Eliminating surgical smoke supports clinician safety and continues to gain legislative traction

In the O.R. — clinician safety is going up in smoke

Health systems can make a jump start on workplace improvements by going directly to their surgical operating rooms (O.R.s) to ensure the health and safety of clinicians. A top issue affecting clinician, surgeon and technician safety is surgical smoke. As tools used in O.R.s and procedure rooms simultaneously cut and cauterize human tissue, the heat generated by these tools vaporizes tissue that results in aerosolized chemicals and substances known as surgical smoke.

While the potential risk from inhaling surgical smoke and the smoke’s contaminates is minimal to surgical patients, the risk is more significant for surgeons, perioperative nurses and surgical technicians who are in the O.R. environment daily. Perioperative personnel experience twice the volume of respiratory health ailments as the general public.¹ It’s estimated that 90% of surgical procedures produce plume, and approximately 500,000 healthcare workers are exposed to laser or electrosurgical smoke annually.^1,2 One study found that, on average, the smoked produced daily in a single O.R. was equivalent to 27 to 30 cigarettes.³

Exposure to carcinogens isn’t the only concern related to surgical smoke. Biological substances considered mutagenic and infectious in nature, including malignant cells and viruses, are also detected in surgical smoke.⁴ These smoke plumes can contain multiple toxic gases and vapors such as benzene, hydrogen cyanide, formaldehyde, bioaerosols, dead or alive cellular material, blood fragments and viruses.⁵

Long-term exposure can have additional effects on the human body. In-vitro mutation has proven to be a contributing factor to higher rates of pregnancy complications.⁵ There is also evidence that surgical smoke can transmit viable bacteria and human papillomavirus.⁵ Additionally, serious lung disease, chronic asthma and cancer are linked to long-term exposure.⁵

Legislative push for surgical smoke guidelines

Since 2018, professional organizations such as state nursing and anesthetist associations, including the Association of Perioperative Registered Nurses (AORN), have pushed for legislation requiring the use of surgical smoke evacuation systems in certain procedures to ensure surgical team safety.⁷

Five states enacted legislation and are operating surgical smoke free: Rhode Island, Colorado, Kentucky, Illinois and most recently Georgia, where legislation was effective on July 1.⁸ See Figure 1.

Figure 1. States with enacted surgical smoke-free legislation

Source: Surgical smoke laws. AORN. Accessed September 1, 2024. https://www.aorn.org/-/media/aorn/government-affairs/downloads/surgical_smoke_laws22.pdf?la=en&hash=C5607D3D5C47205D9C0BCCBE6E1B96B9

Multiple other states enacted legislation addressing this issue that will become effective in the next two years.⁸ See Table 1. With AORN advocating for nationwide legislation, many more states will likely follow suit in the next few years.⁹

Table 1. States enacting surgical smoke-free legislation, as of September 1, 2024

Source: Surgical smoke laws. AORN. Accessed September 1, 2024. https://www.aorn.org/-/media/aorn/government-affairs/downloads/surgical_smoke_laws22.pdf?la=en&hash=C5607D3D5C47205D9C0BCCBE6E1B96B9

Creating a smoke-free surgical environment

Whether required by legislation or motivated to address this workplace hazard for clinicians, implementing a smoke free O.R. demands a programmatic approach that should begin by appointing one or more program champion(s). Champions help develop the program, as well as mentor, educate and achieve staff (and potentially leadership) buy-in around the need to eliminate surgical smoke in the O.R. It is imperative that leadership is well-informed on all governmental regulations, including local, state and federal, to ensure surgical smoke compliance. Additionally, surgical leaders and surgical teams should also receive relevant regulation information and updates and keep it readily available.

Initiatives to guide your organization toward a successful, smoke-free O.R. include:¹⁰

• Create a business case for hospital executives outlining the need for a smoke-free surgical environment.
• Create a budget to help support product purchasing and evaluations.
  • Hold regular stakeholder meetings to ensure consistent communication and updated action items.
  • Document user feedback and identified outcomes as evacuation products are evaluated. Use that data for meaningful decision-making.
  • Collaborate with smoke evacuation vendor to educate your stakeholders on product use.
• Address noncompliance barriers like unavailable products, staff complacency and physician opposition.
• Ensure that the hospital CEO is made aware of the team’s success.

What can best practices lead to?

The AORN Go Clear Award recognizes healthcare facilities that are committed to providing a surgical smoke-free environment in their operating rooms. This prestigious award is given to hospitals and surgical centers that implement and maintain practices to eliminate the hazards of surgical smoke, which poses risks to both patients and healthcare professionals. By achieving the Go Clear Award, facilities demonstrate their dedication to safety, compliance with best practices, and prioritizing the health and well-being of their surgical teams.

Smoke evacuation systems

Smoke evacuators are high-flow vacuum devices that capture and filter the plume generated during electrosurgical or laser procedures. These systems pull the smoke plumes from the surgical site through tubing within a filtration system to capture particles that would otherwise be dispersed in the air and inhaled by the surgical and interventional staff. Basic system components include a vacuum pump, a filter system, a suction hose and a handpiece evacuation instrument.

There are multiple factors to consider when purchasing a smoke evacuation system that best meets staff safety and procedure room requirements, including:

• Air filter - an ultra-low particulate air filter demonstrates an efficiency of no less than 99.999% at a most penetrating particle size (MPPS). MPPS is the particle size that most easily passes through the filter media. An activated carbon filter acts to absorb odors and gases.¹¹
• Life of the filter - generally up to 35 hours
  • Flow rate - minimum of 25 cubic feet per minute and variable¹²
  • System operation noise levels - should not exceed 70 A-weighted decibels¹³

Partnering with smoke evacuation vendors can be a powerful strategy to achieve elimination and compliance. Many of these vendors also work with organizations like AORN that focus on eliminating the hazardous O.R. smoke plume and they can help design an effective, best-practice smoke evacuation program for your facilities. Additionally, vendors can help outfit the O.R. based on the procedures performed in the specific facility.

Internal program champions, vendor collaboration and compliance with local, state and federal regulations, are key guideposts for hospitals in their efforts to eliminate surgical smoke and improve workplace safety for surgical staff. A starting point for equipment evaluation is working with vendors awarded a Vizient agreement, which can offer cost and value-add advantages. Seek out cost information in advance to ensure it is captured in budget planning. Consider any facility expansion plans and associated budgets as patient volumes are steadily shifting to ambulatory surgical centers with a forecasted 29% increase in outpatient surgeries over 10 years.¹⁴

Vizient-awarded agreements for smoke evacuation products