SILENT DANGER Many microorganisms can survive electrosurgery and end up in the lungs of OR staff.

There was nothing magic about the way we began to clear the air in our ORs. Yes, there was smoke, and yes, there were mirrors — to get started, we took a good long look at ourselves and our knowledge base — but ultimately, it was education and information, not sleight of hand, that began to make the difference. Our initiative is ongoing, but we've made some significant progress in protecting the health of our OR teams and patients. Here's how.

1. We studied the issue. The team we put together to address surgical smoke included an OR manager, our educator, two other clinical nurses and me. We wanted the initiative to be evidence-based, so the first thing we did was look at current literature regarding surgical smoke — what it is, how harmful it is, and the most common recommendations for managing it in the operating room. In the 4-and-a-half years I've been in the OR, I'd seen physicians emphasize smoke evacuation on certain procedures, but not with every procedure that generates smoke. That was also true for folks who'd been in the OR longer than I have. The whole process was illuminating, and the team learned a lot.

For example, we found out that many microorganisms survive the electrosurgical process. One article explained that when tissue becomes super-heated, the cells rupture and the liquid within the cells is dispersed into the air. That means cancer cells, hepatitis, HIV and other types of bacteria and fungi can become part of what we all breathe. Additionally, the masks we use in the OR, unless they're the high-filtration type, don't protect us against all the surgical smoke being released. We also looked at studies in which people examined filters in suctioning devices and found that hepatitis, HIV and other bacteria can survive electrosurgery.

One eye-opening case study (tinyurl.com/l475sto) described how a physician who'd been lasering condylomas developed laryngeal papillomatosis, characterized by the same viral types as those he'd been lasering. We also found literature that discussed the long list of potentially toxic compounds that can be contained in surgical smoke. Guidance published by AORN also had a lot of helpful recommendations.

2. We surveyed our staff. We wanted to know how much our staff knew about surgical smoke and how to manage it. Our initial survey found that most people weren't very confident. In general, they didn't know why it was harmful or what the current recommendations for managing it were.

So we put together a multimedia presentation, uploaded it onto our E-learning network and required staff to peruse it and then take a test. We also created a poster that detailed AORN's current recommendations for managing surgical smoke.

Eventually, we brought everyone into a classroom setting, reviewed the basics, and demonstrated both the smoke evacuators that could be used in ORs and all the supply items that are used with them. We demonstrated how to attach the equipment, how to turn it on, how to check filters, and so on. And finally, in a big step, we put together some fact sheets to help people in their discussions with surgeons.

EVACUATE SMOKE AT THE SOURCE
Integrated Smoke Evacuation Pencils

ERGONOMIC EVACUATION Megadyne's Zip Pen is one of a growing number of electrosurgery pencils with a built-in smoke evacuator.

There's no question that surgical smoke evacuation is a "massively important topic," says Robert S. Bray Jr., MD, a neurological spine surgeon and the founder and CEO of DISC Sports and Spine Center in Los Angeles. "The research is overwhelming that smoke is bad for people in the room."

The big question, he says, is how best to handle it. "The challenge that companies have (with electrosurgical devices) is to come up with an instrument that interferes as little as possible, that's as tactile as current pieces and that's as cost-effective as a disposable device," says Dr. Bray.

Several companies are trying to address that challenge, with pens that are designed to be light and ergonomic while minimizing the impact of the relatively thin built-in tubing by, among other things, engineering it with the capability to rotate 360 degrees as the surgeon maneuvers.

Some also offer a variety of grip methods, so surgeons don't have to adapt their preferred grips. Newer devices can also be connected to most, if not all, evacuators, making it easier to virtually eliminate the smoke-related hazards faced by staff who spend hours at a time in the OR.

— Jim Burger

3. We encouraged staff members to make themselves heard. We wanted them to talk to surgeons, and when they did, we wanted to make sure they had solid facts and data, based on the research we'd done. We continued to provide talking points and support for people who wanted to have those conversations and help get the program off the ground.

We also knew that sometimes, even if physicians aren't convinced that something is a big issue, they'll cooperate because they've developed strong working relationships with staff and they want to keep the team happy. To bolster the effort, we created a series of posters and hung them by every scrub sink outside the OR. And we changed the posters every 2 weeks, so people wouldn't just look at them and say, Oh, I've already read that one.

4. We collected feedback. We got positive responses from several physicians who said they didn't know surgical smoke was so harmful. In fact, many began asking for smoke evacuation supplies. To make it as easy as possible for them, we've added the supplies to our equipment carts. We've also updated those surgeons' preference cards to include smoke-evacuation supplies.

To provide further incentives and help solidify good habits, we created a "smoke busters" group that audits ORs and rewards teams that are using evacuation in cases that call for it. Every member of the team — the physician, the anesthesia provider, the nurses and the techs — gets a coupon good for $5 off lunch. That's a good motivator for everyone.

I'd like to say that every surgeon is sold on the idea, but we had — and still have — some holdouts. Some have asked why, if surgical smoke is such an issue, they don't see information about it in the publications they read. Some also seem to look at surgical smoke as the cost of doing business in the OR. You work in the OR, you're going to be around smoke. That's how it is and that's how it's been for as long as they remember. Naturally, those surgeons are a challenge, but this doesn't have to be an all-or-nothing initiative.

VESTED INTEREST Several physicians began asking for smoke-evacuation supplies as a result of our initiative.

5. We continued to communicate. We're still working with the physicians who simply refuse — at least so far — to use the evacuators, and we've also asked team leaders to talk to their surgeons and find out what their concerns are. If possible, we want to find products that address those concerns and get those surgeons on board, too.

One common complaint was the noise. Smoke evacuation can be like having a noisy fan running all the time, and people can't talk to each other as easily. To address that, we purchased devices that trigger the evacuator to run only when the device is in use. That's been helpful and well-received by surgeons.

Large-diameter tubing that gets in the way in the surgical field has also been a concern. So we trialed some devices that have smoke-evacuation tubing already connected. The electrosurgical pen that has the tubing attached has also worked very well for us. We also have a passive device we use in laparoscopic surgery that has tubing that attaches to the trocars and a filter. It keeps the surgical field clear and protects the patient from surgical smoke. Most recently, we've been talking to vendors and working on the challenges posed by bipolar electrosurgery and power tools. As far as I know, there's still no convenient device available to manage the smoke they generate.

As I noted, this is an ongoing initiative. And we plan to keep at it until we can all breathe a little easier.