Canadian Occupational Safety

August/September 2016 19 you have other safety issues now." Fortunately, technology is always evolving to take into consideration the factors that would improve com- pliance, added Khotar. For example, a device introduced last year by a com- pany in the United States offers the surgeon three ergonomic use options so the ESU pencil is comfortable and adapts to his personal preference. Noise level is always something that needs to be taken into consideration when selecting a smoke evacuation system. "The sound of the suction is the equivalent of listening to your vacuum going. In some systems, the vacuum is going on all the time; in others it's instigated by the activation of the cautery pen itself, so one directly cor- relates to the other. It's not on all the time, it's intermittent based on the use of the cautery," says Pottery. A central smoke evacuation system is another option for eliminating plume from the OR. This system is permanently installed and a capture device evacuates the smoke through a fi lter and into piping that exhausts outside the building. These systems are generally quieter than their portable counterparts and can be activated with a foot pedal or automatically. The updated CSA medical gas pipe- line system standard is coming in 2017 and will require all new hospitals — or renovated ones — in Canada to be built with a central pipeline system for plume scavenging, says Hunt. Disposable endoscopic or laparo- scopic smoke evacuators are also an option for minimally invasive surgical procedures. These single-use devices allow for better visibility during surgery. Medical vacuums, which are used to aspirate fl uids and secretions in the OR, should not be used for smoke evacuation as they do not have a fi lter. Unfortunately, some hospitals are still using this method, which was a stop-gap solution in ORs many years ago before smoke evacuation systems were available. Taylor recalls visiting a hospital in New Brunswick in the early 2000s where the medical vacuums were being used to eliminate surgical plume. Eventually, the wall suction was not working properly and the nurses investigated the cause. "They actually cut the yellow tubing that went from the regulator into the port in the wall and they said all this brown gluck came pouring out. They were just grossed out and (they said) 'That's when we realized we should not be using the wall suction,'" says Taylor. "It's a good place for bacteria to grow, so you can end up with sick building syndrome and you cannot clean these pipes." When determining what type of smoke evacuation system is right for your OR, there are a few things to keep in mind. "The more automatic it is the better, the closer to the surgical site the better, the more integrated the better, the more intuitive the better, the quieter the better," says Hunt. It's also a good idea to have a unit with an adjustable air fl ow. For exam- ple, a breast reduction will need 800 litres per minute of fl ow (LPM) while a laparoscopic surgery will need 8 LPM. "You need a very adaptable, ver- satile system that can generate small fl ows and large fl ows and everything in between," says Hunt. "You need to cover a broad range and be able to do it very effectively." To get buy-in for improved smoke evacuation systems, health and safety professionals can always crunch the numbers to show how it can impact the bottom line. "A typical hospital-acquired infec- tion in Canada is assumed to be $20,000 to treat and a surgical site infection can be double that. So, if you are capturing the smoke, that helps to reduce, in particular, surgical site infections which could be up to $40,000 each. Saving one infection is three times the cost of a machine," says Hunt. Having a physician champion is a great asset as well, says Taylor. When portable smoke evacuators were fi rst installed in St. Joseph's in the late 1980s, there was a surgeon who threw his support behind them. "He loved them. He said, 'I don't want to breathe that stuff in, it reeks. I can smell it when I walk out of the OR for a day,'" recalls Taylor. "If his resi- dents didn't use the plume evacuator, oh they got a real dressing down, so he was there making sure our physicians used it. And if we didn't have enough, he made sure it was in the budget for us to get more." Having a hospital with a strong safety culture certainly helps get updated systems in place, such as at St. Paul's, which sees a smoke evacua- tor as a basic work tool. "We have a department that stays well informed… and we are very con- nected and concerned with standards of practice," says Khotar. "We have a defi ned OR safety culture and people are not afraid to speak up." EDUCATE WORKERS All workers who go into the operating room need to be educated on what's in the plume, why it's bad for them and how to prevent it, says Taylor. Most hospitals set aside one hour per week for in-servicing, which pro- vides a great opportunity to educate workers on this hazard. There are also e-learning modules that hospitals have developed on surgical smoke. "There is no reason why they can't put something like that (in place) and have it be a mandatory thing on an annual basis like they do for fi re safety," says Taylor. "It's still safety for the staff and they need it." However, nearly one-half of work- ers exposed to surgical smoke have never received training on its hazards, according to a study from the National Institute of Occupational Safety and Health (NIOSH) in the United States. Workers also need instructions on how to keep the equipment in good working order. It's important for all workers to understand that a surgical mask does not provide protection from surgical smoke. A surgical mask's main purpose is to provide droplet protection. It generally fi lters particles to about 5 micrometres in size, while a laser mask fi lters to 0.1 micrometres, neither of which protect from viral particles, which can be much smaller than 0.1 micrometres. N95 respirators do not provide ade- quate protection either. "People wear masks and they think it gives them protection from plume but it's a false sense of security," says Taylor. "The rating for an N95 mask is that it fi lters out 95 per cent of par- ticulate matter 0.3 micrometre and larger… Anything smaller than that and you can breathe it right in. And they don't protect you from any of the chemicals, such as toluene, benzene or formaldehyde." The only way to really protect work- ers is to gather plume at the source by implementing smoke evacuation systems. However, only one-half of employees in the NIOSH survey said local exhaust ventilation was always used during laser surgery and 15 per cent reported it was always used during electrosurgery. Hospitals across the country need to get on board — and soon, says Taylor. "At this point, nurses and any of the staff that are in the OR are going to become a very limited resource because of the fact that budgets are so tight, and they need to keep this resource as healthy as possible," she says. "Bringing in these plume evacu- ators and ensuring they are used will help towards the goal of cutting down on sick time and making sure their staff is as safe as possible." Taylor. "It's a good place for bacteria to grow, so you can end up with sick building syndrome and you cannot clean these pipes." CHEMICALS IDENTIFIED WITHIN SURGICAL SMOKE Ace tonitrile Ace t ylene Acroloin Acr ylonitrile Alkyl benzene Benzaldehyde Benzene Benzonitrile Butadiene Butene 3-Butenenitrile Carbon monoxide Creosol 1-Decene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) Ethane Ethene Ethylene Ethyl benzene Ethynyl benzene Formaldehyde Furfural (aldehyde) Hexadecanoic acid Hydrogen cyanide Indole (amine) Isobutene Me thane 3-Me thyl butenal (aldehyde) 6-Me thyl indole (amine) 4-Me thyl phenol 2-Me thyl propanol (aldehyde) Me thyl pyrazine Phenol Propene 2-Propylene nitrile Pyridine Pyrrole (amine) St yrene Toluene (hydrocarbon) 1-Undecene (hydrocarbon) Xylene Source: Surgical Smoke – A Revie w of the Literature by William Barre t t and Shawn Garber 1-Decene (hydrocarbon) 1-Decene (hydrocarbon) 1-Decene (hydrocarbon) 1-Decene (hydrocarbon) 1-Decene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) 2,3-Dihydro indene (hydrocarbon) Ethylene Ethylene Ethylene Ethylene Ethyl benzene Ethyl benzene Ethyl benzene Ethyl benzene Ethyl benzene Ethynyl benzene Ethynyl benzene Ethynyl benzene Ethynyl benzene Ethynyl benzene Ethynyl benzene Ethynyl benzene Ethynyl benzene Formaldehyde Formaldehyde Formaldehyde Formaldehyde Formaldehyde Formaldehyde Formaldehyde Formaldehyde Formaldehyde Formaldehyde Formaldehyde Furfural (aldehyde) Furfural (aldehyde) Furfural (aldehyde) Furfural (aldehyde) Furfural (aldehyde) Furfural (aldehyde) Furfural (aldehyde) Furfural (aldehyde) Furfural (aldehyde) Furfural (aldehyde) Furfural (aldehyde) Furfural (aldehyde) Furfural (aldehyde) Furfural (aldehyde) Furfural (aldehyde) Furfural (aldehyde) Furfural (aldehyde) Furfural (aldehyde) Furfural (aldehyde) Hexadecanoic acid Hexadecanoic acid Hexadecanoic acid Hexadecanoic acid Hexadecanoic acid Hexadecanoic acid Hexadecanoic acid Hexadecanoic acid Hexadecanoic acid Hexadecanoic acid Hexadecanoic acid Hexadecanoic acid Hexadecanoic acid Hexadecanoic acid Hexadecanoic acid Hydrogen cyanide Hydrogen cyanide Hydrogen cyanide Hydrogen cyanide Hydrogen cyanide Hydrogen cyanide Hydrogen cyanide Hydrogen cyanide Hydrogen cyanide Hydrogen cyanide Hydrogen cyanide Hydrogen cyanide Hydrogen cyanide Hydrogen cyanide Hydrogen cyanide Indole (amine) Indole (amine) Indole (amine) Indole (amine) Indole (amine) Indole (amine) Indole (amine) Indole (amine) Indole (amine) Indole (amine) Indole (amine) Isobutene Isobutene Isobutene Isobutene Isobutene Isobutene Isobutene Isobutene Isobutene Isobutene Isobutene Me thane Me thane Me thane Me thane

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