AORN Journal 2018 Conference Poster Collection

These posters were originally presented at the 2018 AORN Global Surgical Conference & Expo, reprinted here from the AORN Journal.

Operation Clean Air

Susan M. Titone, MSN, RN, CNOR; Maria T. Fezza, BSN, RN, CNOR; Mary K. Dobbie, RN, CNOR; Mark L. Saraceni, MBA; Martha Kent, EdD, MSN, RN, CPAN, NEA; Suzannah Sorin, MSPAS, PA-C; Jane Lu, RN

Surgical smoke is a deadly byproduct of any operating room utilizing electrocautery and laser. Although professional organizations and literature have recognized inhalation and exposure as harmful to patients and pre-operative staff, surgical smoke continues to remain a hazard. Consequently, an interdisciplinary team at New York University Langone Health sought to improve safety by instituting a smoke-free program throughout the institution. Known as Operation Clear Air, the process change was based upon recommended practices, gap analyses, and education. The team consisted of Registered Nurses (RNs), Surgical Technicians (CSTs), a Certified Registered Nurse Anesthetist (CRNA), and a Physician Assistant (PA) to ensure that all operating room floors and specialties were represented. MD champions were conjointly recruited for each surgical service to assist with compliance, support, and scheduling of the educational sessions. Specifically tailored educational presentations took place for each audience group: RNs, CSTs, PAs, Anesthesia, and MD specialties. The sessions were a platform to bridge the knowledge deficit regarding the hazards of surgical smoke and increase familiarity with smoke evacuation equipment. Online modules developed by the Association of periOperative Registered Nurses (AORN) were assigned to RNs, CSTs, Clinical Perfusionists, and Surgical PAs to supplement the sessions. Data was then collected on total surgical smoke evacuation supply usage prior to and after the initiation of the program, as a means to monitor compliance. The total usage has more than quadrupled since the start of education, and weekly audits in all operating room suites have occurred to ensure that staff understood the proper handling of all equipment. Additional unit based education continues daily and is a constant reminder that safety is the responsibility of all preoperative staff members.

Going Smoke Free: A Journey of Persistence and Innovation

Lauren M. Fujihara, MN, RN, CNOR CNS; Christine M. Pizzulli, BSN, RN; Kristine M. Alessandrini, BSN, RN, CNOR

With increasing awareness, addressing surgical smoke safety and methods of smoke evacuation has become a priority for perioperative nurses. There is much strategy involved in preparing a case to request product trials for this initiative, as advocating for a change in practice to create a smoke-free procedural environment has significant cost considerations. When the traditional approach of presenting the abundance of compelling evidence in the literature, as well as the regulatory and professional recommendations was not sufficient, persistence and re-strategizing became necessary. It was identified that additional information related to the efficacy of a smoke evacuation device would be helpful in building support to move for-ward with requesting a trial. This translated to designing a data collection project to gather information on how effective a smoke evacuation device is in reducing the number of surgical smoke particles. It is well documented that surgical smoke contains 150 chemicals, 80 of which are toxic. It is significant to note that this journey, initiated by surgical specialty service-line nurse leaders, began prior to the publication of the 2017 AORN (Association of periOperative Registered Nurses) Guidelines for Surgical Smoke Safety, so the quantity of easily accessible research was not conveniently available as it is now. Having to formulate a plan to collect this data, a multidisciplinary collaborative team was identified and essential to support this project. Data was collected from patients having unilateral mastectomy and immediate DIEP (deep inferior epigastric perforator) free flap reconstruction. In an attempt to reduce contributing variables, we isolated the data collection to a single operating room and matched the patients in regards to those having the same surgical oncologist and plastic surgeon. Considerations were also made in regards to the patients’ body mass index (BMI). The analyzed data was compelling and offered much promise in helping to move the trial requests forward to being approved. This homegrown data was powerful in conveying that surgical smoke particles can be effectively removed from the surgical field; therefore reducing exposure to the patient and health care providers. In addition to presenting these findings, further support for this initiative was highlight-ed by presenting the newly published professional nursing guidelines, as well as information related to a recently passed state assembly bill requiring the development of “a regulation that requires a health facility to evacuate or remove plume...” The concluding push to initiate this trial was to simply point out that this is the right thing to do, especially when the associated academic campus and hospital system have a smoke free policy. With the perseverance, commitment and hard work of the surgical specialty service-line perioperative nurse leaders, this trial to go smoke-free was approved and supported.

Ways We are Making Our OR Safer at UPMC Horizon

Jeanne A. Schrantz, RN, CNOR

Our patients are our utmost and main priority. We are their advocate while under our care, so we feel it is important that we should strive for the best optimum outcome for our patients during the perioperative phase.

Some of the ways we are making Horizon Surgical Services a safe environment:

  • When greeting our patients in the pre-op area and introducing yourself and checking their name band and allergy bracelet along with asking their name and the surgery that they are having. Answering any questions or concerns that they may have. Reviewing their chart, to make sure that the permit is correct procedure, signed and dated correctly. All orders and lab values are done. Making sure the Surgeon has seen the patient and the surgical site is marked (if it is bilateral). Once the patient is taken into the OR suite introducing the patient to the other surgical team members and have the patient tell them the surgery that he or she is having along with showing the permit to the team members.
    • This is done to make sure we have the correct patient and they are able to verbalize before anesthesia, the correct surgical procedure and correct site. That the chart is correct with the orders and lab values. And that we have the correct equipment in the OR suite.
  • After our patient is safely transferred onto the surgical table and positioned safely with safety belt along with warm blankets, during the induction phase we stand by them and hold their hand to help them feel safe and to possibly help anesthesia. After the patient is properly and safely positioned for the particular surgery and surgical prep is done.
    • This is done for the safety of the patient. And also to help alleviate fears while going under anesthesia and to be there to help if the Anesthetist may need it. The patient is properly positioned to prevent any nerve injuries. If we are using chloraprep, we wait a minimum of three minutes to dry before draping to prevent any potential fire hazard.
  • The Time Out is done right before the surgical incision is made-the permit is read and all have to verbalize agreement, along with antibiotic given, allergies, fire safety from either electrocautery or light source.
    • This is done for last check before incision with surgeon, anesthesia, nurses and scrub techs all involved. Fire safety is done to be reminded to continuously watch for potential fire hazards, either from electrocautery, light sources, laser, (O2 if a patient has nasal cannula on). Solution available on back table or nearby if using laser Fire extinguisher is OR suite for electrical fires.
  • We have made our OR Latex-Free, all of our supplies do not contain natural rubber latex.
    • We did this to help prevent any latex allergy reactions. We changed all of our sterile surgical gloves, our Foley catheters, our penroses, ace bandages all to latex free for the safety of our patients.
  • We are encouraging our nurses be CNORS
    • We have hosted a CNOR Prep Course (Wendy Zanders) at our facility and invited the nurses from the surrounding hospitals. Increased knowledge in the surgical setting is crucial to the patient well-being and safety. Our new nurses also take the Perioperative 101 Course during orientation. Several of our RNS including myself are now proud CNOR’s.
  • PPC Surgical Council of Nurses and Scrub Techs-we have monthly meetings and try to bring new ideas and changes to help the OR work more effectively.
    • This has helped with surgical trays and the count papers which used to be placed in the tray, but has since moved into small envelope away from the instruments to help prevent the possible contamination from the ink.
  • On the late start dates that the Surgeons have meetings, we try to cover a topic, along with a presenter. Some of our topics include: anesthesiologist going over difficult intubations and malignant hyperthermia; orthopedic surgeon presentation on compartment syndrome; nurses going over laser safety and the laser machine; our mesh cart, the different meshes and why certain mesh is used, staple cart.
    • All of the topics pertain to the OR for our staff to learn or reinforcement of knowledge, which is a good review for old nurses and new staff.
  • Safe and Sterile Environment as possible-during surgical procedures. Surgical field continuously monitored for any breaks in surgical technique, keeping traffic from entering suites to a minimum. Daily monitoring of room temps and humidity.
    • This is to help prevent infection and safety for the patient.
  • Keeping an open line of communication on a daily basis on any changes that are happening. An example: new equipment or a new supply item and where it is kept.
    • This is done to help keep the OR staff informed and to work more effectively.
  • We have changed our electrocautery pens to smoke evac/cautery pens to help remove smoke plume in the OR.
    • We have been concerned about the harmful effects of the smoke plume in the OR to both our patients and our surgical staff. We have trialed several smoke evacuation pens and had the surgeons evaluate them. We then agreed on one particular pen and we now have only one smoke evac/cautery pen in our packs that connects to a smoke evac filter on our neptunes. We also use the smoke evac. filters. On our laparoscopic cases. We applied for the GOClear and have been working on the audits, modules and requirements from AORN.
  • We follow AORN Guidelines and Recommended practices.
    • We have the standards on our computer site to help our staff when they have a possible question. We try and encourage the attendance of AORN meetings, several of us belong to the Northwest Chapter of Pa. and we try and attend the designated meetings and get involved.
  • Being kind to each other
    • It is important for us to be a team and help co-workers whenever we can. Our patients matter, and it is up to us to be their advocate!

Suck It Up! ... For a Safer OR Environment

Ann Z. Russ, BSN, RN; Alexandra Muehlbronner; Lauren Kalanty

Smoke produced from the use of electrosurgical units (ESU) during surgery has been a known health hazard since 1985 (Okoshi et al, 2015). Research gathered from numerous sources including AORN, PubMed, and CINAHL continues to show that repeated exposure to surgical smoke can result in adverse health effects to staff in the perioperative environment (Dobrogowski et al, 2015). Furthermore, one of the best remedies to reduce or eliminate the hazard is via use of smoke evacuation pencils (smoke evacuators) and prudent use of smoke-generating devices (Okoshi et al, 2015; Tramontini, Galvao, Claudio, Ribiero & Martins, 2016). The goal of this project was to increase the use of smoke evacuators after implementing staff education on the dangers of surgical smoke and existing solutions for smoke evacuation. The following question sought to be answered: In the population of Cupp Operating Room staff, including nurses and surgical technicians, at PPMC, will education on electrosurgical smoke and smoke evacuation increase the use of smoke evacuators? Prior to implementing an education session, baseline data collected shows that six (6) smoke evacuators were used over the course of four weeks. Education on surgical smoke and evacuation methods was then presented to operating room nurses and surgical technicians. Data was gathered again for four weeks post-education and result-ed in 28 smoke evacuators, including a 366.7% increase in smoke evacuator usage. Next steps involve getting smoke evacuators including in specialty-specific packs, increasing the number of suction units that are required to use the smoke evacuator, exploring further options and products for smoke evacuation and including the dangers of surgical smoke and smoke evacuation solutions in new hire education as well as annual competencies.

Objectives:

  1. At the end of the education session, participants will be able to recognize the dangers of surgical smoke and related health hazards.
  2. At the end of the session, participants will be able to identify examples of proper smoke evacuation methods.

Surgical Smoke Evacuation: A Survey of OR Nursing Staff

Karen K. Giuliano, PhD, RN, FAAN; Cris Salinas, MD; Steve Docsa; Randee Randoll

Purpose

Electrosurgery devices, laser ablation, and ultrasonic scalpels are widely recognized as major advances in surgical technology. Electrosurgery is used in more than 85% of 24 million surgeries performed annually in the US. Unfortunately, electrosurgery devices create a gaseous by-product commonly referred to as surgical smoke or plume and each year, an estimated 500,000 perioperative staff are exposed. More than 150 different hazardous chemi-cals have been identified in surgical smoke, with the potential to cause human cell damage, cancer and infectious disease. Smoke evacuation devices are effective for limit-ing exposure. However, despite AORN recommendations, smoke evacuation devices have not been implemented into routine use in most operating rooms. The purpose of our survey was to identify the level of OR nursing knowledge regarding the risks of surgical smoke exposure, and nursing perceptions on the barriers to routine smoke evacuation system use.

Methodology

A convenience sample of OR nurses was obtained from attendees at the 2017 AORN national conference in Boston, MA. Survey data were collected us-ing an audience responses system. IRB review determined the research as exempt and OR nurse participation was anonymous and voluntary. Demographic data were limit-ed to clinical background and facility type. All data analyses were descriptive in nature. The Roy Adaptation Model provided the theoretical framework for this study.

Results

The majority of participants (N=155/198; 78%) were direct care providers, and the sample included a variety of hospital types and geographic regions. The most common barriers were identified as surgeons dictating when smoke evacuation can be used (42%), and hospital/facility leadership not enforcing the use of smoke evacuation equipment (28%). While most nurses (65%) strongly agreed to understanding the risks associated with surgical smoke, some nurses (12%) were not aware of the risks at all. Over half of respondents reported use of smoke evacuation only in procedures considered high risk (53%), while 23% did not use smoke evacuation in any procedures.s

Conclusion

While most OR nurses are knowledgeable on the risks of surgical smoke, our data support a clear knowledge/practice gap. This is an issue of serious concern, as current practice places perioperative nurses and all members of the team at increased risk for exposure to the health hazards associated with surgical smoke. Further research and dissemination is needed regarding successful strategies to improve compliance with this important AORN recommendation.