Electrosurgery units are the most dangerous devices we encounter in the OR daily, according to AORN. If your facility performs electrosurgery, you should write and enforce a safety policy that specifies the standards of care for your staff. In addition to protecting your staff from the electromedical device that causes more patient injury than any other device used in the OR, your standards of care and quality improvement methods are something that organizations such as JCAHO assess in accreditation. Perhaps most importantly, codifying your electrosurgery program maximizes safety for your patients. Here are five steps to creating an electrosurgery policy.

Don't reinvent the wheel
Electrosurgery is used across specialties - in head and neck surgery, open general surgery and laparoscopic GYN surgery, to name a few - and in monopolar and bipolar modalities, so developing an electrosurgery policy can get overwhelming if you attempt it alone. A good first place to look is the safety practices and competencies recommended by AORN. Many facilities, including ours, develop their policies based on these guidelines. AORN recommends that your policy incorporate these elements: electrosurgical unit brands in use at your facility; each unit's identification number; the range of settings; instructions for active electrode inspection; dispersive electrode and ECG pad placement; a requirement to examine and record the patient's skin before and after the procedure; and any other electrical devices in use in the OR.

A second key resource for your policy development is the Emergency Care Research Institute (ECRI). Not only can it guide you to current safety data (for example, reducing the risk of capacitive coupling) as you evaluate electrosurgery devices, it can also keep you posted on compliance with the Safe Medical Device Act (SMDA) and other regulations. For example, if a patient or staff suffer an electrosurgery injury or you experience equipment failure, you should know the protocol for investigating the incident. Detail the event in writing, and retain the pencil, pad and generator used in the case, along with all related device-maintenance and service information to evaluate the potential cause of the incident.

Consult the manufacturer
Because every electrosurgery unit has properties unique to its operation, including different waveforms, built-in safety features and compatibilities with certain electrodes, you must consult the manufacturer about the specifications, characteristics and safe operation of the unit. Attach these survival tips to the generator for easy staff reference. The device manufacturers can provide you resources for developing staff competencies with their units. For instance, they may conduct an in-service on the operation, care and handling of the device, including pre-use inspection and testing.

Assign a biomed number to each device to foster accurate internal record keeping on its performance and service history. JCAHO recommends doing preventive maintenance on the unit every six months.

Evaluate safety technologies
Stay current and evaluate the latest electrosurgery safety technologies. Unlike some modifications made to other medical devices, these are not mere bells and whistles. Anything that reduces the risk of human error or equipment failure is worth taking time (and money) to consider. Remember, the cost of a single electrosurgical burn, in both human and financial terms, is astronomical. Here are several technologies to consider:

• Tissue-resistance sensor. If the surgeon activates the foot pedal before touching the electrosurgical instrument tip to tissue, the generator will detect an increase in resistance, and the unit will automatically drop the voltage of the generator.
• Active electrode monitoring. AEM doesn't allow electrical energy leakage from an active electrode with compromised insulation and eliminates capacitive coupling during the procedure. If you don't use AEM, consider such devices as InsulScan to supplement visual between-case inspection of the electrode.
• Contact quality monitoring. CQM reads the return pad surface area to ensure adequate surface contact to avoid burns. There is also a CQM alternative technology manufactured by Megadyne that replaces the adhesive pad with a capacitive return pad that is set underneath the patient on the OR table. Proponents of the latter technology point to the fact that it obviates searching for a pad placement site and potentially shaving the site.

Once you decide to incorporate these technologies, update your electrosurgery policy to reflect the facility-wide use of these safety features.

Consider the variables
There is no such thing as a one-size-fits-all policy. Every case is different. If, for example, you do head and neck electrosurgery and laparoscopy, you need to spell out your safety protocols for both. Your policy should address the many possibilities for pad placement. While the thigh is the most common site, staff should place the pad near the active pencil. Shortening the distance decreases the area of the patient's body the electrical current has to flow through. However, avoid placing the pad on bony prominences, skin folds, skin over metal prosthetics, hairy surfaces and areas where the grounding pad will come in contact with spilled fluids or blood.

Your policy also should differentiate between monopolar and bipolar electrosurgery. Bipolar electrosurgery does not require return electrodes; the active electrodes function differently than their monopolar counterpart and carry a different set of manufacturer's recommendations. Key bipolar considerations include the generator's waveform, the thermal energy delivery system (the types and size of paddles), the amount of tissue grasped between the paddles and differences in physicians' techniques.

Instruct staff and docs
Your electrosurgery policy should require a good deal of staff education to effectively develop the desired competencies. You don't want your OR staff to regard the standards as a collection of static policies. It is impossible to cover every possibility, and they need to understand that no document takes the place of their judgment. But you also need to be able to address the inevitable best-practice questions they'll have.

For example, let's look again at assessing variables for determining pad placement. Staff may be confused by an instruction that reads "if necessary, shave body hair before placing the pad." First, nurses are now used to hearing that they should never shave the patient pre-operatively. Secondly, they may miss the key words: if necessary. Therefore, you need to address these issues in your educational sessions. In this instance, remind staff that, first of all, usually an alternative site can often be used, and secondly, while shaving is now discouraged for operative-site preparation, and the pad ideally goes near the operative site, it is not part of the operative site itself.

Lastly, do not forget your physicians. Many facilities consider their electrosurgery policy a strictly nurse-related standard of care. However, electrosurgery safety education is an educational area where we've dropped the ball with many physicians. While more and more medical training programs incorporate electrosurgery safety instruction, many docs (especially those who have been practicing awhile) are not aware of guidelines for preventing non-user errors, such as capacitive coupling and insulation failure. Getting docs on board with your nursing staff can only increase the success of your electrosurgery safety program.

Change with the times
As with any facility policy, your electrosurgery policy is useless if it sits on a shelf. To keep your standards of care relevant and current, make them available to staff and subject them to ongoing review and refinement as you fine-tune the policy to meet your case mix and reflect new technologies. With proper attention, your electrosurgery policy should serve your staff - and your patients - well for many years.