The most effective safety system in electrosurgery is a knowledgeable perioperative nurse. A basic understanding of electrosurgery and adherence to the necessary precautions will ensure a safe environment for both patients and personnel.

Today's electrosurgery units have more built-in safety features than ever, but they are no substitute for a staff that's committed to safe electrosurgery practice. In addition to knowing the devices inside out and honing their clinical skills, your staff must be committed to safety. Cutting corners for convenience or to save money might literally be playing with fire. Although fire hazards have been greatly reduced over the years, faulty wiring, poorly maintained equipment and lack of appropriate safety measures are still causes for concern. Here are some basic but often-overlooked practices to help keep staff and patients safe.

For the safe use
Electrosurgery safety and performance start with the generator. I recommend standardizing and using a single make and model in every OR. This expedites and simplifies familiarizing staff with the machines. Every electrosurgery unit (ESU) has properties unique to its operation, including different processors and waveforms. They also have different safety features such as audible and visual alarms and compatibilities with certain electrodes.

A key safety feature to look for is the way the machine monitors current to prevent stray site burns. For example, to eliminate or minimize the risk of capacitive coupling, I'm a believer in selecting a unit with active electrode monitoring technology or at least a reliable means of monitoring current and automatically dropping power.

Consult the manufacturer about the specifications, characteristics and safe operation of the unit. Attach these survival tips to the generator for quick staff reference. The manufacturers can provide you with resources for training staff in the care and handling of the device, including pre-use inspection and testing. Before you introduce a new generator to your ORs, do an in-service on their features and reinforce safe practices. Here are some key points to stress to avoid common real-life problems.

• Practice OR timeout. After staff works with a certain surgeon for a period of time, they get to know his desired ESU voltage settings (which may also be on his preference card). Nevertheless, the settings should always be confirmed verbally with the operator. Good practice is to always use the lowest possible power settings. Additionally, make sure to communicate when the ESU is activated - never operate in an open circuit.
• Follow manufacturer's instructions. Always use approved instruments and electrodes. For instance, nurses are notorious for rigging the ESU with all sorts of adapters. This can cause devices to short out.
• Keep the ESU secure. I had this problem at my own facility. The generator must be mounted securely on its cart or boom to prevent tipping or falling. Never place the ESU directly on the floor.
• Keep surface clear. Staff should never place anything on top of the generator - it's not a shelf. In particular, it's potentially dangerous to place fluids on the generator surface.
• Place the footswitch in an impervious bag. The pedal doesn't automatically protect the operator from a shock. Fluid from blood and irrigation solutions can cause a shock.
• Enforce cord and plug safety. The cord should be of adequate length (the generator shouldn't strain to plug into the wall, and electrode cords shouldn't strain to reach the generator). Staff should never yank the plug out of the outlet.
• Practice smart prepping. Be careful about the types of prepping solutions you use. The ESU should not be used in the presence of flammable agents. Additionally, your nurses should be able to assess the patient's skin integrity before, during and after electrosurgery.

Lastly, for preventive maintenance, assign a biomed number to each generator in the facility to foster accurate internal record keeping on its performance and service history. JCAHO recommends doing preventive maintenance on the unit every six months.

Active electrode competencies
While generator-safety technologies such as active electrode monitoring (AEM) can eliminate the risk of capacitive coupling and injuries from insulation failure, staff should visually inspect the integrity of the active electrodes and implement equipment that can assist in determining insulation failure. Be aware, however, that these lesser steps still don't eliminate the potential for capacitive coupling of the electrical energy. Emphasize staff education so that they'll understand the dynamics of capacitive coupling and how it can be set up surgically. This is true whether you purchase reusable or disposable active electrodes. Check the cord, too, because electrical current can also escape through the cord and cause a stray site burn.

Avoid securing electrodes and towels with metal clips. Current can transfer to the metal clip, potentially cause a drape fire, or cause an electric spark burn to the patient, operator, or staff.

Take special care with bipolar electrodes. Be aware that if you have different generator models manufactured by the same company, bipolar electrodes may behave differently.

Staff can get haphazard with connections, too, so always check them. It's possible to connect a bipolar electrode into a monopolar electrode slot on the generator. It's also possible not to connect a monopolar electrode tip properly to the pencil. Make sure the tip is secured. If it's not depressed all the way in, it leaves a gap. The electrical current tries to complete the connection to the metal tip and can cause the pencil to catch fire.

On a more frequent basis, your staff needs to be reminded to put the active electrode in an insulated holster whenever it's not in use during a procedure. Otherwise, for the sake of convenience, they'll lay it on the drape. This is the root cause of many surgical drape fires. Likewise, staff often fail to clean off the electrode tip during a procedure. This often happens because the surgeon is in a hurry and doesn't want to stop. The problem is that if dessicated tissue is on the tip, the tissue won't conduct current, and the current from the generator can flame up on the tip or cause a spark to jump.

Dispersive-pad competencies
All monopolar procedures require a dispersive pad to dissipate heat and let the current flow back to the generator. To prevent pad-site burns, check the pad's integrity and always use monitored pads with generator technology that monitors for good contact. Some older generators still let you use non-monitored pads (called quality pads). While they cost a few dollars less per pad, the saving doesn't remotely cost-justify (in monetary or human impact terms) adding even slightly to the risk of a pad-site burn.

Staff must assess the patient's skin integrity before applying the dispersive pad and after removing it. An even bigger issue is training staff in proper pad placement. There are no absolutes here. Optimally, the nurse should place the pad as close as possible to the active electrode. But it's better to place the pad on a well-muscled area further away than on a nearby fatty area. Avoid bony prominences and take into consideration body hair and scar tissue. Be especially careful with patients who have pacemakers and metal prosthetic devices, which can transfer electricity and cause burns.

There is also a viable alternative device to dispersive pads called a capacitor. This is a plate placed underneath the patient. Make sure nurses are trained in its proper placement and staff always makes sure the device surface is not compromised before use. Lastly, be aware that the device is not approved for pediatric use.

The power of decision
You will find your staff pays much closer attention to electrosurgery safety if the facility teaches and enforces competencies. You can also show your commitment by putting the proper tools in your staff and surgeons' hands.