Editors note: This is the final installment in a three-part series of articles about an evidence-based

practice committee at Childrens Hospital Boston, describing one initiative and its implementation.
Examples of how clinical practice or policy changed as a result of the curiosity of staff nurses and
their desire to improve the quality of care and working conditions are detailed in this article and in
the two that preceded it.

Implementing Surgical Smoke Evacuation in the Operating Room

A nurse-led initiative changes policy to provide health care workers
and patients more protection.
Overview: Inspired by a presentation at an educational conference, two
operating room (OR) nurses at Childrens Hospital Boston raised concerns
at the hospitals perioperative evidence-based practice committee meeting about the potential hazards associated with exposure to surgical
smoke and aerosols. The nurses initiated a safety project involving the
use of smoke evacuation devices in ORs. The subsequent policy development took two years and involved a literature review, a survey of other
institutions, and the support of numerous stakeholders. A utilization review
and supportive educational initiatives are ongoing.

urgical smoke, sometimes

called smoke plume or
aerosol, is created from
the destruction of tissue during
operations in which lasers or electrocautery instruments are used.
Much is unknown about the hazards of inhaling surgical smoke,
but concern about exposure is
mounting.
The smoke consists largely of
hydrocarbons, phenols, nitriles,
amines, aldehydes, and fatty
acids,1 although viral DNA2, 3 and
viable bacteria4 have also been
identified as constituents. In addition to the risk of pulmonary
irritation and inflammation associated with surgical smoke exposure, theres evidence that such
exposure can be a source of infection. Garden and colleagues
demonstrated the presence of
bovine papillomavirus DNA in
surgical smoke,3 and Hallmo
and Naess reported a case of laryngeal infection with human
papillomavirus in a laser surgeon

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treating patients with anogenital

condylomas.5
According to a 2003 review,
the size of the particulate matter
in surgical smoke, which averages 0.07 microns with electrocautery and 0.31 microns with
laser ablation,6 presents another
problem. Most surgical masks
are designed to filter particles
that are 5 microns and larger.
Even high-filtration laser masks
are unable to filter particles
smaller than 0.1 microns. The
fact that surgical masks arent
fit tested and are sometimes
worn loosely is yet another reason not to rely on them as the
sole means of protection from
surgical smoke.7
Aside from the unpleasant
odor of surgical smoke, its chemical makeup and the size of its
constituent particulate matter
have sounded alarm bells in
some clinicians about the need
for an effective means of evacuating surgical smoke in the

operating room (OR). National

organizations such as the Association of periOperative Registered
Nurses (AORN) and the National Institute for Occupational
Safety and Health (NIOSH) suggest limiting exposure to surgical
smoke and recommend its evacuation, but the Occupational
Safety and Health Administration (OSHA), which has legal
and regulatory power, has yet
to mandate surgical smoke evacuation.7-10 (In 2008 OSHA added
a brief hospital eTool about
surgical smoke to its Web site,
addressing potential hazards
and possible solutions.11)
THE INITIATIVE

The evidence-based practice

(EBP) project to improve surgical smoke evacuation in the ORs
at Childrens Hospital Boston
began in March 2007 and took
two years to complete. Although
some aspects of this projects
launch are institution specific,
they demonstrate how such quality improvement projects evolve
from conception through implementation.
The catalyst for change was
an extended presentation on creating smokeless ORs, which was
given at the 2007 AORN Congress and attended by two Childrens Hospital OR nurses, who
then shared the information
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By Ashley W.G. Waddell, MS, RN, CNOR

with the hospitals perioperative

EBP committee. By the fall of
2007 the project had been designed and had begun to gain
momentum. An employees concern about surgical smoke exposure, which had been reported
through the hospitals occupational health office at around
the same time, provided further
incentive.
The goal of the project was to
arrive at a consensus regarding
the hospitals approach to surgical smoke evacuation in the ORs.
We began by creating a searchable, focused question: Is there
sufficient evidence of health risks
from exposure to surgical smoke
to develop and implement a surgical smoke evacuation policy in
our OR? For the sake of clarity,
we expressed the question in the
four-part PICO format created
by Melnyk and Fineout-Overholt,12 specifying the population
of interest (P), the intervention
of interest (I), a comparison intervention (C), and the outcome
(O). (Editors note: Melnyk and
Fineout-Overholt have recently
added a fifth element to the format, now known by the acronym
PICOT, in which T stands for
time frame.)
REVIEWING THE EVIDENCE

A small, multidisciplinary working group came together to review

health care literature, practice
standards, and government regulations regarding employee exposure to surgical smoke in the
OR. I represented OR nurses;
other members included a physician specializing in infectious
disease, an NP working in occupational health, and a representative from the risk management
department. Each group member reviewed literature from
within her or his specialty and
introduced noteworthy findings
at periodic meetings over the
next year.
ajn@wolterskluwer.com

My preliminary literature
review included 61 possible
sources of evidence obtained by
our hospital librarian, who at
my request had conducted a
search of Medline and CINAHL
databases for terms such as surgical smoke, surgical smoke
plumes, and operating room
air, alone and in combination
with the term nursing. After
eliminating advertising and questions sent to expert forums, I
focused on the 16 articles that
seemed most relevant to our project and 10 or more studies referenced in the articles that were not
uncovered in the preliminary
search. Two of the items were
narrative review articles7, 13; in
the hierarchy of evidence used in
EBP, narrative reviews are considered to be at a low level, but
they were helpful in directing
me to important investigations.
In addition to these, I reviewed
10 original studies, one case
report, one surveillance report,
one survey of practice, and practice guidelines from three organizations (AORN, NIOSH, and
OSHA).1, 3-5, 9-11, 14-22
The literature search pointed
to overwhelming evidence of
harmful, irritating, and potentially infective contaminants in
surgical smoke;1, 3-5, 14, 15, 18, 19
raised concerns about the size of
particles in surgical smoke and
the inadequacy of surgical masks
as filters;13, 17, 20 and offered recommendations, based on the
available evidence, that localexhaust ventilation be used to
help protect health care workers
and patients from exposure to
surgical smoke.9-11 With regard
to practice, the evidence suggested
that very few hospitals have established policies on surgical
smoke evacuation; that this is
likely a result of the absence of
regulatory mandates; and that
institutions equipped with localexhaust ventilation equipment

report using it more frequently

during laser surgery than during
electrosurgery, electrocautery,
or diathermy procedures, although the smoke generated in
these procedures is comparably
hazardous.16
To further explore current
smoke-evacuation practices, I
e-mailed and sent follow-up
requests to the 40 perioperative
director members of Child Health
Corporation of America (an organization of freestanding childrens hospitals), asking whether
their institutions have policies
recommending smoke evacuation for some or all operations.
I received only six responses, and
none of these described consistent practices of smoke evacuation during all types of surgery.
Despite the low response rate,
this research supported the findings of my literature reviewthat
few hospitals have a policy on
surgical smoke evacuationand
was consistent with the input I
received from OR nurse managers at surrounding hospitals.
Other evidence used to support this project included expert
opinion offered by the multidisciplinary working group, based
on findings from the literature
reviews and taken from a presentation on the subject of surgical smoke evacuation given at
AORNs 2007 Congress by Ball,
DAlessandro, and Dennis. While
expert opinion provides less powerful evidence than a research
article, its still considered a legitimate resource by EBP authorities
Melnyk and Fineout-Overholt.12
FROM RECOMMENDATION TO
IMPLEMENTATION

Based on our findings, the perioperative multidisciplinary practice committee recommended

that the hospital develop a policy
on surgical smoke evacuation.
This recommendation helped
steer conversations toward how
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55

Table 1. Committees Involved in the Smoke Evacuation Project

Committee name

Membership

Role in project

Operating room (OR)

governance committee

Evaluated recommendation from the

multidisciplinary group
Provided initial approval for the project
Approved the policy

Perioperative multidisciplinary
practice committee

Surgeons
Anesthesiologists
Perioperative nurses

Provided feedback on project structure,

plans for implementation, and plans for
evaluation

OR practice committee

Director of perioperative nursing

OR staff nurses
Surgical technicians

Generated ideas for shaping the OR

smoke evacuation policy and implementing the multidisciplinary group recommendation
Developed the policy on surgical smoke
evacuation
Created an educational presentation for
staff on surgical smoke

OR products evaluation
committee

OR business manager
Perioperative nurses

Researched and selected smoke

evacuation products
Planned educational in-service for product
rollout
Managed product rollout

OR measurement committee

Collect data on smoke evacuation use

through retrospective chart review
(ongoing)

Surgical executive committee

Surgical chiefs
Anesthesiologist-in-chief

Surgeon-in-chief
Perioperative medical director
Anesthesiologist-in-chief
Perioperative division chief
Senior vice president of patient care services
Perioperative nursing director
OR business manager
Director of finance for patient care services
Representative from the hospitals revenue and
financial management office

Perioperative nurses
Cardiac profusionist
Central processing department manager
OR nurse manager

we were going to accomplish

smoke evacuation in our ORs,
as opposed to why it was
important to do so, when we
presented the project to the
multiple committees within the
hospitals shared governance
structure. Membership and roles
of the hospitals shared governance structure for this project
are detailed in Table 1. (For more
on the concept of shared governance, see the first article in this
series, Shared Governance Supports Evidence-Based Practice,
November 2009.) When initiating
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Provided information about the smoke

evaluation policy

a change in practice, sharing such

information with the committees likely to be involved and
affected in the change promotes
an understanding of the reasons
behind the change, provides opportunities to enlist the support
of the stakeholders (in this case,
the surgical chiefs, the OR nurse
managers, and the perioperative
nursing director), gives the people involved a chance to ask questions; and provides a venue for
open discussion.
The OR products committee
was charged with searching

for the best smoke evacuation

products for Childrens Hospital
Boston. We needed a system that
would evacuate and filter smoke
from the surgical field without
interfering with the surgeons fine
motor movements or disrupting
either visualization of the surgical
field or communication in the
OR. Furthermore, it had to perform well at all three Childrens
Hospital Boston OR sites, each
of which has slightly different
engineering requirements.
Once suitable equipment was
identified for the various sites,
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the OR practice committee met

to discuss the pros and cons of
mandating smoke evacuation for
every operation. It was decided
that such a mandate was unnecessary because some surgery
produces a minimal amount of
smoke. Therefore, we developed a
policy that gives any nurse, surgical technician, anesthesiologist,
or surgeon the authority to request that smoke evacuation be
part of any surgical procedure,
at any time. This policy was
approved by the perioperative
nursing director and by the OR
governance committee.
Become NASTI (Nurses
Advocating Smoke-free Theatres
Immediately),23 a Web site sponsored by AMT Electrosurgery,
features smoke evacuation policies
in use at four Canadian hospitals.
These models and advice provided by the sites expert helped
us in the development, structure,
and wording of our policy.
A one-hour in-service training
was provided for OR nurses and
surgical technicians on the hazards of surgical smoke exposure,
the hospital policy, and the operation of the smoke evacuation
equipment. Anesthesiologists and
surgeons were also given this information. To give staff an opportunity to examine the smoke
evacuation equipment, it was set
up in a high-traffic hallway between the OR locker rooms and
the OR for two weeks prior to
policy implementation in the
spring of 2009.
EVALUATING OUR EFFORTS

I met with both the perioperative multidisciplinary practice

and OR governance committees
to discuss how to evaluate the
project after implementation. We
determined that measuring the
density of smoke particles in OR
air was beyond the scope of our
project. Ultimately, we agreed to
collect data on smoke evacuation
ajn@wolterskluwer.com

use, by means of an informal retrospective chart review, because

use is documented in the intraoperative nursing record and the
data could reveal whether practice was actually changing.
The OR measurement committee began collecting the data
three months after implementation and will continue to collect
them on a quarterly basis until
we achieve consistent smoke
evacuation practices. The data
revealed that within the first quarter after implementation, smoke
evacuation was used most frequently during laparoscopic gynecologic surgery and inconsistently
during other laparoscopic surgery, spinal fusions, and orthopedic surgery. It was used only
occasionally by the plastic surgery, otolaryngology, genitourinary, and cardiac surgery services.
At the next OR equipment education session, I plan to set up
and demonstrate smoke evacuation equipment. The OR measurement committee plans to
begin collecting data again the
month following that reeducation.
The goal of such reeducation
efforts is to encourage surgical
staff to use smoke evacuation
equipment during all procedures
that can be expected to generate
significant smoke.
PROJECT PLANNING AND RESOURCE
COMMITMENT

A large project like this can take

several years to complete, so seeing it through takes persistence
and dedication. In my case, over
the past two years, this project
took me away from direct
patient care for roughly eight
hours a month. Planning time
for meetings and project work
required me to be in close contact
with my OR nurse manger, who
assigns project time based on
staff levels and the intensity of the
OR schedule. A number of OR
nurses are involved with projects

that compete for time and resources within the perioperative

program, so it was important for
me to keep the nurse manager
apprised of the projects status and
foreseeable time requirements.
Project timelines are affected
not only by individuals workloads, but also by the needs and
goals of the institution, which
often change over time. Projects
that have greater numbers of

Mandating smoke evacuation

was unnecessary because some
surgery produces a minimal
amount of smoke.

people invested in the outcome

have an easier time maintaining
their place on the organizations
list of priorities. Regardless of the
number of stakeholders, however, its not uncommon to have
to reenlist supporters from time
to time.
Although you cant write flexibility into your project plan, you
are certain to need it. Leaving
some questions unanswered at
the start of the project can help.
For example, at the start of this
project, I envisioned an institutional policy that would specify
the types of surgical procedures
requiring smoke evacuation. The
project, however, went in another
direction. While attending an OR
nursing practice committee meeting, I realized that we didnt have
to define the procedures that
required smoke evacuation, but
needed, rather, to focus our efforts
on educating staff on the dangers
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57

of exposure to surgical smoke,

thereby empowering them to
protect themselves. This enabled
me to lead conversations in a
more productive direction.
SUGGESTIONS FOR SUCCESS

It can be very helpful to find

someone in your organization
who has completed a project of
roughly the same scale as the one
youre planning. This person can
act as a mentor, providing suggestions about which stakeholders to include in project planning
and the leadership thats necessary to support the project. Finally, if your project requires
in-service time or the purchase of
new equipment or involves other
costs, its important to discuss
these investments with those who
make financial decisions on your
unit and to demonstrate that
your project is in line with institutional and unit goals.
In our case, leaders with institutional power included the nursing director for the perioperative
program, the director of nursing
for the satellites, the OR business
manager, and anesthesiologists
and surgeons in leadership positions within their departments.
Expert support is also essential in
moving projects forward. In this
case, such support came from the
small multidisciplinary working
group established at the outset.
The dedication and persistence
of the nurses involved in this project moved it from conception
through implementation. Nurses
who spend the majority of their
time in direct patient care can
often visualize new ways to improve patient care and working
conditions. By attending educational conferences, they can gain
the skills to effect constructive
change and, with appropriate
support, can learn how to investigate best practices and positively
transform their working environment.
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Vol. 110, No. 1

Ashley W. G. Waddell is a staff nurse

level III at Childrens Hospital Boston.
Contact author: ashley.waddell@
childrens.harvard.edu. The project
described in this article was inspired by
a presentation given by Kay Ball,
Maryann DAlessandro, and Vangie
Dennis at the 2007 AORN Congress. In
presentation materials, Ms. Ball disclosed
an affiliation with K & D Medical Inc.
She is currently the featured expert on
the Become NASTI Web site, which is
sponsored by AMT Electrosurgery.
During this project, Ms. Ball and the
Become NASTI Web site provided
Childrens Hospital Boston with guidance regarding smoke evacuation policy
development.

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ajnonline.com