This course reviews air quality in the operating suite, including identifying the dangers of surgical smoke, mitigation methods, compliance improvement efforts, and ways to bring smoke evacuation practices beyond the health care facility level.
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Air Quality in the Operating Suite
Disclosure Statement
This course reviews air quality in the operating suite, including identifying the dangers of surgical smoke, mitigation methods, compliance improvement efforts, and ways to bring smoke evacuation practices beyond the health care facility level.
By the completion of this module, learners should be able to:
- Explore the contents and health hazards of surgical smoke.
- Review case reports of perioperative personnel negatively affected by the poor air quality in operating suites.
- Explore the risks to patients from poor air quality in operating suites.
- Understand the key components of a surgical smoke evacuation program.
- Review the Association for periOperative Registered Nurses' Go Clear Award.
- Explore the milestones of surgical smoke evacuation legislation.
Poor air quality in the operating suite can negatively affect everyone present, including the healthcare providers (HCP) and the patient. The primary cause of poor air quality in the operating suite is surgical smoke (Williams, 2022). Vortman and colleagues (2021) identified that surgical smoke had not been clearly defined in the literature and was often referred to by various surrogate names (e.g., plume, bioaerosols, lung-damaging dust). They conducted a concept analysis and defined surgical smoke as "a visible plume of aerosolized combustion byproducts produced by heat-generating surgical instruments" (p. 1). Surgical smoke is created from energy-generating devices, such as lasers and electrosurgical units, used within the operating suite. It can contain toxic chemicals as well as bacteria, viruses, and tumor particles that may be inhaled and may obscure the surgical field and diminish HCP visibility. Surgical smoke contains biohazardous substances that pose risks to perioperative HCPs and patients, including eye and upper respiratory irritation. More information and research regarding the dangers of surgical smoke are emerging daily, but it is still not common practice to reduce surgical smoke in the operating suite. This is primarily due to the lack of knowledge regarding the dangers of surgical smoke and a lack of compliance with products designed to reduce surgical smoke. Smoke evacuation implementation programs vastly improve the air quality in the operating suite. By following a few essential steps (i.e., performing a literature search, identifying barriers, building awareness and gaining buy-in, creating an interprofessional team, conducting trials, and establishing policies), operating suites can have proper air quality to reduce the harmful risks to HCPs and patients. Recently, legislation has been created to help control surgical smoke. Perioperative nurses are responsible for protecting themselves, their colleagues, and patients from the dangers of surgical smoke (Association of PeriOperative Registered Nurses [AORN], 2024; Ball, 2018; Vortman et al., 2021; Williams, 2022).
What is Surgical Smoke, and Why is it Dangerous?
Over the last few decades, various organizations and accrediting bodies have called attention to the importance of recognizing and minimizing the risk of harm to HCPs and patients. In 2000, the National Academy of Medicine (NAM), previously the Institute of Medicine (IOM), released the report, To Err is Human: Building a Safer Health System, which brought patient safety to the forefront of health care (IOM Committee on Quality of Health Care in America, 2000). Similarly, The Joint Commission (TJC) released National Patient Safety Goals annually to address emerging trends that place patients at risk for adverse events (TJC, n.d.). More recently, other professional organizations have launched initiatives to challenge health care organizations to not only prioritize patient safety but also the safety of their employees. For example, the American Nurses Association (ANA) launched the Healthy Nurse, Healthy Nation campaign, and the Institute for Healthcare Improvement (IHI) released the quadruple aim, which highlighted the importance of elevating health equity and joy in work (ANA, n.d.; Feeley, 2017). Similarly, the Occupational Safety and Health Administration (OSHA, n.d.-a) recognizes that HCPs experience health and safety hazards while caring for patients in various clinical environments. They have established a list of workers' rights, which includes the right to environmental conditions that do not pose a risk of serious harm (Vortman et al., 2021).
In the perioperative environment, HCPs and patients are exposed to chemicals, viruses, bacteria, and other harmful substances that are emitted into the air when heat-generating instruments are used to cut and coagulate tissues during various surgical procedures. Surgical smoke is created when these energy-generating devices (e.g., electrosurgical units, lasers, high-speed powered instruments [bone saws, drills], ultrasonic devices) are activated on organic material, such as human tissue, raising intracellular temperatures to 100˚ C (212˚ F), which causes tissues to vaporize. Surgical smoke comprises 95% water vapor and 5% combustion byproducts and cellular residues. While it can be seen, surgical smoke is more easily identified by its noxious and malodorous vapor (AORN, 2024; Spruce, 2020). Studies performed 40 years ago by Tomita and colleagues (1981) demonstrated surgical smoke's mutagenic potency. Surgical smoke can contain chemicals, bioaerosols, bacteria, viruses (e.g., HIV and human papillomavirus [HPV]), tissue, blood, nonviable particles, and viable cancer cells. The hazards of breathing in the contents of surgical smoke include chemical, carcinogenic, mutagenic, respiratory, and cytotoxic concerns. It is currently unknown whether COVID-19 is transmissible through surgical smoke, but evidence has confirmed the transmission of other viruses. Therefore, this risk is certainly possible. Researchers hypothesize that the aerosolization of COVID-19 endangers perioperative teams because the virus is located in the cells that line the respiratory tract as well as the gastrointestinal tract (Croke, 2021; Spruce, 2020; Vortman et al., 2021).
OSHA (1988) issued a Hazard Information Bulletin regarding the potential associated harm of surgical smoke related to the increased use of carbon dioxide in laser surgery. The regulatory body urged the medical community to consider these hazards carefully within this bulletin. They cited multiple studies that indicated the potential contaminants of surgical smoke, including viral particles/DNA and those too small to be filtered out by a standard surgical mask. The bulletin urged operating suites to establish appropriate precautions and referenced the effectiveness of mechanical smoke vacuuming systems (OSHA, 1988). More recently, OSHA acknowledged the hazards of surgical smoke and recognized that HCPs are at risk for cardiovascular and pulmonary adverse effects based on acute and chronic exposure to surgical smoke. In addition, organizations were cautioned to consider the potentially harmful long-term health effects and possible reproductive effects based on exposure to volatile organic compounds (AORN, 2024; OSHA, n.d.-b).
Surgical smoke has been compared to tobacco cigarette smoke due to its similar contents and equivalent risk of harm. Surgical smoke contains over 150 chemicals, including formaldehyde, carbon monoxide, benzene, toluene, acetaldehyde, hydrogen cyanide, and volatile organic compounds. These chemical contents of surgical smoke include 16 U.S. Environmental Protection Agency (EPA) priority pollutants (refer to Box 1) (Hedley, 2018). Cauterizing one gram of tissue (i.e., about the size of a penny) with an electrosurgical unit is equivalent to smoking six unfiltered cigarettes in 15 minutes. Conditions and symptoms that may develop from surgical smoke inhalation include coughing, a sore
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throat, watery eyes, headaches, dizziness, drowsiness, nausea, rhinitis, sneezing, and bad odors absorbed into an individual's hair (Dobbie et al., 2017; Spruce, 2018, 2020; TJC, 2020; Vortman et al., 2021).
Box 1: Primary Chemicals Identified in Surgical Smoke - Acetonitrile
- Acetylene
- Acrolein
- Acrylonitrile
- Alkylbenzene
- Benzaldehyde
- Benzene
- Benzonitrile
- Butadiene
- Butene
- Carbon monoxide
- Creosol
- 2,3-dihydro indene (hydrocarbon)
- Ethane
- Ethene
- Ethylene
- Ethylbenzene
- Formaldehyde
- Furfural (aldehyde)
- Hexadecanoic acid
- Hydrogen cyanide
- Indole (amine)
- Isobutene
- Methane
- 3-methyl butenal (aldehyde)
- 6-methyl indole (amine)
- 4-methyl phenol
- 2-methyl propanol (aldehyde)
- Methyl pyrazine
- Phenol
- Propene
- 2-propylene nitrile
- Pyridine
- Pyrrole (amine)
- Styrene
- Toluene (hydrocarbon)
- 1-undecene (hydrocarbon)
- Xylene
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(AORN, 2024; Hedley, 2018)
There have been numerous reports of human disease directly connected with the inhalation of surgical smoke. One case report involves a gynecology surgical nurse who developed a histologically proven recurrent case of laryngeal papillomatosis. The correlation between the diagnosis and surgical smoke was strong because the nurse repeatedly assisted in surgical cases involving the excision of genital condylomas using electrosurgical units and a laser. In a similar case, an adult gynecologist had a lump on their neck biopsied, which tested positive for HPV type 16 and squamous cell carcinoma. The gynecologist did not have any risk factors for HPV or oropharyngeal cancer except via surgical smoke from more than 3,000 surgical cases involving dysplastic cervical and vulvar lesions (AORN, 2024; Spruce, 2018).
Dr. Anthony Hedley, an orthopedic surgeon, published an article to warn others of the dangers of surgical smoke. Hedley was diagnosed with idiopathic pulmonary fibrosis and required a double lung transplant to survive. Environmental pollutants are attributed to idiopathic pulmonary fibrosis, but Dr. Hedley did not smoke cigarettes, and he was not exposed to Agent Orange while in the military. His primary environmental pollutant exposure was surgical smoke (Hedley, 2018). Compared to the general public, perioperative nurses experience twice as many respiratory-related health issues. OSHA estimates that more than 500,000 health care workers are exposed to surgical smoke each year (AORN, 2024; Spruce, 2018; Vortman et al., 2021).
Patients are also at risk for adverse health effects from surgical smoke. Risks to patients from surgical smoke include port-site metastasis, carbon monoxide exposure, high levels of carboxyhemoglobin, and extended procedure time due to a reduction in surgical field visibility from the smoke. Patients undergoing laparoscopic cholecystectomies were studied to identify the chemical composition of surgical smoke within the body following surgery. A urine sample was collected from each patient upon admission to the hospital to establish a baseline. The patients were anesthetized using the same methods and equipment, and the patients all recovered in the same room postoperatively to reduce variability. Each patient's first urine sample was collected within 5 to 12 hours postoperatively and stored at 4° C (39° F) until analyzed. Researchers found over 40 chemicals in the urine with significantly high concentrations of benzene and toluene, known human carcinogens. Benzene was three times higher than the preoperative levels (AORN, 2024; Ball, 2018; Vortman et al., 2021).
In another study examining the effects of surgical smoke, researchers studied patients receiving laparoscopic gynecological procedures. In the control group, surgeons did not use smoke-generating devices, while surgeons in the intervention group utilized a carbon dioxide laser and an electrosurgical unit. Patients in the control group did not show any changes postoperatively in their pulse oximetry readings, carboxyhemoglobin levels, or intra-abdominal carbon monoxide levels. In contrast, patients in the intervention group showed increased intra-abdominal carbon monoxide levels. This is a significant health concern because it may enter the bloodstream, causing hypoxic stress in an otherwise healthy patient. Postoperative blood samples taken from patients in the intervention group demonstrated increased carboxyhemoglobin and methemoglobin levels, which can decrease the red blood cell's capability to carry oxygen. Port-site metastasis is another concern with laparoscopic surgery and surgical smoke. This occurs when cancer cells spread to the trocar port sites after the cancer cells become aerosolized. Although this is a concern, scientists acknowledge that more research needs to be done (Ball, 2018).
While there are no specific standards related to surgical plumes, OSHA (2021) has two general industry standards related to air quality. The first standard, 1910 Subpart I, involves respiratory protection with the primary goal of controlling occupational harm caused by inhaling contaminated air. The OSHA standard states that this is to be achieved through engineering controls, such as room ventilation, equipment, surgical smoke evacuation systems, and respiratory protection. In addition, the standard specifies that surgical masks are not certified as respiratory protection for medical professionals. The second general industry standard, 1910 Subpart Z, covers toxic and hazardous substances. Standard Z states that employers must provide personal protective equipment (PPE), including N95 masks, if smoke evacuation systems are unavailable. By reducing surgical smoke in the operating suite, perioperative nurses and nurse leaders can improve the health and safety of perioperative personnel and surgical patients. OSHA's hierarchy of controls should be utilized to do this. The OSHA hierarchy entails smoke evacuation systems, room ventilation, and PPE, such as N95 masks, for added respiratory protection (Croke, 2021; OSHA, 2021).
The AORN Guidelines for Perioperative Practice (2024) provide the following recommendations for surgical smoke safety:
- Health care organizations should provide a smoke-free surgical work environment.
- Health care organizations should evaluate the risk of exposure to surgical smoke for the perioperative team. Use the OSHA-endorsed Centers for Disease Control and Prevention (CDC)/National Institute of Occupational Safety and Health (NIOSH) hierarchy of controls to reduce exposure to surgical smoke.
- Eliminating the hazard (e.g., avoiding smoke-generating devices)
- Substituting the hazard (e.g., using alternative devices)
- Using engineering controls (e.g., room ventilation of 20 total air exchanges per hour, work practices, surgical-smoke evacuation, and filtration)
- Wearing PPE
- Using administrative controls (e.g., policies and procedures, education, and training)
- Health care organizations should evacuate and filter all surgical smoke using a smoke evacuation system (e.g., portable smoke evacuator with filtration, medical-surgical vacuum with an in-line filter, and centralized stationary smoke evacuation system). Use an evacuator system that contains an ultra-low particulate air (ULPA) filter with an activated carbon filter.
- PPE used for respiratory protection should not be considered a replacement for surgical smoke evacuation and filtration. PPE should be worn as a secondary protection against surgical smoke. A surgical mask is not considered respiratory protection. Instead, use a surgical N95 mask.
- Organizations should provide initial and ongoing education to perioperative team members for surgical smoke safety. Individual organizations should establish intervals for education and competency verification.
- Organizations should develop policies and procedures for surgical smoke safety and review, revise, and make them readily available.
- Organizations should participate in a variety of quality assurance and performance improvement activities consistent with a plan to improve understanding and compliance with surgical smoke safety and evacuation.
Implementing a Smoke Evacuation Program
Health care facilities across the nation are considered smoke-free environments. However, this does not usually apply to the facility's operating suite. Perioperative personnel and patients require the same protection as the rest of the health care facility. As more research has continued to demonstrate the harmful effects of surgical smoke on HCPs and patients, many states have enacted legislation laying the groundwork for laws that would require health care facilities to implement surgical smoke evacuation policies and procedures. The AORN (2024) provides steps for the management of surgical smoke and recommendations for mitigation strategies. The first step is to perform a literature search to gain evidence that surgical smoke is harmful and determine how to minimize the risks of surgical smoke inhalation. The next steps are identifying barriers, building awareness, educating, and gaining buy-in. Next, an interprofessional team should be assembled, and equipment and devices should be tested and evaluated. The last step is creating a policy to ensure consistent use of equipment that will provide the best air quality in the operating suite (Croke, 2021; Vortman et al., 2021).
Conducting a Literature Search
A literature search can supply key information regarding surgical smoke and how to mitigate it. This will build the necessary evidence to validate perioperative nurses trying to create change within the operating suite and provide a rationale for investing in a surgical smoke evacuation program. It is imperative to use evidence-based research and qualified sources when conducting this literature search. Organizations that provide evidence and recommendations for surgical smoke evacuation include the American National Standards Institute, the AORN, the NIOSH, and OSHA (AORN, 2024; Croke, 2021; Vortman et al., 2021).
Identifying Barriers
Numerous barriers can impact the success of mitigation strategies for surgical smoke in the operating suite. Common barriers include staff refusal, limited or no access to smoke evacuation equipment, the noise of existing equipment options, staff competency, and a lack of leadership/policy (Vortman et al., 2021). Even when health care organizations recognize the importance of surgical smoke evacuation policies and procedures, creating them and successfully implementing them can be challenging. In 2019, an urban teaching hospital conducted a review of nursing documentation and found that HCPs were properly evacuating surgical smoke in less than 0.5% of the applicable procedures. An interprofessional team was initiated, and a quality improvement project was implemented. This project included a smoke evacuation policy, the acquisition of proper smoke evacuation equipment, and HCP education on the hazards of surgical smoke and the proper use of evacuation devices. After implementation, surgical smoke evacuation device use increased but was only used in 30% of applicable cases (Ostapovych & Vortman, 2022).
Building Awareness and Gaining Buy-In
Identifying and addressing knowledge gaps of perioperative personnel is an essential step in the process. Providing an educational in-service to staff will spread awareness of the dangers of surgical smoke. This may encourage other perioperative staff to address air-quality issues within the operating suite. Gaining buy-in from key personnel in the health care facility and the operating suite will increase support for and interest in a surgical smoke evacuation program. By building awareness through education, perioperative personnel may come forward to aid in the surgical smoke evacuation program. An engaged team will be more apt to accept change and utilize the necessary equipment (Croke, 2021). Wagner and colleagues (2024) found a knowledge gap among HCPs regarding their understanding of surgical smoke hazards and how to use evacuation devices. Many perioperative personnel have reported receiving limited education on the risks of surgical smoke. When education had been completed, there was still a general lack of understanding of high-risk procedures. More education and training are needed to build awareness and gain buy-in to adopt surgical smoke evacuation policies and procedures (Croke, 2021).
Creating an Interprofessional Team
Creating an interprofessional team can allow medical leadership to establish and maintain a surgical smoke evacuation program. The team may consist of perioperative nurses, surgical technologists, surgeons, anesthesia providers, a perioperative nurse manager, a perioperative department director, and a member of the supply chain, among others. An interprofessional team approach will ensure appropriate representation. Surgeon champions must appear on this team, as they are often instrumental to the change process and can help combat the surgeon refusal barrier. This team should set a goal date for achieving a smoke-free operating suite and share this date with the perioperative department. This allows the perioperative staff to work toward a common target. In addition, having a clear goal date may increase teamwork, morale, and engagement (Croke, 2021; Dobbie et al., 2017).
Trialing and Evaluating Equipment
In addition to room ventilation, a surgical smoke evacuator is the first line of defense against surgical smoke inhalation. Many options for smoke evacuation systems are available. Therefore, it is ideal to try a few systems to find the one that works best for the entire perioperative department. The interprofessional team can research the options available and make selections. Trialing and evaluating systems will help users decide which system they prefer to purchase. Each system will come with product representatives for guidance and assistance during setup and use. They educate the perioperative team on setting up and using the smoke evacuation system and answer any questions or concerns the team may have. Everyone in the perioperative department who works directly in the operating suite should be encouraged to participate in these trials and evaluations. The evaluations offer each team member the opportunity to document their insights, preferences, and rationale for liking or disliking a certain device (Croke, 2021; Williams, 2022).
All evaluations shall be tallied at the end of the trials to determine the surgical smoke evacuation system that received the most votes. Depending on the budget, a perioperative department may purchase different systems based on surgeon preference. To increase compliance, it would be wise to add the smoke evacuator system and cautery pencils to each surgeon's preference card so they are not overlooked when preparing for a surgical case. The cautery pencils may also be added to custom procedure packs to promote seamless use (Croke, 2021).
Establishing Policies and Monitoring Compliance
Policies regarding air quality in the operating suite should be developed to standardize the smoke evacuation process. Clear and comprehensive policies can guide perioperative teams and ensure compliance. The policies should contain information including, but not limited to, positioning the smoke evacuation cautery pencil as close to the surgical site as possible, indicating when the smoke evacuation systems are required (i.e., ideally for all surgical smoke-producing cases), wearing respiratory protection (N95 mask or alternative) for high-risk procedures, and meeting requirements for competency and education. These policies must be routinely assessed and updated as needed. In addition, staff should perform quality-assurance audits for compliance with current policies and proper use of the equipment. Medical leadership should be open and honest with the perioperative staff regarding the audit results and remind them that (a) the air quality in the operating suite affects everyone and (b) surgical smoke evacuation is an important safety measure to protect the health of the staff, providers, and patients (Croke, 2021).
AORN's Go Clear Award Program
AORN created the Go Clear Award Program to establish smoke-free operating suites and acknowledge facilities that complete the program for their commitment to safety. The goals of the Go Clear Award Program are to protect patients and perioperative personnel from the dangers of surgical smoke, educate perioperative personnel on the health hazards of surgical smoke and mitigation efforts, increase surgical smoke evacuation system compliance, and aid health care facilities in attracting and retaining perioperative personnel by providing a smoke-free work environment (Croke, 2020). Participants in the program must follow a series of steps, including:
- Committing to a smoke-free operating suite and obtaining leadership support
- Assembling an implementation team
- Conducting a gap analysis to determine whether smoke evacuators are being utilized (if the facility has any)
- Creating a plan of action and a goal date for becoming smoke-free
- Creating an implementation plan and sharing it with leadership and perioperative staff
- Educating the perioperative department
- Auditing and monitoring compliance using the CLEAR (Check, Learn, Evaluate, Assess, and Report) tool (Croke, 2020)
To be considered for the award, participants must perform audits for 3 months before submitting their compliance data to AORN. Recertification can be applied for after 3 years, and the requirements entail that newly hired staff must complete the program's education modules, all perioperative personnel must retake the program's posttest, and facility leaders must conduct 3 months of compliance audits. The award has three classifications: gold, silver, and bronze. The criteria for award designation are based on the availability of surgical smoke evacuation systems in the operating suite and the facility's compliance and educational performance regarding surgical smoke evacuation. Award recipients are listed on AORN's website, acknowledged at the AORN Global Surgical Conference and Expo, receive a plaque, and gain access to the Go Clear Award media kit (Croke, 2020). AORN has also established the AORN Center of Excellence in Surgery Safety: Smoke Evacuation Program. Currently, more than 800 surgical teams have adopted this program and are committed to making surgical smoke evacuation a top priority (AORN, n.d.-a).
Legislation
Since 2018, perioperative personnel and professional organizations throughout the US (e.g., AORN, state associations representing nurse anesthetists, and state nursing associations) have driven the pursuit of surgical smoke evacuation legislation. As a result, more smoke evacuation milestones are being reached. As of 2024, 18 states have enacted surgical smoke evacuation legislation, an increase from just three states in 2021. These acts require state-licensed ambulatory surgery centers and hospitals to use surgical smoke evacuation systems during all smoke-generating procedures (AORN, n.d.-b; Vortman et al., 2021). The National Fire Protection Association (NFPA) has required the capture of surgical smoke plumes since 2012. In 2024, the NFPA requires the capture to occur as close as possible to the point of generation in operating suites nationwide. As health care facilities are built or remodeled, they will be required to comply with these new codes. TJC recognizes the hazards but currently does not require evacuation. Similarly, OSHA acknowledges the hazards of surgical smoke and makes recommendations for evacuation of surgical smoke but does not make them requirements. Instead, the standards are left to the General Duty Clause, which requires employers to provide a place of employment that is free from hazards, leaving room for organizations not to evacuate surgical smoke (Kyle, 2024). OSHA (n.d.-c) does provide some recommendations for the evacuation of surgical smoke, including:
- Use portable smoke evacuators and room suctions with in-line filters.
- Keep the evacuator or room suction hose nozzle inlet within 2 inches (5 cm) of the surgical site.
- Have an evacuator available for every operating suite room where a plume is generated.
- Evacuate all smoke.
- Keep the smoke evacuator on at all times.
- Inspect the evacuator systems regularly.
- Consider all tubing, filters, and absorbers as infectious waste and dispose of them properly.
- Use new tubing before each procedure and replace filters as recommended by the manufacturer.
References
American Nurses Association. (n.d.). Healthy nurse, healthy nation. Retrieved September 9, 2024, from https://www.nursingworld.org/practice-policy/hnhn
Association of PeriOperative Registered Nurses. (n.d.-a). AORN Center of Excellence in Surgical Safety: Smoke evacuation. Retrieved September 20, 2024, from https://www.aorn.org/education/education-for-facilities/surgical-safety-center-of-excellence/go-clear-awards
Association of PeriOperative Registered Nurses. (n.d.-b). Surgical smoke-free OR. Retrieved September 20, 2024, from https://www.aorn.org/get-involved/government-affairs/policy-agenda/surgical-smoke-free-or
Association of PeriOperative Registered Nurses. (2024). Guidelines for perioperative practice (2024 ed.). AORN, Inc.
Ball, K. (2018). Protecting patients from surgical smoke. AORN Journal: The Official Voice of Perioperative Nursing, 108(6), 680-684. http://doi.org/10.1002/aorn.12436
Croke, L. (2020). The AORN Go Clear Award Program recognizes facilities working to eliminate surgical smoke. AORN Journal, 111(4), 5. https://doi.org/10.1002/aorn.13025
Croke, L. (2021). Implementing a surgical smoke evacuation program. AORN Journal: The Official Voice of Perioperative Nursing, 113(3), 5-8. https://doi.org/10.1002/aorn.12052
Dobbie, M. K., Fezza, M., Kent, M., Lu, J., Saraceni, M. L., & Titone, S. (2017). Operation clean air: Implementing a surgical smoke evacuation program. AORN Journal: The Official Voice of Perioperative Nursing, 106(6), 502-512. https://doi.org/10.1016/j.aorn.2017.09.011
Feeley, D. (2017). The triple aim or the quadruple aim? Four points to help set your strategy. https://www.ihi.org/insights/triple-aim-or-quadruple-aim-four-points-help-set-your-strategy
Hedley, A. (2018). Surgical smoke nearly killed me. Outpatient Surgery Magazine. https://www.aorn.org/outpatient-surgery/articles/outpatient-surgery-magazine/2018/february/surgical-smoke-nearly-killed-me
Institute of Medicine (US), & Committee on Quality of Health Care in America. (2000). To err is human: Building a safer health system. (L. T. Kohn, J. M. Corrigan, & M. S. Donaldson, Eds.). National Academies Press. https://doi.org/10.17226/9728
The Joint Commission. (n.d.). National patient safety goals. Retrieved September 19, 2024, from https://www.jointcommission.org/en/standards/national-patient-safety-goals
The Joint Commission. (2020). Quick Safety issue 56: Alleviating the dangers of surgical smoke. https://www.jointcommission.org/resources/news-and-multimedia/newsletters/newsletters/quick-safety/quick-safety-issue-56
Kyle, E. (2024). Surgical smoke codes and safety issues. Health Facilities Management Magazine. https://www.hfmmagazine.com/articles/4967-surgical-smoke-codes-and-safety-issues
Occupational Safety and Health Administration (n.d.-a). Healthcare. Retrieved September 18, 2024, from https://www.osha.gov/healthcare
Occupational Safety and Health Administration (n.d.-b). Laser/electrosurgery plume. Retrieved September 18, 2024, from https://www.osha.gov/laser-electrosurgery-plume/standards
Occupational Safety and Health Administration (n.d.-c). Surgical suite: Smoke plume. Retrieved September 18, 2024, from https://www.osha.gov/etools/hospitals/surgical-suite/smoke-plume
Occupational Safety and Health Administration (1988). OSHA hazard information bulletins: Hazard of laser surgery smoke. https://www.osha.gov/publications/hib19880411
Ostapovych, U., & Vortman, R. (2022). Implementing a surgical smoke evacuation policy and procedure: A quality improvement project. AORN Journal: The Official Voice of Perioperative Nursing, 115(2), 139-146. https://doi.org/10.1002/aorn.13603
Spruce, L. (2018). Back to basics: Protection from surgical smoke. AORN Journal: The Official Voice of Perioperative Nursing, 108(1), 24-32. https://doi.org/10.1002/aorn.12273
Spruce, L. (2020). Preventing exposure to surgical smoke. AORN Journal: The Official Voice of Perioperative Nursing, 112(6), 709-710. http://doi.org/10.1002/aorn.13265
Tomita, Y., Mihashi, S., Nagata, K., Ueda, S., Fujiki, M., Hirano, M., & Hirohata, T. (1981). Mutagenicity of smoke condensates induced by CO2-laser irradiation and electrocauterization. Mutation Research, 89(2), 145–149. https://doi.org/10.1016/0165-1218(81)90120-8
Vortman, R., McPherson, S., & Wendler, M. C. (2021). State of the science: A concept analysis of surgical smoke. AORN Journal: The Official Voice of Perioperative Nursing, 113(1), 41-51. http://doi.org/10.1002/aorn.13271
Wagner, D., Pearcey, S., Hudgins, C. J., & Ulmer, B. C. (2024). Surgical smoke knowledge and practices before and after onset of COVID-19: A national survey of OR personnel. Perioperative Care and Operating Room Management, 35, 100411. https://doi.org/10.1016/j.pcorm.2024.100411
Williams, K. (2022). Guidelines in practice: Surgical smoke safety. AORN Journal: The Official Voice of Perioperative Nursing, 116(2), 145-149. https://doi.org/10.1002/aorn.13745