Results of a survey on current surgical smoke control practices

AORN Journal,  April, 2008  by Ben E. Edwards,  Robert E. Reiman

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For several decades, health care workers have been aware of the hazards posed by aerosols, particulates, and vapors, collectively referred to as smoke, that are generated during some types of electrocautery, electrosurgery, ultrasonic scalpel, and laser procedures. Numerous studies have established the presence of hazardous components in surgical smoke and documented potentially harmful consequences of exposure to these airborne contaminants. (1-7) Surgical smoke exposure can lead to hazardous chemical and biological agent effects on health care providers and patients, (8) as well as a potentially debilitating allergic sensitization for surgical staff members. (9)

POSITION STATEMENTS

In response, industry leaders and professional organizations, including the American Nurses Association, (10) the American National Standards Institute (ANSI), (11,12) AORN, (13) the American Society for Laser Medicine and Surgery, (14) and the ECRI, (15) have adopted position statements directing the use of local exhaust ventilation (LEV) during procedures in which surgical smoke is created. The guidance from the 2005 ANSI standard Z136.3, Safe Use of Lasers in Health Care Facilities, (12) is typical: "The primary measure to control [surgical smoke] ... shall be local exhaust ventilation." (12(p18)) Several US government agencies, including the National Institute for Occupational Safety and Health (NIOSH) (16) and the Occupational Safety and Health Administration (OSHA), (17) have issued concurring statements. In light of these directives, a question arises: have health care facilities universally implemented the use of LEV systems? Unfortunately, the answer is "no."

Reflecting the experience of many health care workers, one nurse's question in the October 2002 AORN Journal Clinical Issues column included the following comment: "A surgeon in our OR refuses to use the smoke evacuator when performing electrosurgery." (18(p689)) As the column's author responded, currently there is no specific OSHA standard requiring LEV to protect workers from surgical smoke. In an OSHA Standard Interpretation letter from April 18, 1996, (19) however, Ruth McCully, director of the Office of Health Compliance, notes that OSHA's General Duty Clause (20) may be interpreted as requiring employers to protect workers from recognized hazards. In an OSHA Standard Interpretation letter dated September 6, 2000, (21) however, Richard E. Fairfax, director of enforcement programs for OSHA, stated OSHA's position that the Bloodborne Pathogen Standard (22) does not apply to surgical smoke.

Health care providers, therefore, are confronted with a paradox. There appears to be overwhelming support for LEV use among professional organizations; however, the lack of a clear regulatory mandate complicates conclusive resolution of this matter at the practice level. In light of this paradox, how have clinicians and health care facilities responded?

Little information exists on the extent of LEV use in US clinical settings, so a health physicist at the Occupational and Environmental Safety Office--Radiation Safety Division at Duke University Medical Center, Durham, North Carolina, and an assistant professor at the Department of Radiology, Duke University Medical Center, created a survey to measure the current status of US health care industry practice regarding surgical smoke evacuation. The survey also examined the use of several respiratory protection measures (eg, laser masks, N95 or other NIOSH-approved respirators) in health care settings.

METHODS

The authors developed a web-based survey form consisting of a demographics section and a surgical smoke control measure practices section. For the demographic data, respondents selected their location (ie, the name of their state if located in the United States, "other US territory," "Canada," "other foreign country"); facility type; clinical role; and practice areas from a list of options.

The surgical smoke control measures section listed procedures in which airborne contaminants are produced. Accompanying this list was a five-point Likert scale for respondents to evaluate the extent to which several control measures were employed (ie, from i = "never" to 5 = "always"). Control measures included

* LEV, comprising the following responses: ** none, ** wall suction, or ** smoke evacuator; and

* respiratory protection, comprising the following responses:

** none or surgical mask, ** laser mask, or ** N95 or other NIOSH-approved respirator.

A narrative comments field on the online survey form gave respondents the opportunity to provide more information if they desired. The site maintained anonymity for survey respondents unless they voluntarily provided contact information in the comments section.

AORN solicited its members to participate in this survey through a series of e-mails, newsletter articles, and notifications in the AORN Journal during the summer of 2007. These announcements encouraged health care professionals' participation in the survey and included the web site address for the online survey. Members who had access to the Internet could visit the web site and quickly input their responses to the survey queries. All responses were electronically tallied and stored in an associated database. Responses were accepted from mid May 2007 until the end of August 2007.