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Safeguard OSH Solutions - Thomson Reuters

Safeguard OSH Solutions - Thomson Reuters

Safeguard Magazine

Surgery without smoke

A private surgical hospital is on a mission to have electrosurgical smoke plume acknowledged as a significant hazard in operating theatres around the country. PETER BATEMAN reports.

“To put it bluntly, it’s human tissue being turned into smoke. Not the sort of stuff you want in your lungs or on your person.”

Theatre manager Richard Ward’s description of electrosurgical smoke plume (ESP) is vivid enough, but it doesn’t tell half the story. The plume has been analysed and shown to contain toxic gases and vapours such as benzene, formaldehyde and hydrogen cyanide – as well as bio-aerosols and dead and living cell material, including blood fragments and viruses.

Most of us would go out of our way to avoid inhaling smoke like this, yet surgeons, anaesthetists and theatre nurses are exposed to it in most New Zealand operating theatres every day. Ward and his colleagues at Dunedin’s Mercy Hospital aim to stop it, and have taken the hospital’s theatres smokefree in an initiative which won the occupational health category at the 2014 NZ Workplace Health and Safety Awards.

In a phone conversation with Ward and his colleague, occupational health and infection prevention nurse Miriam Vollweiler, it becomes clear that the campaign to stamp out ESP from Mercy’s operating theatres stands as a copybook example of how to mount a compelling case for a health intervention.

But first a primer on ESP, which is generated when surgeons use an electrosurgical device to cut, coagulate, vaporise and remove tissue. The technique, says Ward, is known as diathermy and has been around for decades, and in common use for at least the last 40 years. The devices have gradually become smaller and more efficient, and they are used in two modes: coagulation (of bleeding blood vessels) or cutting. “If you had a red hot knife cutting through steak, you can imagine the smoke coming off it.”

According to Vollweiler, the smell in theatre was just accepted as part of the job, and ESP wasn’t recognised as a hazard to health. “You could tell what kind of surgery was going on just by the smell.”

Regular exposure to ESP doesn’t necessarily make anyone feel violently ill, but people report symptoms typical of constant cigarette or other smoke exposure: headaches, tiredness, respiratory difficulties. “Breathing this stuff in, it just doesn’t make you feel great,” explains Ward. “It’s like the days of going to a smoky bar, whether you were a smoker or not – how you felt coming home that night.”

Mercy’s journey to eliminate ESP began in 2009 when two staff attended a workshop in Christchurch to discuss the subject and look at some smoke evacuation gear. The following year a theatre nurse undertook a study project on the health hazards of ESP and presented her findings to colleagues. The germ of an idea was now seeded.

“We were reviewing our smokefree policy for the hospital around the same time,” recalls Vollweiler. “All those gains we were making by having our grounds smokefree made what was happening in theatre an anomaly.”

In 2012 Vollweiler and another nurse attended a workshop in Wellington where US expert Kay Ball outlined ESP standards and control measures in the United States, and issued a challenge to participants to make their own theatre environments smokefree. The seed had now germinated, resulting in Canadian ESP expert Penny Smalley being invited to Mercy Hospital later that year to run an education forum for all theatre staff, including surgeons and anaesthetists from other public and private hospitals in the wider region.

The challenge was now accepted. ESP entered Mercy’s hazard register for the first time, Smokefree posters appeared in all theatres, and detailed discussions with an equipment supplier enabled each theatre team to trial equipment and be trained in best practice techniques to use it effectively. A business case was prepared and accepted for the purchase of new equipment, and ESP training modules were developed and run for all theatre staff.

By early 2013 Mercy had a formal policy on ESP control measures and put it up on its website. Annual educational updates are required for all theatre staff, and through a credentialing process surgeons and anaesthetists new to Mercy are informed of the requirement to use smoke evacuation equipment.

Which raises the obvious question: surely there was a degree of resistance to the new order? Ward agrees a few older surgeons took the view “we didn’t do this in my day”, but the younger ones were happy to trial the extraction gear – and in any case, most people were on board after attending the educational sessions and being convinced ESP really is a hazard. But a key factor in winning broad acceptance was getting the ergonomics right when clipping an extraction device onto the diathermy pencil.

“Surgeons work with this thing for hours in their hand. A lot of the early extraction models were heavy and when clipped on doubled the diameter – cumbersome, not very effective, noisy. Some of the early models sounded like vacuum cleaners.”

Surgeons, he says, are focused on the task and quite unforgiving: they’ll pick up a new tool for a few seconds and if they don’t like it they’ll demand their usual one. So the new equipment had to make a positive first impression or the project wouldn’t work. Eventually Mercy’s supplier came up with a great solution: everything that was required in one package with a small well-fitting handpiece and an extendable tip if required, with quiet smoke sucking.

“It took a while for all those things to line up, and there is the cost. But what price are you prepared to put on the health of your staff if you say it is too expensive?”

For Vollweiler, the key was getting managers to attend the education seminars from the specialists so they could appreciate ESP is a hazard and that it can be dealt with. “It really reframed people’s view of the work environment.”

Another success element was to build a close partnership with the equipment supplier to set up not only the best equipment and consumables deal, but ongoing education, training and technical support.

They acknowledge that other New Zealand hospitals have purchased ESP evacuation equipment and are using it on an ad-hoc basis, but reckon Mercy is the only one to have a clear legislated policy and full standardised implementation across all its theatres, with buy-in from all theatre staff, both in-house and visiting. According to Kay Ball and Penny Smalley, says Vollweiler, many hospitals have purchased gear but it isn’t necessarily used. “A comprehensive risk management approach is needed. Just purchasing some equipment isn’t the solution.”

Challenges remain. There is some surgery – shoulder and knee arthroscopy, or urological surgery in the bladder – where extraction can’t be used because surgery is in water and there is no way to extract the plume. But the air quality in Mercy’s theatres is now immeasurably better than before. “When you are suddenly not being exposed to smoke you realise how much better you feel,” says Ward.

Another essential is to have an ESP champion in every operating theatre; someone who can remind an unwilling surgeon – “tetchy” is Vollweiler’s word – that the hospital’s policy is non-negotiable, and who can follow up to answer any issues that arise.

For her, the mission is to spread the word that ESP is a significant health hazard, and to use Mercy’s example to show how it can be tackled using a comprehensive, risk-based approach. ESP is “totally below the radar”, as a former nurse colleague now working on contract in Australia can attest. After the Safeguard award she phoned Mercy to say she couldn’t believe she was working in major Australian hospitals which hadn’t recognised and managed the hazard of ESP.

“The purpose of our entry was to put what we’ve done up there and put the pressure on. We are regularly getting enquiries from hospitals in New Zealand, and recently we had our first from Australia.”

Ward is more than happy to be first point of contact for anyone who wants more information on ESP. Having succeeded at one hospital in Dunedin, the two of them wish to challenge all other theatres in New Zealand to embark on the same journey.

“Countrywide we are doing everything we can to stop people smoking,” Ward explains. “Gratuitously exposing people in operating theatres is a bit of a double standard.”


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