AORN's Position Statement on Surgical Smoke and Bio-aerosols, ratified in April, charges healthcare personnel with responsibility for educating themselves about these airborne hazards and taking steps to minimize their risks. This directive makes smoke evacuation systems essential equipment for any OR using electrosurgery units, lasers or similar instruments. If you're planning to equip your surgical suites or replace outmoded models, you'll want to ensure that the equipment not only works well, but works for your staff.

Beyond room suction
While it's true that the suction devices standard to every OR capture surgical smoke in addition to fluid wastes in their canisters, the in-line filter between the suction device and the wall-mounted system doesn't provide fine enough filtration to protect the staff. It only prevents the system from becoming occluded by carbon buildup. Additionally, it's possible that particulate matter in the smoke is able to escape through the collected fluid. To adequately protect the OR staff, a stand-alone smoke evacuation device is needed in every room in which smoke is generated. Such devices are designed to have a greater amount of suction, and therefore a greater ability to pull smoke from the site, as well as more efficient filtration than room suction.

This distinction may be important in gaining buy-in from the administration to purchase smoke evacuation systems for your ORs. How can you get the go-ahead? Make your request measurable with statistics on the perioperative environment and the available equipment, with official statements from industry groups on the hazards of surgical smoke and with your staff's accounts of working with surgical smoke. Don't forget to tap your risk manager, infection control committee and safety committee for assistance. They can be big allies on this front.

Once you've gotten the approval to buy, your decision shouldn't be driven primarily by price. In fact, the critical factors that determine how well a smoke evacuator works are the ones that distinguish it from standard suction — namely suction capacity and filtration quality.

While a manufacturer may promote its device's airflow through data on cubic feet per minute moved, a more important measure of plume capture efficiency is the air intake velocity at the smoke evacuator's nozzle. This function creates the device's suction capacity, and a higher velocity means greater efficiency.

Regarding filtration, activated charcoal filters are standard in smoke evacuators, but you'll want to make sure you get a device that uses ULPA filters. ULPA, or "ultra-low penetration air," filters are 99.999 percent effective at capturing particles larger than 0.12 microns. Compare that to HEPA, or "high-efficiency penetration air," filters, a slightly older technology that catches 99.97 percent of particles down to 0.3 microns, which can still let some smoke particles escape into the OR.

Advances in filtration technology require an occasional reassessment of what's needed for efficient smoke evacuation. The devices do become outdated. If your facility is still using smoke evacuators that employ HEPA filters, it is strongly recommended that you upgrade to an ULPA filter system.

It's also helpful if your smoke evacuator includes visual indicators — a light or other reminder — to alert you to change the filter or to get service.

Integrating the input
You may get your facility's approval, purchase smoke evacuators and station them in every OR only to wonder why they're still not being used. To prevent this from happening, you need to not only study the characteristics of the device, but also examine your center's culture. The first has to be adaptable to the second.

Make sure that your surgical staff has ample opportunity to use the devices you're considering in actual procedures, and listen to their input. I've found that the most common objections to smoke evacuators fall into three categories:

"It's too noisy." A hands-on trial is valuable because it lets staff hear how an evacuator sounds in their OR as they're trying to communicate. Some models are quieter than others, and keep in mind that some let users adjust their suction power — and consequently their noise volume — with a situation's evacuation need.

"It's never around when I need it." Time is of the essence in surgery. No one's going to wait if a staff member has to locate, transport and assemble a smoke evacuator. While most devices are portable, your choice should also be affordable enough that you can buy one for every room, making them available and accessible.

"It interferes with the practice of surgery." I've heard surgeons complain that the process of smoke evacuation interrupts the rhythm of their surgery, adding too many steps and requiring staff to concern themselves with sucking up smoke and not concentrating on the case. For this reason, you'll want a device that they find easy to use. A foot pedal switch may prove convenient, or a system that turns on and off automatically with the use of an electrosurgery unit or other instrument.

These objections suggest that compliance with AORN's standard requires not just the purchase of efficient equipment, but also changes in staff behavior. Educating them on the issue of surgical smoke is the best way to get them to use this equipment, as is enlisting them in the development of any protocol you enact. If you want something to fail, write it into nursing policy without including everyone.

Buffalo Filter
LapEvac
(800) 343-2324
www.buffalofilter.com
List price: $89
FYI: This disposable, battery-powered smoke evacuator creates a constant closed-loop flow to filter and recirculate gas within the peritoneal cavity, says the company.

Geiger Medical Technologies
Geiger Smoke Evacuator
(888) GEIGER-1
www.geigermedical.com
List price: $995
FYI: Offers a 99.999 percent effective particulate filtration at 0.2 microns as well as odor absorption via activated charcoal for about 60 minutes of use.

IC Medical
"Crystal Vision" Automatic Smoke Evacuation System, Models 350D and 360
(800) 766-5336
www.icmedical.com
List price: not disclosed
FYI: Offers particle reduction and an accidental fluid trap included with the ULPA filter, says the company. Model 350D is able to maintain intra-abdominal pressure during evacuation. The telescopic "PenEvac" ESU pencil attachment facilitates a full spectrum of procedures.

Implantech Associates
SE-100 Smoke Aspiration Tip
(800) 733-0833
www.implantech.com
List price: box of 10, $160; box of 25, $305
FYI: Universally adaptable to all electrocautery pencils, this disposable, sterile-packaged tip is easy to attach and is transparent for improved visibility, says the company. It can be cut to the optimum length for each procedure and connects to any standard vacuum source.

JLJ Medical Devices International
SeeClear MAX
(952) 929-3881
www.jljmedicaldevices.com
List price: $21.50
FYI: Silently provides continuous and automatic smoke, bio-aerosol and odor clearance without OR staff involvement during surgical procedures, says the company. The clinically determined optimal flow rate is preset and no suction or extra tubing are required, letting staff "connect it and forget it."

Medline Industries
Aaron Smoke Shark
(800) MEDLINE
www.medline.com
List price: $1,200
FYI: Its 18-hour filter combines four-stage filtration into one casing, reducing cost per procedure and waste while capturing particles down to 0.01 micron at 99.99995 percent efficiency and eliminating odor. Includes a pneumatic footswitch.

Megadyne
Mega Vac
(800) 747-6110
www.megadyne.com
List price: $3,750 to $3,900
FYI: Easy to use and quiet, says the company. Patented sensor system turns the evacuator on and off with the surgeon's use of electrosurgical instruments.

New Leaf Medical
E-Vac
(866) 598-6464
www.newleafmedical.com
List price: box of 10, $87.50
FYI: Easy-to-use device accommodates multiple electrodes and requires no adapters or additional assistance to operate, providing a simple, inexpensive and hands-free solution, says the company.

Pall Medical
Laparoshield Laparoscopic Smoke Filtration System
(866) 347-3428
www.pall.com
List price: not disclosed
FYI: Passive smoke filter connects to trocars via a universal luer adapter and is equipped with a roller clamp that can be adjusted to provide continual gas exchange without deflating the pneumoperitoneum, creating a clear view for the surgical team.

Surgiform Technology
Saf-T-Vac
(866) 225-5785
www.surgiform.com
List price: box of 10, $97.50
FYI: A dual-action chamber simultaneously removes smoke and fluids, adapts to short or long electrodes and attaches to handheld devices to save time, effort and costs, says the company.

Surgimedics
Surgifresh Mini Turbo
(800) 840-9906
www.surgimedics.com
List price: $1,200
FYI: Low-cost, removable pre-filter protects and extends the life of the smoke evacuator's primary four-stage ULPA filter, which is the main source of consumable costs in smoke evacuation systems, says the company.

Utah Medical Products
Filtresse Smoke Filtration System
(800) 533-4984
www.utahmed.com/gynuroelect.htm
List price: not disclosed
FYI: Three-stage disposable filter system attaches to most wands and instruments for quick plume evacuation at the source. Includes variable motor speeds for flow rate adjustability and noise suppression, and a pneumatic footswitch for hands-free operation, says the company.

Viasys MedSystems
(a division of Cardinal Health)
Stackhouse VitalVac Smoke Evacuator
(800) 323-6305
www.viasyshealthcare.com
List price: $2,500
FYI: With a separate mode for laparoscopic procedures, the unit delivers a wide range of suction levels essential for laser procedures and fluid evacuation, says the company.