Evidence Based Practice and Applied Nursing Research
C361
Task Two
A. While working in the operating room there are many processes, patient care, and or procedures that we do and do because that is how it has always been done. There are many policies to support why things are done certain ways. If there isn’t a policy in place, we fall back to AORN’s Perioperative Standards and Recommended Practices. We use what is called electrocautery units when performing surgical procedures. These units cut and coagulate thru tissue and decrease bleeding by coagulating small vessels as it dissects. A grounding pad is placed on the patient to complete the circuit to avoid any unnecessary burns for the patient, then the grounding cord is plugged into the unit and the hand piece is also plugged into the unit. The unit is then set to the desired coagulating numbers the surgeon prefers.
A1 Based on the evidence that I have gathered from various sources, I believe the process of using the electrocautery for surgery needs to be changed. While gathering data, the data suggests that the smoke plume that is given off when the tissue is cauterized is unhealthy to staff and patients. One of the chemicals that have been found in the electrocautery smoke plume is Benzene. Benzene, is a chemical that has been noted to be a trigger for leukemia. Other harmful chemicals are, hydrogen cyanide, formaldehyde, bioaerosols. One study suggests that after analyzing the plume from an electorcautery that the smoke staff members were inhaling was equivalent to smoking 6-7 cigarettes a day. . There is equipment available that will connect to the hand piece, a smoke evacuator, that is attached to the hand piece, that is less than 2 inches away from the smoke plume and this will eliminate the smoke plume, thus decreasing harm to staff and patients.
A2a After much discussion with the current nursing managers, who have worked in my unit for over 30 years, and I myself for over 20 could not find a policy for our surgical unit or the hospital for that matter on electrocautery units usage. There isn’t a director for the area. The nurse manager said that when we do not have a policy, we use the AORN Perioperative Standards and Recommended Practices.
A2b The decision makers’ rationale for supporting the current process is that it they have been going by the AORN Perioperative Standards and Recommended Practices, but they also admitted to not reading all of the AORN Perioperative Standards and Recommended Practices and what it says about the smoke plume from the electrocautery units in the newer addition. The decision maker said this is how it has been done since they were here and haven’t had a problem with it.
A2c The decision maker implemented this current process because that is how it was done prior to their arrival and they haven’t seen any reason to change the way it is performed.
A3 With the evidence that I have found with the research that has been gathered, I suggest that a smoke evacuator that has been made to use with the electrocautery pencils be used to eliminate the hazardous smoke plume that is given off when cauterizing a patients tissue during procedures. This will keep the plume from the staff and have a clearer surgical site for the surgeon to see. The smoke plume has been analyzed in more than one study and is suggested that some may contain carcinogenic such as benzene, ethyl benzene, styrene, toluene, heptene, and methylpropene. brief exposures to Benzene has been known to cause nausea and serve headaches, while long-term exposure can lead to disorders of the hematopoietic system.
A3a The following are the credible sources that are very relevant that support my suggested change in practice in the operating room. They are:
ConMed Electrosurgery. (2012). Avoiding the Hazards of Surgical Smoke. Aurora: Pfiedler Enterprises.
Conner, R. (2014). Recommended Practices for Electrosurgery. In AORN, Perioperative Standards and Recommended Practices (p. 804). AORN,Inc.
FITZGERALD, J., MALIK, M., & AHMED. (2012). A single-blind controlled study of electrocautery and ultrasonic scalpel smoke plumes in laparoscopic surgery. Surgical Endoscopy, 337-342.
Gapinski, K. (2015, February). The Hazards of Surgical Smoke. Retrieved from Outpatient surgery : http://www.outpatientsurgery.net/surgical-facility-administration/personal-safety/the-hazards-of-surgical-smoke–02-15
NIOSH. (2014, June 6). Control of Smoke From Laser/Electric Surgical Procedures. Retrieved from CDC: http://www.cdc.gov/niosh/docs/hazardcontrol/hc11.html
Ramona Conner, R. M. (2011). Perioperative Standards and Recommended Practices. AORN.
Syrus Karsai, G. D. (2012, August). “Smoking guns”: Hazards generated by last and electocautery smoke. Retrieved from Western Governors Library: https://wgu.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=mdc&AN=22747881&site=eds-live&scope=site
Tregoning, C. (2015). Risks of surgical smoke exposure. Occupational Health, 27-30.
Ulmer, B. R. (2014, October). How Dangerous is Surgical Smoke. Retrieved from Outpatient Surgery Magazine: http://magazine.outpatientsurgery.net/i/386326-managers-guide-to-staff-patient-safety-october-2014
A4 The implications of my recommendation for the change in our process of using the electrocautery unit will have little clinical changes to the patient due to the fact that once the surgeon begins to use the electrocautery unit, the patient has already been intubated by anesthesia. When doing this, the patient has a tube placed into his mouth, down thru his or her trachea to the top of the lungs. The patient will then be inhaling the oxygen that is given to them thru the machine provided by the nurse anesthetist, not the room air. The cost may go up to the patient due to the added piece of equipment that will be used to help control the hazardous toxins that are released into the air.
A5 The implications that could result from my recommended changes is a trial of different smoke evacuators that are on the market right now. trialing different vendors and getting quotes from various vendors would be a huge step, then implement the new process. Cost would be a concern, as it always is. With purchasing, for the entire hospital, we would be able to contain costs so as it would not be a large increase to the patient. With the implantation of the new process, I believe it would increase the operating rooms staff overall health, short term and long term. With using the new smoke evacuator, you would eliminate the hazardous toxins in the air that the staff breaths and give the surgeon a clearer surgical field to work thru.
A6 First step for this process is to get the education staff on board. Show them the research regarding the hazardous toxins that the staff breaths in every day and what the ramifications could be if we do not address the information we have now learned. Secondly, we would need to set down with purchasing to look at the various vendors and see all the tools available on the market to eliminate the hazardous plume in the operating room. Thirdly, and the most important, would be to involve the surgeons. Have all the different vendors with their sales person in the operating room suite so the surgeons could have their questions answered right on the spot as they are trialing the new devices. That will be the hardest area, to get the surgeons to trial the devices and implement change. With education staff on board, they can help comply educate the staff and the surgeons on my findings.
B1 There are several barriers when applying this research into processes and procedures into my current operating room setting. When analyzing this research, it is not clear how long the procedures were, and where in the operating room the air was tested. The laparoscopic procedures were controlled and contained. Mastectomies were discussed . However, open spinal surgery cases and open exploratory laparotomy surgical procedure cases not discussed to name a few procedures. Short surgical cases would need to be analyzed to get an idea of exposure as well. Our own audit and analysis would have to be performed. Cost is a large barrier. In an era where everything you do in the medical field is looked at, then analyzed to streamline and cut costs, cost is a factor, thus a barrier. Another barrier would be the surgeons. Surgeons do not like change, they are set in their ways and do not care to be told what they need to use to perform their surgeries. This would be a very large barrier to overcome, and probably the most difficult.
B2 To look at the cost for implementations of this process would be to look at the market and the various companies and see what different hand pieces and devices are available to address the electrocautery smoke plume issue. Then, once this is established, look into specific pieces and see the breakdown in cost. Examples would be to see the price difference if buying in a bulk, or once a month, every three months, or just when needed. Secondly, see if the company will supply the neptune suctions evacuators that are needed to accommodate the smoke plume for all the operating rooms at no cost to our facility. Once we work with these vendors and get the best of three items from three different vendors on price and performance, the next strategy to overcome, in my opinion, would be the surgeons. They are the biggest barrier, and getting them involved would be the only way to get them on board. Bring the three different vendors into the operating suites on three different days or even weeks and actually have them in the operating rooms with the surgeons to trial the various devices and answer the surgeons questions regarding their equipment. This way, we can assess the situation and see which devices the surgeons prefer, and see which piece of equipment performs the best and suites their needs.
B3 To implement my recommended process bases on my research findings is to first write a policy for the operating room. Secondly, involve the nurse educator so the staff can be educated on the policy change, the reason for the policy change and to teach them the proper way to hook up the equipment and how to trouble shoot the equipment when problems arise. Next, the surgeons need to be educated and informed as well to the policy change and the reasoning behind be the changes in the policy ( the safety of the staff AND themselves). Educate the surgeons on the Benzene numbers and the other carcinogenic smoke that is released into the operating room suite. In the policy, we would state what surgical procedures the evacuators would be used on due to the research that has been found on the dangers of electorcautery smoke plume. Lastly, we would work together with staff, vendors and surgeons and set a go live date. We would reevaluate the policy and process after three months and implement any needed changes that need to be addressed.
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