evaluation with materials management can help confirm the upfront cost of smoke evacuation equipment as well as long-term expenses for filters, tubing and other components that will need to be replaced.

In addition to sharing detailed numbers on the actual cost of the equipment, it can be beneficial to discuss the costs of not evacuating surgical smoke, specifically OR team members requiring medical care for acute and chronic conditions such as chronic obstructive pulmonary disease that can result from surgical smoke exposure.

Another good idea is to evaluate the cost of onboarding and training new perioperative nurses. That’s because staff working at facilities that do not evacuate surgical smoke often leave for facilities that consistently do, or move to states where smoke evacuation laws are in place. “With healthcare staff retention such a big issue and major concern with policy makers and stakeholders, the cost of not evacuating surgical smoke is too great when ASCs are competing for staff in a tight job market,” says Jennifer Pennock, AORN’s associate director of government affairs.

The technology has come a long way. An historic barrier to becoming smoke-free for many facilities has been pushback from surgeons. Often this concern stems from poor experiences with smoke evacuation systems in the past, as well as issues with how using the technology can negatively impact workflow and create delays. Listen and validate those concerns, while also carefully and confidently explaining how seamless and efficient the new systems have become. If your surgeons haven’t worked with smoke evacuation for many years, arrange for them to try out the latest systems. The experience could likely alleviate or eliminate their previous concerns.

Why is Surgical Smoke Evacuation in the OR So Important?
Sponsored Content

Using a smoke evacuation system benefits healthcare workers who are exposed to chronic second-hand smoke and health risks every day.

STERIS STERIS Smoke Evacuation unit.

According to the Association of periOperative Registered Nurses (AORN), the average daily impact of surgical smoke on an OR team is equivalent to inhaling the smoke of 27 to 30 unfiltered cigarettes. AORN has led the fight in preventing the risk of surgical smoke for healthcare professionals who provide safe surgical care for their patients every day. That effort includes guidelines for smoke evacuation, education and lobbying efforts across the country. The momentum is growing as 11 states have passed legislation to protect the workers that put themselves at risk every day in the OR (see Article | Outpatient Surgery Magazine (

Until just a few years ago, policies for smoke evacuation in the operating room have been left up to the discretion of the individual healthcare facility and its leadership. That appears to be changing with states either enacting or proposing surgical smoke regulations requiring operating room (OR) environments to be smoke-free for the benefit of both patient and staff safety.

What is surgical smoke? Surgical smoke, or surgical plume, is the vaporization of substances (e.g., tissue, fluid, and blood) into a gaseous form. It is dangerous because it can contain toxic compounds, bioaerosols and live or dead cellular material, including viruses and bacteria. Smoke is comprised of 95% water and 5% other particulates, gases and microorganisms. Although the water vapor itself is not harmful, it acts as a carrier for the hazardous chemicals in surgical smoke.

Surgical smoke is produced by using lasers and electrosurgical units (ESUs) and is a byproduct of human tissue contact with mechanical, heat-producing medical devices, such as electro-surgery knives, commonly used for dissection and hemostasis. Surgical smoke exposes OR staff to biological contaminants, including aerosolized blood. Constant exposure can result in serious health issues for the doctor, support staff and patient.1 Studies have identified the presence of bacteria, HPV and viable malignant cells in surgical smoke, reflecting the importance of smoke evacuation and respiratory protection.

Today, facilities can use highly effective devices that are easily implemented in their ORs and systems to create surgical smoke evacuation – capturing the plume at the incision site and helping to prevent it from remaining in the patient or being inhaled by staff members.

How can this be done? Surgical smoke evacuation is the act of removing the plume caused by lasers and ESUs during a procedure. A common misconception is that implementing smoke evacuation will involve construction to redesign the room or even an HVAC overhaul, but this is not the case. A high-flow vacuum generates suction to collect the smoke while a filter removes the harmful particles and traps fluids within the smoke evacuation unit.

These devices can be portable on a cart or even standalone when placed on a surgical boom. While other methods of respiratory protection, such as a HEPA respirator (N95) mask and exhaust ventilation in the OR, are often in place, a more effective way of controlling surgical smoke is through the use of a smoke evacuator. The National Institute for Occupational Safety and Health (NIOSH) recommended that smoke evacuation be used in addition to general room ventilation to control smoke emission better – preventing it from reaching the breathing zone of healthcare workers and patients – and reducing the workers’ continuous exposure.

Smoke evacuation systems collect and filter the plume from electrosurgical or laser procedures at the surgical site. A typical smoke evacuation system includes a suction pump motor, sensors for activating the system, filters for trapping and purifying surgical plumes, smoke evacuation tubing, and an ESU smoke evacuation pencil. A highly effective system includes smoke evacuation tubing that slips over the electrosurgery pencil in the surgeon’s hand, allowing the tubing to be positioned to remove plumes directly at the incision site before they can escape.

Filtering capability and suction power play a significant factor in the effectiveness of the system. The types of smoke evacuators that tend to be preferred by OR teams possess a high-flow vacuum but emit a low sound level while in operation to minimize noise distractions during surgery and allow OR teams to communicate without interference.

The STERIS Smoke evacuation system is one of these such technologies available today. The STERIS smoke evacuator has improved technology and delivers a highly effective method of collecting and filtering smoke produced during either open or laparoscopic procedures. A high-speed, brushless motor helps create suction pressure up to five times greater than other evacuators, quietly pulling smoke particles expelled from the surgical site and capturing them before they can escape. It works with all surgical cutting devices found in operating rooms, and the patented electrocautery pencil with an integrated surgical smoke evacuation mechanism captures surgical plume right at the source to improve patient and staff safety.

The use of a smoke evacuation system is not only a benefit to the health and safety of everyone in the OR, but also is becoming a legal requirement in a growing number of states. Advances in technology and reducing risk are making it easier to overcome the challenge of implementing this type of device and provide a safer environment for everyone.


1. Katoch, S., & Mysore, V. (2019). Surgical Smoke in Dermatology: Its Hazards and Management. Journal of Cutaneous and Aesthetic Surgery, 12(1), 1-7.

Note: For more information go to STERIS Smoke evacuation system and Surgical Smoke Evacuation Systems In The OR | Knowledge Center (

Smoke-Free in Stages

Memorial Sloan Kettering Cancer Center staff found resounding evidence to clear the air in its ORs, but wisely didn’t rush to implement it.

No matter how big or small it may be, implementing change is never a linear process. That didn’t deter New York City’s Memorial Sloan Kettering Cancer Center from putting a standard surgical smoke evacuation program in place.

In 2019, a group of perioperative nurses at Sloan Kettering tackled the issue by conducting a systematic review of available evidence on the effects of surgical smoke. They reviewed 151 articles from the American Association of Nurse Anesthesiology, the Association of periOperative Registered Nurses, the Centers for Disease Control and Prevention and the National Institute for Occupational Safety and Health to get the ball rolling.

“Our physicians and colleagues are very much into making decisions based on evidence,” says Yessenia V. Salgado, DNP, RN, NE-BC, CNOR, director of nursing for perioperative services at the facility. The evidence-based recommendations all pointed to a major area of concern: The lack of smoke evacuation in the OR leads to decreased staff health and air quality.

Despite the resounding evidence, however, the team did not rush implementation because they didn’t want surgeons and staff to feel forced to use a new device. Instead, they set a goal to employ a phased rollout to a different surgical specialty each month, while transitioning away from the standard electrosurgical (ESU) pencil for all appropriate surgical procedures within six months to smoke-free ESU pencils.

“The devices have a different feel in a surgeon’s hand, and the team of nurses wanted to be mindful of ensuring the engagement of the surgeons,” says Marcia Levine, MSN, RN, NE-BC, vice president of nursing for inpatient and perioperative services at the hospital.

Dr. Salgado advises leaders interested in launching their own smoke-free efforts that when team members raise concerns or seem apprehensive about the change, be sure to listen to them and let them voice their fears.

“Some of our surgeons had legitimate concerns,” she says. “For instance, we have a large sarcoma specialty service, and a couple of our surgeons shared that when operating deep in the pelvis, the size of the smoke-free ESU pencil limits the precision needed when resecting in such deep and small cavities. We worked together and found a compromise that included the use of the smoke-free ESU pencil for the majority of the cases with the removal of the tubing when working deep in the pelvis.”

Mississippi VA Site Recognized for Smoke-Free OR Efforts

It’s the only healthcare system in the state so far to receive AORN’s Gold Level Go Clear Award.

A U.S. Department of Veterans Affairs (VA) site in Biloxi, Miss., became the first healthcare system in the state to receive the Gold Level Go Clear Award from the Association of periOperative Registered Nurses (AORN) in recognition of its efforts to reduce surgical smoke in its operating rooms.

The recognition came after Gulf Coast VA Operating Room Nurses Sheena Strong and Kristin Mate submitted a project to the Veterans Health Administration Innovators Network’s Spark-Seed-Spread Investment Program titled “Greening the Operating Room: One Wrapper at a Time.”

“I wanted to initiate a project that would benefit our veterans and our team,” says Ms. Mate. “It truly is an honor to be able to provide world-class health care to our nation’s heroes. I am proud that I was able to make that care even better.”

The project consisted of a three-tiered approach to improve the environment and safety within the operating room for veterans and staff, with smoke evacuation just one of the three tiers. The components of the project included a recycling initiative, implementation of closed fluid management devices and a mandated addition of surgical smoke evacuation devices.

A third perioperative nurse, Kristi Antonucci, RN, conducted extensive education and training for the OR team, and completed the steps to win AORN’s Go Clear Award, which is presented to healthcare facilities across the U.S. that have committed to providing increased surgical patient and healthcare worker safety by implementing practices that eliminate smoke caused by the intraoperative use of lasers and electrosurgery devices.

“I am so proud of our clinical and administrative teams who worked together to improve the safety and surgical outcomes for our veterans,” says Stephanie Repasky, MD, Gulf Coast VA’s interim medical center director. “This is a shining example of why we are the best healthcare system for our veterans and why our veterans will continue to choose the VA.” OSM

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