What You Need to Know Before Your Next Joint Commission Audit
Unless you are one of the thousands of perioperative professionals struggling with respiratory illness, surgical smoke may not be on your radar. But this once familiar foe in the operating room has recently become subject to oversight from government agencies.
Hospitals and Ambulatory Surgical Centers (ASCs) can expect more scrutiny of their surgical smoke policies and procedures in future audits. Some states, notably Colorado and Rhode Island, have even stricter standards regarding cautery plume than the Joint Commission.
To meet the requirements of these new standards, hospitals and ASCs must equip every operating room with a surgical smoke evacuation system and related equipment. Below is a framework for evidence-based purchasing of a surgical smoke evacuation system.
Smoke Evacuation in the OR
Standards from Joint Commission and CDC
The Center for Disease control recommends several guidelines for effective surgical smoke evacuation. Further, the National Institute of Occupational Safety and Health (NIOSH) and the Joint Commission have issued multiple documents outlining best practices for mitigating the hazards associated with electrocautery smoke. In other words, there’s no excuse for smoke in the OR in 2019.
Central (Room) Vs. Portable Suction Systems
The base of any surgical smoke evacuation system is the suction source (try saying that five times fast). Hospitals as well as ASCs have several options for obtaining and installing this equipment. Many Operating Rooms in larger or newer facilities come equipped with a suction source for smoke and fluid evacuation. These are called “central suction systems”. However, these facilities must also have a back-up portable suction system in case the central system fails. The decision whether to rely on portable or central suction depends on the needs of the facility. Both systems can be outfitted to evacuate smoke as well as fluid.
Portable suction systems should be surface disinfected daily. Any reusable attachments for portable and central systems should also be cleaned and disinfected per your facilities protocol. Perioperative leadership should also consider a validation process for surgical smoke system maintenance to ensure that all OR staff follows best practices for infection control.
In order for hospitals and ASCs to be compliant with new standards, smoke evacuation systems must be equipped with a High Efficiency Particle Air (HEPA) Filter as well as an Ultra-low Penetration Air (ULPA) Filter. Further, surgical technicians should be available to test suction pressure and the capture velocity. The CDC recommends a minimum capture velocity of 100-150 feet per minute. Capture devices must have a functioning filter status indicator, which the surgical tech should check regularly. Filters should be changed every 24-hours at minimum. Facilities that perform procedures that generate more smoke and fluid will require more frequent maintenance
Newer or recently renovated hospitals and ASCs will typically be equipped with an in-room Vacuum regulator attached to the wall. As the name suggests, this device regulates the pressure and capture velocity of suction in the OR. Similar to the Air/Vacuum pumps you will find at the gas station, most built-in vacuum regulators are equipped for oxygen output as well.
The suction source can be used for smoke or fluid evacuation. However, fluid waste requires an additional canister attachment and overflow trap so as to protect the vacuum regulator from becoming clogged. Disposable canisters should be changed out after each use. Reusable canisters need to be disinfected and sanitized.
Vacuum Inlet and Suction Tubing
The vacuum inlet attaches suction tubing to the suction source via the vacuum regulator. The inlet allows the user to control the flow of air through the tubing. Suction tubing and single-use inlets should be thrown out after each procedure. Reusable vacuum inlets can be sanitized with a backflow of disinfectant.
It is important to equip ORs with capture devices that are effective for the procedures most often performed in a given facility. For example, smoke evacuators used for cosmetic or aesthetic surgeries are inappropriate for laparoscopic surgeries because they are not made to fit through a trochar. Conversely, some smoke evacuators are meant to ventilate a large surgical site, but do not offer much in terms of acute cautery plume capture. For most cosmetic and aesthetic procedures, a smoke evacuator attached within two inches of the distal tip offers the highest degree of control while maintaining adequate pressure and capture velocity.
Best Practices for Evacuating Surgical Smoke
Disposable vs. Reusable Attachments
Smaller hospitals and ASCs often make use of disposable attachments in order to cut-down on procedure turn-over time and perioperative staff. Furthermore, the CDC and Joint Commission both recommend disposable attachments wherever possible in order to mitigate sources of contamination and infection. This includes surgical smoke evacuation systems.
A common misconception about the benefits of reusable attachments is that they help hospitals cut back on waste. However, sanitization is a costly and often wasteful process. This is especially true when it comes to tools that require chemical sterilization. Of course, this depends largely on the type of surgery center, the volume of procedures, and the risk of infection associated with those procedures. Evidence-based purchasing requires that each facility determine the most appropriate allocation of resources when it comes to disposal vs. sanitization.
Personal Protective Equipment
Surgical smoke is a unique challenge for those in perioperative care. Healthcare professionals outside of the OR may not understand the purpose or value of taking such measures to evacuate surgical smoke. The most common misconception about PPE is that it is sufficient or even intended for protection from surgical smoke. Studies have shown that many of the ultra-fine particles found in surgical smoke are too small for masks such as the N95. While these are important elements of infection control and sterilization in the OR, they do not offer adequate protection from the negative health impacts associated with surgical smoke. Lack of appropriate respiratory protection and LEV underscores a need for employer and worker education and training concerning appropriate exposure controls for surgical smoke
Smoke Evacuation in Action