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By Herman A. McKenzie

Looking back on my career as a biomedical engineering technologist prior to my position at The Joint Commission, I recall that one of my responsibilities included preparing purchase bid documentation for all new medical equipment in my hospital. I distinctly remember making sure that only high-quality devices were considered and purchased for use in our operating rooms. Today, I more greatly appreciate the quality of the high-capacity dependable smoke evacuators, as smoke plume hazards are more closely studied. Back in the day, smoke plumes seemed, at minimum, unpleasant for clinical staff, but today we are learning more about the potential harm they cause.

In fact, whenever and wherever lasers, electrosurgical systems, radio frequency devices, hyfrecators, ultrasonic scalpels, power tools and other heat destructive devices are used, everyone in the area – including the patient – may be exposed to surgical smoke. Surgical smoke plumes can contain toxic gases and vapors such as benzene, hydrogen cyanide, formaldehyde, bioaerosols, dead and live cellular material (including blood fragments) and viruses.

Over time, I realized there was a tie to physical environment compliance and the need to maintain medical equipment under the medical equipment standards: EC 02.04.01 and EC 02.04.03. As a matter of fact, use of smoke evacuators is tied to The Joint Commission’s element of performance for managing hazardous materials and waste: Standard EC 02.0.201 EP 9 states: “The organization minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous gases and vapors.”(Hazardous gases and vapors include, but are not limited to, ethylene oxide and nitrous oxide gases; vapors generated by glutaraldehyde; cauterizing equipment, such as lasers; waste anesthetic gas disposal (WAGD); and laboratory rooftop exhaust. (For full text, refer to NFPA 99-2012: 9.3.8; 9.3.9)

While exposure of surgical smoke to patients is short-term and relatively low risk, surgeons, perioperative nurses and other operating room staff are exposed to surgical smoke daily. At high concentrations, surgical smoke may cause ocular and upper respiratory tract irritation and potentially create visual problems for the surgeon. Therefore, it is so important for ambulatory surgery centers to be aware of the risks of surgical smoke and how they can best mitigate those risks.

A recent Quick Safety advisory from The Joint Commission, “Alleviating the dangers of surgical smoke,” reviews current regulations, recommendations and standards on surgical smoke or lasers from several governmental and professional organizations, including from the Occupational Safety and Health Administration (OSHA), National Institute of Occupational Safety and Health (NIOSH), American National Standards Institute (ANSI), Association of periOperative Registered Nurses (AORN) and ECRI.

The advisory also includes several safety actions for health care organizations that conduct surgery and other procedures using lasers and other devices that produce surgical smoke. Recommended safety actions to protect patients and health care workers include:

  • Implementing standard procedures for the removal of surgical smoke and plume through the use of engineering controls, such as smoke evacuators and high filtration masks.
  • During laser procedures, using standard precautions to prevent exposure to the aerosolized blood, blood by-products and pathogens contained in surgical smoke plumes.
  • Establishing and periodically reviewing policies and procedures for surgical smoke safety and control – making these policies and procedures available to staff in all areas where surgical smoke is generated.
  • Providing surgical team members with initial and ongoing education and competency verification on surgical smoke safety, including the organization’s policies and procedures.
  • Conducting periodic training exercises to assess surgical smoke precautions and consistent evacuation for the surgical suite and procedural area.

Additional resources from The Joint Commission are provided in the advisory, along with resources from the Centers for Disease Control and Prevention (CDC), ANSI, AORN and several other academic journals.

– Herman A. McKenzie, MBA, CHSP, is the director, engineering, standards interpretation group at The Joint Commission.

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