By Don Sadler
Perioperative personnel have long known about the health hazards posed by surgical smoke in the operating room. It has been more than 30 years since researchers first documented that particulate matter in surgical smoke can pose dangers to nurses and others in the operating room (OR).
For many years, little was done to protect OR personnel from the dangers of surgical smoke. However, this is finally starting to change as a growing number of states are passing legislation designed to reduce the dangers of surgical smoke plume.
OSHA Alert … in the 1980s
The U.S. Occupational Safety and Health Administration (OSHA) first issued an alert about the health hazards from surgical smoke way back in 1988. However, they didn’t follow up with any regulations requiring hospitals and ASCs to limit or eliminate surgical smoke.
“Policy changes at the federal level can move slowly,” says Jennifer Pennock, associate director, government affairs for the Association of periOperative Registered Nurses (AORN). “So, our primary focus remains on the state level. We are seeing a positive response from our legislative outreach as many states seek to strengthen protections for health care workers and patients.”
According to Pennock, nine states have passed laws requiring hospitals and ASCs to use smoke evacuation systems to prevent human exposure to surgical smoke: Rhode Island, Colorado, Kentucky, Oregon, Illinois, Washington, Arizona, Georgia and Connecticut.
Surgical smoke legislation is pending in eight states – Utah, Iowa, Missouri, Arkansas, Ohio, West Virginia, Pennsylvania and New York. Also, the Texas Health and Human Services Commission is set to issue rules that would include provisions for surgical smoke evacuation for all operating rooms in the state, according to Pennock.
These laws require hospitals and ambulatory surgery centers (ASCs) to use smoke evacuation systems that prevent human exposure to surgical smoke. “Each year we build upon the momentum from the prior legislative sessions,” says Pennock.
“Legislators are incredibly worried about health care workers and are committed to the health and safety of the people dedicated to saving lives,” says Pennock. “They recognize that nurses and other health care workers are leaving their professions and want to make the changes needed to stabilize the workforce.”
As part of its advocacy efforts to effect changes for OR staff and patients, AORN launched a national petition drive last year urging OSHA to issue regulations requiring worker and patient protections from harmful surgical smoke.
Status of State Legislation
Kay Ball, Ph.D., RN, CNOR, CMLSO, FAAN, a perioperative consultant and adjunct professor at Otterbein University in Westerville, Ohio, has been performing research on the effects of surgical smoke on perioperative personnel for more than a decade. She is optimistic about surgical smoke legislation passing in Ohio soon.
“We’re hoping to get some action during the legislative session after the midterm elections,” says Ball. “We want to get our legislation (SB161) out of the Senate Health Committee and on to the Senate floor for a vote, and then on to the House.
“If the legislation isn’t passed in this general assembly,” adds Ball, “it will be reintroduced after January 1 during the Ohio 135th General Assembly.”
In Georgia, SB573 was signed into law on May 9, 2022, thanks in large part to the work of a dedicated team of perioperative professionals led by Brenda Ulmer, RN, MN, CNOR. She started her efforts to get surgical smoke legislation passed in Georgia in 2019 after learning that the first two states in the nation (Rhode Island and Colorado) had passed surgical smoke laws.
“That’s when I decided Georgia should be the next state to pass legislation to protect patients and health care workers from surgical smoke,” says Ulmer, who served as the Georgia Council Legislative Chair.
Beverly Kirchner, immediate past president of the Texas Collaboration of periOperative Registered Nurses (TCORN), has been spearheading efforts the past several years to get surgical smoke legislation passed in Texas. After Senate Bill 429 failed to make it to committee last year, she and her team decided to go the regulatory route.
“The regulations are in draft format and the Texas Department of Health is now reviewing comments received during the comment period,” says Kirchner. “We will be notified if they change the wording of the regulations, which follow the wording of Senate Bill 429.”
Pennock says that surgical smoke legislation is most successful in states with a strong group of grassroots advocates committed to working on policy advocacy for multiple years and through legislative sessions. “It’s important for AORN and the advocates to engage with stakeholders early in the process,” says Pennock.
It’s also important to identify a strong bill sponsor in the House or Senate who will throw their political influence into the success of the bill. “A strong bill sponsor can help all the stakeholders involved see the merits of the legislation,” says Pennock.
In Illinois, for example, Rebecca Vortman, clinical assistant professor of population health nursing science in the UIC College of Nursing, and Penny Smalley, an independent nurse consultant and director of education and regulatory affairs for the International Council on Surgical Plume, worked closely with the legislative sponsors of a surgical smoke bill that was passed in 2021.
Together, they built a grassroots coalition that was critical to getting the legislation across the finish line. The new law took effect on January 1, 2022, requiring hospitals and ASCs in the state to adopt policies to ensure surgical smoke plume elimination with an appropriate evacuation system for every procedure that generates surgical smoke due to the use of energy-based devices.
“We are so proud that we were two nurses who proved that our voices could be heard and that we could effectively lead the advocacy efforts needed to get this bipartisan bill passed through a grassroots effort,” says Vortman.
In addition to state legislation, regulatory bodies have also issued recommendations and guidelines regarding surgical smoke. This includes NIOSH, which recommends that a smoke evacuator be on at all times when airborne particles are produced during all surgical or other procedures.
However, this is only a recommendation, not a requirement.
“State laws requiring surgical smoke evacuation policies provide a pathway for the accrediting organizations to enforce facility adherence to their own policies on surgical smoke evacuation through the organization’s accreditation processes,” says Pennock.
Damaging Effects of Surgical Smoke
Surgical smoke plume is formed when substances like tissue, blood and fluid are vaporized into a gaseous form. It is produced during most OR procedures when lasers and electrocautery devices are used to dissect tissue and stop bleeding. Numerous studies confirm that surgical smoke contains hazardous chemicals, bacteria and live viruses.
“Most of what’s in surgical plume is 1.1 microns in size or smaller,” says Ball. “Any particles less than 10 microns can be irritating to lung tissue, and ultrafine particles can settle in alveoli, causing lung and air exchange problems.”
Vortman has performed research demonstrating the hazardous health consequences faced by OR personnel from prolonged exposure to surgical smoke, including eye and upper respiratory tract irritation. Surgical smoke plume also has mutagenic and carcinogenic potential, according to Vortman’s research.
Other studies have shown that surgical smoke plume may contain E. coli, MRSA, HPV, hepatitis viruses and HIV. There may also be SARS-CoV-2 and variants in surgical smoke plume, as well as toxic gases such as benzene, toluene, carbon monoxide, formaldehyde and hydrogen cyanide.
In addition, patients may be at risk from internal absorption of hazardous gasses and particulates in surgical plume.
Ball first performed research into the effects of surgical smoke on OR personnel in 2010 and then repeated parts of the research in 2020. “The results of the first study repeated 10 years later, which demonstrates a profile for perioperative nurses,” she says.
When asked if they had respiratory disorders or diseases, OR nurses in Ball’s study reported twice the incidences of respiratory problems compared to the general population. For example:
- 22.9% of OR nurses reported sinus infections and sinus problems compared to 11% of the general population.
- 10.9% of OR nurses reported asthma compared to 7.6% of the general population.
- 9% of OR nurses reported bronchitis compared to 3.4% in the general population.
- 24.2% of OR nurses reported allergies compared to 15% in the general population.
- “Many research studies have shown the dangers of surgical smoke,” says Ball.
For example, AORN’s Guideline for Surgical Smoke Safety includes 223 references documenting the hazards of surgical smoke.
Ball also points to a study reported in the Journal of Clinical Nursing in 2016. In this study, 49% of nurses and 58% of surgeons reported experiencing headaches, 40% of nurses and 42% of surgeons reported watery eyes, and 49% of nurses and 28% of surgeons reported coughing due to exposure to surgical smoke.
Sore throat, nausea, drowsiness, dizziness, sneezing, rhinitis and bad odors absorbed in the hair were also attributed to surgical smoke by nurses and surgeons in this study.
The Lowdown on Smoke Evacuation Technology
Many experts agree that using smoke evacuation technology is the most effective way to eliminate surgical smoke in the OR. “AORN and our members would like to see more widespread use of these devices,” says Pennock.
Julie Miller, MS, principal project engineer, device evaluation with ECRI, explains how smoke evacuator devices work: “A smoke evacuator is a suction source that incorporates ultra-high-efficiency filters to remove smoke particles from the suctioned airstream at the surgical site.”
“The device uses high flows or high intake velocities to capture smoke at the nozzle, draw it through the tubing, pass it through the filters and recirculate to room air,” adds Miller. “Most systems have variable flow control to tailor the capture for the given procedure.”
According to Miller, the ULPA filters that most smoke evacuators use must demonstrate at least 99.999% efficiency for removing particles that are in the range of 0.12 micrometers in diameter, which is the most penetrating or difficult particle size for this filter grade to capture. “Surgical smoke is generally within this range,” she says.
“The size of the smoke particles generated, and the distance from the surgical site from which they captured smoke, can play a role in the efficiency of the device’s capacity for reducing surgical smoke,” adds Miller.
While using smoke evacuation devices might seem like a no-brainer, Miller says there are a few obstacles that may prevent some hospitals from using them. This includes concerns among some surgeons about their usability.
“There’s a persistent belief that the smoke evac handpiece may be more cumbersome for surgeons than older designs,” says Miller. “But newer pencils exist that have integrated tubing with encapsulation of the wire, as well as swiveling bases and extendable nozzles.”
Miller say there are also concerns about potentially disruptive noise caused by devices. “However, our evaluation of some portable evacuators showed an average operational noise of about 57 dB at max suction settings while the device is actively suctioning,” she says. “For reference, that’s about a normal conversational volume.”
There may also be cost concerns about using smoke evacuators. “The components needed for smoke evacuation are more expensive per procedure than standard accessories,” says Miller. “For example, a standard ESU pencil and holster may cost about $2.50 while a smoke evacuation pencil with nozzle, tubing, holster and swiveling capabilities may be closer to $25.”
Protecting the Perioperative Workforce
Part of Vortman’s motivation for advocating for surgical smoke legislation is her concern for both the current and future perioperative workforce.
“If my daughter decides to pursue a career in the operating room, I want to make sure she’s working in a safe environment,” says Vortman. “I don’t want her or any surgical team members to be exposed to the harmful contaminants of surgical smoke plume.”
AORN provides ongoing education about surgical smoke, including the AORN Go Clear program. “This is a comprehensive approach to protecting patient and worker safety by promoting a smoke-free environment wherever surgical smoke is generated,” says Pennock.
The AORN Go Clear Program includes all the tools and protocols needed to start or enhance smoke evacuation practices. To learn more visit https://www.aorn.org/member_apps/Product/Detail?productID=9709.
