Management of Surgical Smoke in the Perioperative Setting AORN Smoke Tool Kit 2013 Management of Surgical Smoke in the Perioperative Setting

AORN Smoke Tool Kit 2013 Thank You This Tool Kit was funded through the AORN Foundation and supported by ConMed Electrosurgery

AORN Smoke Tool Kit 2013 Overview and Goal Surgical smoke is hazardous and can negatively affect the health of surgical patients and the perioperative team members. The purpose of this activity is to discuss perioperative nursing care and recommended practices for operative and/or invasive procedures that have a potential to expose patients and the perioperative team to surgical smoke. The goal of this activity is to educate perioperative RNs about the hazards of surgical smoke and the associated nursing care to promote patient and worker safety. Presenter Notes: please read the overview and goal of the presentation to your audience.

AORN Smoke Tool Kit 2013 Objectives After completion of this continuing nursing education activity, the participant will be able to: Identify the hazardous contents of surgical smoke. Discuss recommendations for surgical smoke evacuation and control. Describe perioperative nursing care to minimize the hazards of surgical smoke. Presenter notes: please read these objectives to your audience.

Management of Surgical Smoke in the Perioperative Setting AORN Smoke Tool Kit 2013 Management of Surgical Smoke in the Perioperative Setting Presenter Notes: Let’s begin with the definition of surgical smoke and the potential hazards of surgical smoke.

What is Surgical Smoke/Plume? AORN Smoke Tool Kit 2013 What is Surgical Smoke/Plume? Smoke Plume or Smoke Aerosol is the vaporization of substances (i.e. tissue, fluid, blood) into a gaseous form and are the by-products of surgical instruments used to destroy tissue. Instruments: Lasers, Electrosurgery, Orthopedic, and Ultrasonics Devices. Chemical Mixes - may produce plume or aerosols What is Surgical Smoke? “Surgical smoke”, “surgical plume”, “plume”, or “smoke aerosol”, you may hear all of these terms, and this can be described as the vaporization of substances (i.e. tissue, fluid, blood) into a gaseous form and they are the by-products of surgical instruments used to destroy tissue. Surgical smoke can be generated by a variety of energy-producing equipment including the use of lasers, ESU units, orthopedic devices, and ultrasonic devices. Chemicals mixed in the perioperative setting may also produce plume and aerosols.

What generates Surgical Smoke/Plume? AORN Smoke Tool Kit 2013 What generates Surgical Smoke/Plume? Laser Powered Surgical Equipment ESU unit Ultrasonic equipment There are many energy devices used in surgery today that can generate surgical smoke. Electrosurgery is used in over 85% of the 24 million procedures performed annually. Lasers, used 5% of the time, are the second most common high-energy devices used in surgery. Powered surgical instruments are often overlooked as a source of air borne contamination, but they are used in procedures where there are often copious amounts of blood and tissue spray. These are some examples of the type of medical equipment used in the perioperative setting that can generate surgical smoke.

Content of Surgical Smoke AORN Smoke Tool Kit 2013 Content of Surgical Smoke Gaseous toxic compounds Bio-aerosols Dead and live cellular material (including blood fragments) Viruses Carbonized tissue Bacteria As you see on the slide, surgical smoke can contain gaseous toxic compounds, bio-aerosols, live and dead cellular material including virus and bacteria.

Composition of Surgical Smoke AORN Smoke Tool Kit 2013 Composition of Surgical Smoke 150 different chemicals identified in surgical smoke (Pierce, et al. 2011) Surgical smoke produced by the CO 2 laser is consistent with other energy-producing devices that generate surgical smoke. This smoke is comprised of 95% water and 5% of particulate, gases, and microorganisms. Roughly 150 different chemicals including benzene, toluene, formaldehyde, cyanide, and aerolin have been identified in surgical smoke.

Water Vapor Smoke plume and aerosols contain 95% water vapor AORN Smoke Tool Kit 2013 Water Vapor Smoke plume and aerosols contain 95% water vapor Water vapor is itself not harmful, but acts as a carrier We know water vapor is not in itself harmful, yet it can act as a carrier for particulates of surgical smoke.

So.. is Surgical Smoke Harmful? AORN Smoke Tool Kit 2013 So.. is Surgical Smoke Harmful? Past Misconceptions: “Surgical Smoke is not Hazardous” “Surgical Smoke is Sterile” Surgical Smoke is Hazardous! In the past, there may have been misconceptions about laser plume in that surgical smoke was not a health hazard as many thought that when tissue was vaporized with the laser, then the smoke was sterile. This is not true! We know now that exposure to surgical smoke can be harmful to patients as well as perioperative team members.

Inhalation and Exposure Potential to Harm AORN Smoke Tool Kit 2013 Inhalation and Exposure Potential to Harm Patients Perioperative Staff Members Others (anyone in the procedure) There’s potential harm with inhalation and exposure to surgical smoke to the patient and the surgical staff from the smoke content. We know the smoke can include carbonized tissue, blood, and/or virus and bacteria. We also need to think about everyone in the operating room during a procedure when the energy-producing devices are generating surgical smoke. Everyone should be protected!

Viable/non-viable virus or bacteria AORN Smoke Tool Kit 2013 Hazards Odor Particulate Matter Viable/non-viable virus or bacteria There are three main hazards associated with surgical smoke. These include the odor, particulate matter size, and viability. If you smell the distinctive odor of surgical smoke, then you are being exposed to the potential hazards. The particulate matter can cause respiratory problems and can have the ability to clog suction lines. Surgical smoke may also contain viable organisms, such as virus or bacterial contamination. Because of these hazards, smoke evacuation practices must be employed.

Inhaling Surgical Smoke AORN Smoke Tool Kit 2013 Inhaling Surgical Smoke Using the CO2 laser on one gram of tissue is like inhaling the smoke from three cigarettes in 15 minutes. Using ESU on one gram of tissue is like inhaling smoke from six cigarettes in 15 minutes. (Tomita et al., 1989) Dr. Tomita and his colleagues conducted a classic study in 1989 that is still being referenced today since it makes such a powerful point. This study compared the inhalation of smoke from vaporized human tissue to the smoke created by cigarettes. They determined that inhaling the plume produced when using the CO2 laser to vaporize one gram of tissue (which is not a lot of tissue) is like smoking three unfiltered cigarettes in 15 minutes.  Inhaling the smoke produced when using an electrosurgery device to vaporize one gram of tissue is like smoking six unfiltered cigarettes in 15 minutes. This study demonstrates that smoke generated by using an electrosurgery device may be more hazardous than that produced by a laser. Let’s just agree that these plumes are very similar and both need to be evacuated completely. When laser technology was first introduced, classes were conducted to educate healthcare providers on laser practices and hazards, such as surgical smoke. The laser went hand-in-hand with the smoke evacuator. Today, compliance with smoke evacuation using the laser is much greater than when electrosurgical energy is used. Therefore, we must focus on the realization that electrosurgical smoke can be just as hazardous as laser plume and must be evacuated consistently.

150 Chemical constituents of plume AORN Smoke Tool Kit 2013 Toxic Gases 150 Chemical constituents of plume Chemical Constituents Acrolein Benzene Carbon Monoxide Formaldehyde Hydrogen cyanide Methane Toluene Polycyclic aromatic hydrocarbons (PAH) Some Are Carcinogenic! (Pierce, 2011) Toxic substances have been identified in surgical smoke. Some of these substances are carcinogenic. When tissue is pyrolyzed (pyrolysis: a chemical change brought about by the action of heat) with energy devices (such as electrosurgery or laser), toxic gases are produced that produce an offensive odor. Over 150 different chemical constituents have been identified in surgical smoke. Some of these gases are carcinogenic. These gases exist in trace amounts in surgical smoke but we inhale them everyday which can create an accumulative effect. There’s a need to determine the impact of cumulative effects of the toxic gases in surgical smoke. There is a lot of research about the inhalation of different individual chemicals. Benezene, for example, has been shown to be a possible trigger for leukemia. Many of these chemicals are very toxic effects on the human body.

Chemical Effect Soft contact lenses can absorb toxic gases AORN Smoke Tool Kit 2013 Chemical Effect Soft contact lenses can absorb toxic gases produced by surgical smoke. Recommendation made by an OSHA safety violation not related to plume, 1990 Soft contact lenses can absorb the toxic gases produced by surgical smoke. They can become cloudy and uncomfortable. OSHA made the recommendation that soft contact lenses should not be worn if surgical smoke isn’t evacuated appropriately during surgical procedures. OSHA made this recommendation after realizing this concern during a safety violation citation that wasn’t even related to compliance with surgical smoke evacuation recommendations.

Particulate Matter Carbonized tissue Blood AORN Smoke Tool Kit 2013 Particulate Matter Carbonized tissue Blood Intact virus and bacteria (HIV, HPV, Hepatitis) Along with the toxic gases that create the surgical smoke odor, tiny particles are generated within surgical smoke that can easily be inhaled. These particles can consist of carbonized tissue, blood fragments, and possibly intact virus or bacteria.

Size of Particulate Matter AORN Smoke Tool Kit 2013 Size of Particulate Matter 77% of Surgical Smoke Particles are less than 1.1 microns In a classic study in 1975, Dr. Mihashi and his colleagues noted that 77% of the particles within surgical smoke are less than 1.1 microns in size. Inhaling particles of this size can easily be deposited in the alveoli, the gas exchange regions of the lungs, which can lead to respiratory problems. Also the circulating blood will pick up whatever is in the alveoli and circulate it randomly throughout the body.

Virus Sizes Human Immunodeficiency Virus = 0.15 micron AORN Smoke Tool Kit 2013 Virus Sizes Human Immunodeficiency Virus = 0.15 micron Human Pappillomavirus = 0.055 micron Hepatitis B = 0.042 micron Others Tobacco Smoke = 0.1-3.0 micron Surgical Smoke = 0.1-5.0 micron Bacteria = 0.3-15.0 micron Lung Damaging Dust = 0.5-5.0 micron Smallest Visible Particle = 20 micron The particulate matter within surgical smoke have the potential to carry minute viral particles. Typical virus particles and the comparison to other particles are listed above. Lung damaging dust is among the largest particles—with virus and bacteria particles being much smaller. Remember Dr. Mihashi study noted that 77% of the particles in surgical smoke are 1.1 microns in size and smaller. A standard surgical mask filters 5 micron in size particles and are ineffective when used during procedures not employing proper smoke evacuation practices.

Particle Distribution (Nicola, et al. 2002) AORN Smoke Tool Kit 2013 Particle Distribution (Nicola, et al. 2002) Smoke is evenly distributed throughout the operating room Smoke particles can travel about 40 mph When ESU is activated, the concentration of the particles can rise from 60,000 particles/cubic feet to over 1 million particles/cubic feet It takes 20 min after the activation of the ESU for the concentration will return to the baseline level. A study reported by Nicola, et al. in 2002 found that surgical smoke is evenly distributed throughout the operating room. Smoke particles can travel about 40 mph. This research demonstrated that when the ESU is activated, the concentration of the particles can rise from 60,000 particles/cubic feet to over 1 million particles/cubic feet. After activating the ESU and generating surgical smoke, the concentration of particles returns to the baseline level after about 20 minutes. Adding to this concern is the fact that every surgical suite must have an air exchange of at least 15 times per hour; therefore, surgical smoke particles get caught up on these air currents and evenly distribute them throughout the OR.

Air Pollution and Women AORN Smoke Tool Kit 2013 Air Pollution and Women Results: Long time exposure to fine particulate air pollution associated with incidence of CV disease & death among postmenopausal women. Research has also noted that long time exposure to fine particulate air pollution is associated with the increased incidence of cardiovascular disease and death among postmenopausal women. Since the average age of a perioperative RN is around 48 years old, this study can be a major concern for those women inhaling surgical smoke on a regular basis. Miller et al. (2007). Long-term exposure to air pollution and incidence of cardiovascular events in women. N Engl J Med 356:447-58.

Case Report 44-year old laser physician developed AORN Smoke Tool Kit 2013 Case Report 44-year old laser physician developed laryngeal papillomatosis Biopsy identified the same virus type as anogenital condyloma Hallmo, et al (1991) The potential for the transmission of viable organisms within surgical smoke is great. Since research that would purposely expose humans to the dangers of surgical smoke are unethical, we need to depend on anecdotal reports and animal studies about the potential for transmission of disease from surgical smoke inhalation. In a study by Hallmo, et al (1991) a 44-year old surgeon, who rarely evacuated the surgical smoke when using the laser to vaporize condyloma, developed laryngeal papillomatosis. When his lesions were biopsied, the same type of virus was identified that is found in anogenital warts, which is not normally found in the throat. This report, along with other anecdotal reports continue to support that best practice is to evacuate and filter surgical smoke.

Surgical Smoke: It’s a Universal Concern AORN Smoke Tool Kit 2013 Surgical Smoke: It’s a Universal Concern Surgical smoke evacuation guidelines: Compliance among perioperative nurses. (Ball, 2010) Chemical composition of gases surgeons are exposed to during endoscopic urological resections. (Weston et al. 2009) Surgical smoke: a concern for infection control practitioners. (Ortolano, 2009) Surgical smoke - a health hazard in the operating theatre: a study to quantify exposure and a survey of the use of smoke extractor systems in UK plastic surgery units. (Hill et al. 2012) Occupational hazards facing orthopedic surgeons. (Lester et al. 2012), Becker’s ASC Review reprint of Understanding and Controlling the Hazards of Surgical Smoke (Novak et al March 28, 2011) Surgical smoke and the dermatologist. (Lewin et al Sept 2011) As you can see from recent literature, surgical smoke concerns are universal and impact all types of surgical services, in inpatient settings, ambulatory surgery settings and office-based settings. It’s also important to note that surgical smoke affects patients and health care workers.

Smoke Evacuation Compliance Study AORN Smoke Tool Kit 2013 Smoke Evacuation Compliance Study Surgical smoke compliance study 2009 To identify key indicators of compliance with surgical smoke evacuation recommendations Ball, K. (2010). A research study was conducted by Kay Ball, PhD, RN, CNOR, FAAN to identify the key indicators of compliance with smoke evacuation recommendations during electrosurgical procedures. A internet survey was sent to a random sample 4000 AORN members with 777 responding. The results of the survey appeared in the online AORN Journal (details of the study) in August 2010 while the implications for practice can be found in the printed AORN Journal, August 2010.

Compliance Model* Individual Innovativeness Characteristics (Perioperative nurse characteristics) Perceptions of Attributes (Nurses’ perceptions of smoke evacuation recommendations) Organization Innovativeness Characteristics (Organization’s characteristics) Age Education level Experience Knowledge Training Presence of respiratory problems Relative Advantage Compatibility Complexity Trialability Observability Barriers to practice Descriptors (locale, type) Size Complexity Formalization Interconnectedness Leadership support Barriers to practice This compliance model was designed by researcher Kay Ball based on Roger’s Diffusion of Innovations model, which explores how innovations are accepted into practice. This compliance model explored how smoke evacuation recommendations are accepted into practice. This model involves the individual nurse’s characteristics, his or her perceptions of the smoke evacuation recommendations, and the organization’s characteristics. All of these attributes and characteristics were analyzed against compliance with smoke evacuation recommendations. No compliance Full compliance Compliance with research-based smoke evacuation recommendations * Based on Roger’s Diffusion of Innovations model. Reprinted with permission from Kay Ball, PhD, RN, CNOR, FAAN.

Smoke Evacuation Compliance Study AORN Smoke Tool Kit 2013 Smoke Evacuation Compliance Study Key indicators of compliance: Education Leadership support Easy to follow policies Regular internal collaboration (Ball, K . 2010) Dr. Ball found the most significant key indicator of compliance with education. In other words, if nurses were educated about the hazards of surgical smoke exposure, then they would be more apt to comply with smoke evacuation recommendations. Also significant to compliance was having strong leadership support that supported smoke evacuation practices, having easy to follow policies on smoke evacuation, and promoting regular internal collaboration (physicians and nurses working together to ensure all smoke is evacuated).

Perioperative RN Survey AORN Smoke Tool Kit 2013 Perioperative RN Survey November 2010 Survey e-mailed to current, active members of AORN North American health care facilities 1,356 responses /10,000 email requests Compared findings from 2007 similar study Edwards & Reiman 2012 AORN Journal recently published Edwards and Reiman’s 2010 study of comparison of current and past surgical smoke practices.

Study Results Indicate: AORN Smoke Tool Kit 2013 Study Results Indicate: Use of the wall suction during laser procedures (excepting laser hair removal and LASIK) is similar to that for electrosurgery, electrocautery, diathermy (ES/EC/D), or ultrasonic scalpel procedures. Lower incidence of smoke evacuator use than wall suction use Smoke evacuator use rates have not changed significantly from 2007 to 2010 Indicate that few facilities routinely used effective respiratory protection for surgical smoke (Edwards & Reiman 2012) They found that there was an increased use of the wall suction line to evacuate plume while the overall compliance with smoke evacuation recommendations was still lacking. As you see in the survey results, more awareness of the hazards of exposure to surgical smoke, education, and communication is needed to promote compliance with best practices to avoid exposures to surgical smoke.

Patient Safety: Exposures to Surgical Smoke AORN Smoke Tool Kit 2013 Patient Safety: Exposures to Surgical Smoke How can the patient be protected from surgical smoke? Laparoscopic procedures present unique exposures to smoke to the patient. Let discuss surgical smoke exposures to the patients. How are we protecting them? During a laparoscopic procedure, the patient is exposed to surgical smoke if energy-based devices are used (electrosurgery, laser, ultrasonics) and the plume is not evacuated. This presents a unique set of problems associated with patient absorption of internally produced smoke.

Minimally Invasive Surgery (MIS) AORN Smoke Tool Kit 2013 Minimally Invasive Surgery (MIS)

Laparoscopic Surgical Procedures AORN Smoke Tool Kit 2013 Laparoscopic Surgical Procedures Levels of carboxyhemoglobin of patients who underwent laparoscopic procedures using laser were significantly elevated. (Ott, 1998) Carbon monoxide levels increase in the peritoneal cavity and exceed recommended exposure limits. (Beebe et al 1993) As smoke builds up inside the abdomen during laparoscopy, the smoke is absorbed through the patient’s peritoneal membrane. When the smoke is absorbed by red blood cells, an increase in carboxyhemoglobin and methemoglobin occurs. Both of these substances reduce or deplete the oxygen-carrying capacity of the red blood cell, which remains within the patient’s body throughout the life of the red blood cell. Carbon monoxide levels increase as well exposing both the patient (during the procedure) and the perioperative team (when the insufflated gas is released into the OR at the end of the case) to higher than recommended exposure limits.

MIS and Smoke Loss of Visibility of Surgical Field AORN Smoke Tool Kit 2013 MIS and Smoke Loss of Visibility of Surgical Field Potential to delay the procedure Health effects to Patient Health effects to Perioperative Staff When pneumoperitoneum is released into the OR without filtration Important to use a filtering device or a closed evacuation system There is also a real potential for smoke to interfere with the surgeon’s ability to see the surgical field and this may delay or prolong surgical procedures. Adjusting the gas flow rate and using instrumentation to remove smoke while the procedure is in progress will help maintain the pneumoperitoneum and the visibility of the surgical field. We have talked about the health effects to the patient. Remember also, when the pneumoperitoneum is released during or at the end of the procedure, a filtering device will help protect the perioperative team members from exposure to the surgical smoke. Also smoke evacuators designed to de-insufflate the abdomen using a closed system can be used.

Worker Safety: Exposures to Smoke/Plume AORN Smoke Tool Kit 2013 Worker Safety: Exposures to Smoke/Plume “Each year, an estimated 500,000 workers, including surgeons, nurses, anesthesiologists, and surgical technologists, are exposed to laser or electrosurgical smoke.” Laser/Electrosurgery Plume. Occupational Safety and Health Administration (OSHA) Quick Takes. United States Department of Labor http://www.osha.gov/SLTC/laserelectrosurgeryplume/index.html (accessed Dec 5, 2012) OSHA which is part of the US Department of Labor keeps statistics on worker exposures to laser and surgical smoke.

Health Effects Reported by Healthcare Workers AORN Smoke Tool Kit 2013 Health Effects Reported by Healthcare Workers Eye, nose, throat irritation Headaches Nausea, dizziness Runny nose Coughing Respiratory irritants Fatigue Skin irritation Allergies When surgical smoke is inhaled, there are definite symptoms such as nausea, dizziness, watery eyes, runny nose, headaches, fatigue, respiratory problems, skin irritation, and allergies. These symptoms can be minimized and even eliminated with proper smoke evacuation practices.

AORN Smoke Tool Kit 2013 Respiratory Problems Perioperative nurses have twice the incidence of many respiratory problems as compared to the general population. (Ball, 2010) Allergies Sinus infections/problems Asthma Bronchitis Ball (2010) reports in her research on compliance with smoke evacuation recommendations; perioperative nurses report twice the incidence of many respiratory problems as compared to the general population.

Healthcare and Regulatory Standards and Recommendations AORN Smoke Tool Kit 2013 Healthcare and Regulatory Standards and Recommendations AORN ANSI ECRI International Federation of Perioperative Nurses Joint Commission NIOSH/CDC OSHA There are several international and national organizations that address standards affecting patients and health care workers on the topic of exposure to hazardous materials and surgical smoke.

ANSI Standard 7.4 of Z136.3 - 2011 (Safe Use of Lasers in Healthcare) AORN Smoke Tool Kit 2013 ANSI Standard 7.4 of Z136.3 - 2011 (Safe Use of Lasers in Healthcare) Airborne Contaminants: Shall be controlled by the use of ventilation (ie., smoke evacuator). Respiratory protection for any residual plume escaping capture. Note: ESU produces the same type of airborne contaminants as lasers. The most recent version of the American National Standards Institute Z136.3 (2011) state that airborne contaminants from laser surgery SHALL be controlled. Also they note that the electrosurgical device produces the same type of airborne contaminants as lasers do. Many organizations and agencies are making their recommendations more powerful with changing the verb from “should” to “shall.” This is a more powerful word to help encourage compliance.

NIOSH/CDC: Ventilation AORN Smoke Tool Kit 2013 NIOSH/CDC: Ventilation Ventilation combination of general room and local exhaust ventilation (LEV). portable smoke evacuators room suction systems. The National Institute of Occupational Safety and Health (NIOSH) is part of the Centers for Disease Control and Prevention in the U. S. Department of Health and Human Services. NIOSH investigates potential occupational health risks and makes recommendations to OSHA. NIOSH has no regulatory or enforcement authority, but does conduct health hazard evaluations and issue health hazard alerts. The recommendations of NIOSH are referenced on the OSHA website on smoke evacuation. Following AORN’s 1996 smoke conference, at which NIOSH was represented, the strongest recommendation to date was issued. The NIOSH Hazard Control Alert on the Control of Smoke From Laser/Electric Surgical Procedures is one of most important documents available to healthcare professionals. It recommends evacuation and filtration of surgical smoke. The Hazard Control has remained on the NIOSH website since its development in 1996.

NIOSH/CDC: Work Practices AORN Smoke Tool Kit 2013 NIOSH/CDC: Work Practices The smoke evacuator or room suction hose nozzle inlet must be kept within 2 inches of the surgical site The smoke evacuator should be ON (activated) at all times when airborne particles are produced Follow Standard Precautions NIOSH/CDC recommend that: *The smoke evacuator or room suction hose nozzle inlet must be kept within 2 inches of the surgical site *The smoke evacuator should be ON (activated) at all times when plume is present *Follow Standard Precautions

Follow Standard Precautions at the completion of the Procedure AORN Smoke Tool Kit 2013 Follow Standard Precautions at the completion of the Procedure All smoke evacuator tubing, filters, and absorbers -considered infectious waste -disposed appropriately. New filters and tubing should be installed on the smoke evacuator for each procedure. Local Exhaust Ventilation systems -regularly inspected and maintained It is recommended that standard precautions be followed at the completion of the procedure. All tubing, filters, and absorbers should be considered as infectious waste and disposed of appropriately. New filters and tubing should be installed on the smoke evacuator for each procedure. LEV (local exhaust ventilation systems) such as smoke evacuators should be regularly inspected and maintained in good working order.

Employer MUST provide a safe workplace environment! AORN Smoke Tool Kit 2013 OSHA General Duty Clause: Employer MUST provide a safe workplace environment! The Occupational Safety and Health Administration (OSHA), General Duty clause states the employer must provide a safe work environment. Since employers must provide a safe work place environment, it’s logical that smoke evacuation devices must be provided and used so that staff members are not exposed to surgical smoke.

OSHA Respiratory Protection AORN Smoke Tool Kit 2013 OSHA Respiratory Protection Recognizes: Lasers and electrosurgical plume contains toxic, mutagenic, and carcinogenic elements Mandates and Identifies: Removal of atmospheric contaminants with acceptable engineering controls, local ventilation, including smoke evacuation systems OSHA’s respiratory protection recognizes that lasers and electrosurgical plume contains toxic, mutagenic, and carcinogenic elements. OSHA also mandates and identifies the removal of atmospheric contaminants with acceptable engineering controls, local ventilation, including smoke evacuation systems. In other words, OSHA supports the use of smoke evacuators to ensure a smoke-free environment in surgery.

ECRI Independent, nonprofit organization AORN Smoke Tool Kit 2013 ECRI Independent, nonprofit organization Researches the best approaches to improving the safety, quality, and cost-effectiveness of patient care Electrosurgery smoke is overlooked The spectral content of laser and ESU smoke is very similar https://www.ecri.org/ accessed 12/13/12 ECRI, formerly the Emergency Care Research Institute, a nonprofit agency in Plymouth Meeting, PA, recommends that it is prudent to evacuate surgical smoke, and that there is no difference between smoke produced by lasers and smoke produced by electrosurgery units. ECRI Health Devices: Laser Smoke Evacuators, 1990.

AORN Smoke Tool Kit 2013 Joint Commission The hospital minimizes risks associated with selecting, handling, storing, transporting, using, and disposing of hazardous gases and vapors. Note: Hazardous gases and vapors include, but are not limited to, glutaraldehyde, ethylene oxide, vapors generated while using cauterizing equipment and lasers, and gases such as nitrous oxide. Environment of care. In Comprehensive Accreditation Manual: CAMH for Hospitals. The Official Handbook. Oakbrook Terrace, IL Joint Commission; 2009: EC-6-EC-6. The Joint Commission also addresses standards about minimizing risks associated with exposure to vapors and hazardous gases and they include ESU and laser. The Joint Commission also works collaboratively with OSHA to ensure a safe workplace environment is maintained for workers.

International Federation of Perioperative Nurses AORN Smoke Tool Kit 2013 International Federation of Perioperative Nurses Position Statement Includes: Recognition of blood borne pathogens and potential for viral transmission Identification of smoke as a workplace safety hazard and requirement for compliance with IEC Face masks of 0.1 micron filtration worn according to infection control policy and procedure Use of standard precautions Use of LEV with ULPA filter Collection of smoke not > 2cm from evolution point Use of in-line filters when LEV not available The International Federation of Perioperative Nurses wrote a position statement to represent the global concern for the need to evacuate all surgical smoke. The Position Statement includes: Recognition of blood borne pathogens and potential for viral transmission; identification of smoke as a workplace safety hazard and requirement for compliance with IEC; face masks of 0.1µ filtration worn according to infection control policy and procedure; use of universal precautions; use of LEV with ULPA filter; collection of smoke not greater than 2cm from evolution point; and use of in-line filters when LEV is not available.

Surgical Plume Scavenging for Health Care AORN Smoke Tool Kit 2013 Canadian Standards Surgical Plume Scavenging for Health Care The First Dedicated Standard World Wide - MODEL Covers all plume from surgical & therapeutic devices Addresses all systems: dedicated, central, in-line, free standing “Will seek IEC and ISO for endorsement” Affects all provinces and practice settings Published early 2009 The Canadian Standards Association (CSA) is an organization that collaborates with, and sets standards for healthcare workers in Canada. The CSA has published in January 2009 provides specific and detailed standards on smoke evacuation which are very prescriptive on the need to evacuate and filter surgical smoke (CSA Z 305.07). These standards are being used as a model in many places throughout the world to write policies to encourage the evacuation of all surgical smoke.

AORN Electrosurgery Safety Laser Minimally Invasive Surgery (MIS) AORN Smoke Tool Kit 2013 AORN Electrosurgery Safety Laser Minimally Invasive Surgery (MIS) AORN Position Statement Surgical Smoke and Bio-Aerosols As you can see AORN has several recommended practices and a position statement that address surgical smoke. The recommended practices for ESU safety, Laser safety and Minimally Invasive Surgery all have recommendations that address surgical smoke and the concerns with surgical smoke.

AORN Recommended Practices AORN Smoke Tool Kit 2013 AORN Recommended Practices “Potential hazards associated with surgical smoke generated in the practice setting should be identified, and safe practices established.” Recommended practices for electrosurgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013:125-141. Recommended practices for laser safety in the perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013:143-156. Recommended practices for minimally invasive surgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013::157-184. As you see, the AORN recommended practices are consistent in the wording of the recommendations. These recommendations state, “Potential hazards associated with surgical smoke generated in the practice setting should be identified, and safe practices established.”

AORN Electrosurgery RP X AORN Smoke Tool Kit 2013 AORN Electrosurgery RP X “Evacuate smoke with a smoke evacuation system in open and laparoscopic procedures Use standard precautions and dispose of smoke evacuator filters, tubing and wands (considered as potentially infectious waste) Used smoke evacuator filters, tubing, and wands should be disposed of as potentially infectious waste following standard precautions” Recommended practices for electrosurgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013:125-141. In the electrosurgery Recommended Practice X states: “Evacuate smoke with a smoke evacuation system in open and laparoscopic procedures. Use standard precautions and dispose of smoke evacuator filters, tubing and wands (considered as potentially infectious waste). Used smoke evacuator filters, tubing, and wands should be disposed of as potentially infectious waste following standard precautions”

AORN Recommendations: Laser AORN Smoke Tool Kit 2013 AORN Recommendations: Laser RP. V “Potential hazards associated with surgical smoke generated in the laser practice setting should be identified and safe practices established.” Recommended practices for laser safety in the perioperative practice settings. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013:143-156. The laser RP also addresses exposure to surgical smoke. “Potential hazards associated with surgical smoke generated in the laser practice setting should be identified and safe practices established.”

AORN Recommendations Minimally Invasive Surgery (MIS) AORN Smoke Tool Kit 2013 AORN Recommendations Minimally Invasive Surgery (MIS) “IV.j.1. Surgical smoke should be removed by use of a smoke evacuation system in both open and laparoscopic procedures. IV.j.2. Surgical smoke should be evacuated and filtered during the laparoscopic procedure and at the end of the procedure when the pneumoperitoneum is released.” Recommended practices for minimally invasive surgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc;2013::157-184. It is important to note the MIS recommended practices address the use of a smoke evacuation system as well as the importance of filtering devices. In the Minimally Invasive Surgery Recommended Practice, surgical smoke is again addressed. “Surgical smoke should be removed by use of a smoke evacuation system in both open and laparoscopic procedure. Surgical smoke should be evacuated and filtered during the laparoscopic procedure and at the end of the procedure when the pneumoperitoneum is released.”

AORN Recognizes Surgical Smoke is Hazardous AORN Smoke Tool Kit 2013 AORN Recognizes Surgical Smoke is Hazardous Recommends Wear appropriate PPE Remove smoke with an evacuation system for open procedures and MIS procedures Place capture device close to the source of the smoke Use evacuation system according to manufacturer’s written instructions for use All of the AORN recommendations are consistent in their message. We have discussed some of these recommendations. AORN recommendations recognize the hazards of surgical smoke to patients and the perioperative team and discuss specific implementation methods to protect both patients and perioperative team members. For example, the recommendations state that surgical smoke is hazardous and appropriate PPE must be worn. Surgical smoke should be removed with an evacuation system for open procedures and MIS procedures. The capture device should be positioned as close as possible to the source of the smoke. And the smoke evacuator system should be used according to the manufacturer’s written instructions for use.

Smoke Evacuation in the Perioperative Setting AORN Smoke Tool Kit 2013 Smoke Evacuation in the Perioperative Setting Let’ s now discuss smoke evacuation and best practices to decrease patient and worker exposure to surgical smoke in the perioperative setting.

Smoke Evacuators- First Line of Defense AORN Smoke Tool Kit 2013 Smoke Evacuators- First Line of Defense Smoke evacuator systems: Larger amounts of plume In-line filters: Smaller amounts of plume Laparoscopic filtering devices Management of surgical smoke can be addressed using a variety of solutions. Small amounts of smoke can be handled with wall suction with an in-line ULPA filter. This filter protects the suction line from smoke particle contamination. For cases producing larger amounts of smoke, a dedicated smoke evacuator is needed. Laparoscopic smoke should be evacuated to protect patients from absorbing smoke.

Evaluating Smoke Evacuators AORN Smoke Tool Kit 2013 Evaluating Smoke Evacuators Many products Evaluate the features and benefits Selection A number of manufacturers make smoke evacuators. Healthcare facilities should carefully evaluate the features and benefits of the equipment and select the devices that most suits the needs of the practice area.

Characteristics Smoke Evacuation Systems AORN Smoke Tool Kit 2013 Characteristics Smoke Evacuation Systems Ease of use Quiet Foot pedal activation/automatic on-off Portability and access Indicators for filter changes Efficiency Cost These characteristics should be considered when evaluating a smoke evacuate system. Looking at these points will help to assure that the system selected is best for the practice area. The smoke evacuator should be easy to use and quiet. There should be a foot pedal to activate the system or an automatic sensor that turns the unit on and off as plume is created and evacuated. The smoke evacuator should be easy to access and portable if needed to move it from room to room. The smoke evacuator should have an indicator (such as a light/alarm) that notifies the healthcare worker that the filter needs to be changed. The smoke evacuator’s efficiency or ability to evacuate surgical smoke is extremely important to ensure that surgical smoke is evacuated completely. The cost of the unit is another consideration that must be reviewed before purchase too.

Critical Features of Smoke Evacuators AORN Smoke Tool Kit 2013 Critical Features of Smoke Evacuators Efficiency -Filtering capability -Suction power The most important or critical feature to evaluate in a smoke evacuator is the efficiency which consists of the filtering capability and the suction power of the unit.

Smoke Capture Depends on AORN Smoke Tool Kit 2013 Smoke Capture Depends on Motor Rating Tubing Size Site Proximity Amount of Smoke Generated The amount of smoke that is captured depends on the motor rating of the smoke evacuator, the tubing size of the collection device, the proximity of the collection tubing to the site where the smoke is being generated, and the amount of smoke being created.

Triple Filter System Pre filter (captures large particles) AORN Smoke Tool Kit 2013 Triple Filter System Pre filter (captures large particles) ULPA filter (captures small particles) Charcoal filter (captures toxic gases and odors) Using a smoke evacuator is the best way to capture all surgical smoke. The triple filter system in the smoke evacuator includes a pre-filter to capture large particles and fluid, an ULPA (ultra-low penetration air) filter that captures small particulate matter (filters 0.12 micron and larger particles at 99.999% efficiency – only one in a million particles will escape capture), and a charcoal filter that absorbs toxic gases and odors. Coconut-based charcoal filters are the most absorptive. Ball, K. (2004). Lasers: The Perioperative Challenge, 3rd ed. Denver, CO: AORN.

Ultra-low Penetration Air Filtration (ULPA) AORN Smoke Tool Kit 2013 Ultra-low Penetration Air Filtration (ULPA) Only one in a million particles will escape capture The ULPA filter is the best filter to capture the tiny harmful smoke particles. This filter is made up of a dense mesh-like filter system that traps smoke particles. Remember only one in a million particles will escape capture with an ULPA filter. This is much more effective than a HEPA (high efficiency particulate air) filter.

Wall Suction: Use an In-Line Filter! AORN Smoke Tool Kit 2013 Wall Suction: Use an In-Line Filter! Simple Evacuate less than five cubic feet per minute (CFMs) Effective for small amounts of smoke Use an In-line filter! Use and change as recommended by the manufacturer’s instructions Use standard precautions when changing and disposing of in-line filters Note Cubic feet per minute = CFM The OR wall suction is often used to evacuate very small amounts of plume – for example, smoke that may be generated during a microlaryngoscopy vaporization of a vocal cord polyp. Using the wall suction is very simple but this system only moves air less than five cubic feet per minute (CFM). An inline filter is mandatory to protect the wall suction line from getting clogged with surgical smoke particulate matter. The inline filter should be used and changed as recommended by the manufacturer. Standard precautions must be used when changing and disposing of contaminated inline filters.

In-Line Filters with Wall Suction AORN Smoke Tool Kit 2013 In-Line Filters with Wall Suction To wall suction > From the patient> Again, it is extremely important that an in-line filter must be used when wall suction is chosen to evacuate small amounts of surgical smoke. If there is no inline filter, then the particulate matter from smoke can build up inside the suction lines. For a suction to be effective, the suction lines and filters extending outside the operating room must also be clear. Inline filters must be used according to the manufacturer’s instructions, and changed as recommended while using standard precautions. An overused filter affords absolutely no protection for the suction line. Example of an ULPA filter

Evacuator Filters for MIS Procedures AORN Smoke Tool Kit 2013 Evacuator Filters for MIS Procedures Irrigation/Aspiration System Active System Passive System There are several smoke evacuation devices available for laparoscopic procedures. A irrigation/aspiration system that does not interfere with the physician’s operative area can eliminate or decrease surgical smoke by continuous removal of plume throughout the entire procedure. There are passive and active systems for laparoscopic smoke removal. The passive systems are connected to a trocar sleeve and provide ventilation for air movement to disperse the surgical smoke. The active systems (such as a smoke evacuator for laparoscopic procedures) provide active movement of the insufflation gas with surgical smoke to remove the plume.

CFM is a measure of air flow rate AORN Smoke Tool Kit 2013 Wall Suction Problems When there is no in-line filters: Damage to healthcare facility air exchange Less suction 3.5 – 5 CFM Wall Suction 25-50 CFM Smoke Evacuators CFM is a measure of air flow rate Suction lines can be damaged with surgical smoke particles if an in-line filter is not used. The tiny smoke particles can accumulate and harm the hospital air exchange system, thus further reducing the airflow. Wall suction generally pulls between three to five CFMs, while smoke evacuators can pull between 25 – 50 CFMs (ECRI, November, 2007). Wall suction can only provide air movement for very small amounts of smoke; therefore, smoke evacuators should be used for most plume-producing surgical procedures. Note Cubic feet per minute = CFM

Disposal and Changing Smoke Evacuation Filters AORN Smoke Tool Kit 2013 Disposal and Changing Smoke Evacuation Filters It’s an occupational hazard Wear PPE Dispose of used smoke evacuation filters per manufacturer’s instructions and your facility’s procedures When changing smoke evacuator filters, standard precautions should be used, the manufacturer’s written instructions should be followed, as well as your facility’s procedures to manage hazardous waste.

Perioperative Nursing Care AORN Smoke Tool Kit 2013 Perioperative Nursing Care Let’s now discuss perioperative nursing care to protect patients and healthcare professionals from the hazards of surgical smoke.

Perioperative Nursing Care AORN Smoke Tool Kit 2013 Perioperative Nursing Care Patient assessment Will your patient be exposed or potentially exposed to surgical smoke? Diagnosis Planning care Interventions and evaluation of outcomes Patient outcomes When first assessing your patient, the perioperative nurse should determine if surgical smoke will be generated during the procedure. Planning for the procedure involves ensuring that appropriate smoke evacuation devices are available, in good working order, and will be used properly during the procedure.

Wear appropriate PPE Surgical Attire AORN Smoke Tool Kit 2013 As a reminder, wear the appropriate PPE for the expected or real exposures to surgical smoke.

Surgical Masks Remember, local exhaust ventilation is AORN Smoke Tool Kit 2013 Surgical Masks Remember, local exhaust ventilation is the first line of protection from surgical smoke. A Surgical Mask prevents release of potential contaminants into the environment protects the wearer from large droplets , ie greater than 5 microns, when the mask is fluid resistant does not seal the face and may allow contaminants to enter the wearer’s breathing zone A High Filtration Mask has a filtering capacity of particulate matter at 0.3 to 0.1 microns in size Surgical masks generally filter particles to about 5 micrometers in size. High filtration masks have a filtering capacity of particulate matter at 0.3 to 0.1 microns in size. Approximately 77% of the particulate matter in smoke is 1.1 micrometers and smaller (Kunachak & Sobhon, 1998). Viral particles, however, can be much smaller than 0.1 micrometers. Aerosol transmissible diseases require a fit-tested surgical N-95 respirator. Surgical masks are unfitted and should be worn snugly and changed often. Masks should not, however, be the only defense against surgical smoke. Remember, Local exhaust ventilation is the first line of protection from surgical smoke.

Wear Respiratory Protection Wear a fit-tested surgical N95 filtering face piece respirator or a high-filtration mask during procedures that generate surgical smoke High-filtration mask (0.3 microns to 0.1 microns) This mask does not seal the face and may allow contaminants to enter the wearer’s breathing zone

Wear Respiratory Protection AORN Smoke Tool Kit 2013 Wear Respiratory Protection Wear a fit-tested surgical N95 filtering face piece respirator for Disease transmissible cases (HPV) Aerosol transmissible diseases (TB, Varicella, Rubeola) Aerosol generating procedures (e.g., bronchoscopy) Wear respiratory protection which means wear a fit tested surgical N95 filtering face piece respirator or wear a high-filtration mask during procedures that generate surgical smoke. A fit tested surgical N95 filtering face piece respirator should be worn during disease transmissible cases such as HPV, during aerosol transmissible diseases (TB, Varicella, Rubeola) or aerosol generating procedures such as a bronchoscopy procedure. The high-filtration mask does not seal the face and may allow contaminants to enter the wearer’s breathing zone. It is important to know what type of masks and respiratory protection methods are available in your institution.

AORN Smoke Tool Kit 2013 Team Briefing Communication with Surgeon and Perioperative Team members Plan for Smoke Evacuation Equipment and Optimal placement of equipment Patient and Team member Smoke Protection Methods A good time to discuss the required smoke evacuation methods is when you are planning and preparing for the procedure, as well as during the team briefing. Discussion can include the plan for smoke evacuation, the type of equipment and optimal placement of the smoke evacuation device, patient and team member protection methods, including what type of respiratory protection is recommended. A smoke evacuation program is much more successful when there is collaboration and communication among the surgeons and perioperative team members.

Hand off Communication AORN Smoke Tool Kit 2013 Hand off Communication Discuss PPE and Respiratory Protection/Masks Options Type of Smoke Evacuation Method During a staff change and hand off communication, it is important to inform the incoming staff about the type of smoke evacuation system in use and the respiratory protection. Also, a reminder for safe handling using standard precautions about the disposal of used smoke evacuation equipment and filters.

Safe Handling Use standard precautions when disposing of used smoke filter devices and other used smoke equipment.

AORN Smoke Tool Kit 2013 Documentation Relevant information about smoke evacuation and equipment used It’s important to document relevant information about smoke evacuation and the type of smoke evacuation equipment used in the patient’s medical record.

Smoke Evacuation Program AORN Smoke Tool Kit 2013 Smoke Evacuation Program

Smoke Evacuation Program AORN Smoke Tool Kit 2013 Smoke Evacuation Program Increase awareness of the hazards of surgical smoke Promote and implement safe practices Interdisciplinary Team Include Perioperative RNs, Anesthesia providers, Surgeons, Administration, Infection Preventionist, Employee Health, Safety Officer, Risk Managers A first step in developing a smoke evacuation program is to make the commitment as a facility that protecting patients and staff from the potentially harmful effects of surgical smoke is a priority. The commitment should be made with representatives from each of the professional groups providing care in the operating room: surgeons, anesthesia care providers, perioperative staff, and administration. Agreement from the entire surgical team before the program begins is important and will help ensure success. Once an agreement and commitment have been reached, a plan should be developed to introduce the program through education

Include in process of product selection AORN Smoke Tool Kit 2013 Consider Risk Management Infection Prevention Administration: Director Safety Physicians: Support with data Include in process of product selection Cost Analysis Contracts Financials: Capital Monitor Best Practices OR Colleagues: Educate There is a lot to consider. It’s important to include the entire intradisciplinary team to develop a successful Smoke Evacuation Program at your health care facility.

Implementing Smoke Evacuation Practices AORN Smoke Tool Kit 2013 Implementing Smoke Evacuation Practices Must have data and analyses: Scientific research data Financial analysis Must have support from: Administrative Safety Committee Infection Control Risk Management Educating staff members about the hazards of surgical smoke is a most important key indicator of a successful smoke evacuation program. Take advantage of all available resources in designing education to increase awareness. Leadership support is critical for implementing, maintaining, and enforcing a smoke evacuation program.

Barriers to Compliance for Smoke Evacuation Practices AORN Smoke Tool Kit 2013 Barriers to Compliance for Smoke Evacuation Practices Equipment not available Physician Equipment is Noisy Complacent staff -- Ball, 2010 Surgeons' resistance or refusal Cost Bulkiness Excessive noise --Edwards & Reiman, 2012 Noise Distraction Ergonomic difficulty of equipment --Watson, 2010 Again, as mentioned previously, barriers to smoke evacuation practices must be identified and addressed. As you see on the slide, several authors have reported various reasons for non-compliance of smoke evacuation practices.

Policies and Procedures AORN Smoke Tool Kit 2013 Policies and Procedures Address best practices for the patient and the perioperative team National Regulatory and Professional Standards Credentials, Competency and Training Equipment Operational Guidelines Patient and health care worker incidents Policies and procedures should address best practices for smoke evacuation to protect the patient and the perioperative team. National regulatory and professional standards can be used to write policies to provide consistency and standardization. Smoke evacuation policies should address the needed education, competency skills, and training involved with a comprehensive smoke evacuation program. The equipment, devices, and supplies needed for smoke evacuation can be described within a policy. Operational step by step guidelines that are easy to comprehend and follow are needed for total compliance. Finally, a system to report patient and healthcare worker exposure incidents should be described within the policy too.

Staff Education and Competency AORN Smoke Tool Kit 2013 Staff Education and Competency Aware of surgical smoke hazards for the patient and the perioperative team members? Aware of the PPE required for perioperative team members? Know how and when to use filtering devices and smoke evacuators? Able to set up the smoke evacuators available in the work setting? Know about cleaning, decontamination, and maintenance of smoke evacuation equipment and accessories? It’s important for the perioperative staff to be knowledgeable and competent about the exposure risk associated with surgical smoke, the protective measures required during smoke producing procedures, use of smoke evacuation equipment and how to use it, and the procedures for cleaning, decontamination, and maintenance for smoke evacuation equipment and related accessories. As stated before, education is a critical component to compliance.

Use a Variety of Educational Activities AORN Smoke Tool Kit 2013 Use a Variety of Educational Activities Quality and Safety Committee Reports Educational programs perioperative nursing care research on hazards Equipment, Device, Supply Inservices Reminder signs AORN Posters Checklists Monitor practices Education can be achieved in a variety of different ways. Reviewing quality and safety committee reports can document the success of a smoke evacuation program and note noncompliance issues. Educational programs can provide a venue to discuss research outcomes on surgical smoke hazards. The proper use of the smoke evacuation equipment, devices, and supplies must be understood by the staff members so that consistency can be ensured. Reminder signs (such as AORN Posters in this tool kit) can be posted to remind staff members that smoke evacuation practices must be employed to protect against surgical smoke exposure. Checklists can include smoke evacuation practices so that smoke evacuation becomes a routine practice with all plume-producing procedures. Smoke evacuation practices should be monitored to note compliance and noncompliance. Compliance can be rewarded while noncompliance should be explored to determine the root cause of not using smoke evacuation practices.

Quality Monitoring Education and Competency Equipment Service Reports AORN Smoke Tool Kit 2013 Quality Monitoring Education and Competency Equipment Service Reports A quality monitoring program can include the dates of educational sessions involving surgical smoke hazards and smoke evacuation practices. Regular competency checks can determine if smoke evacuation recommendations are being followed consistently. All smoke evacuation equipment must comply with routine maintenance recommendations to ensure proper functioning.

Are Hospitals Really Smoke Free? AORN Smoke Tool Kit 2013 Are Hospitals Really Smoke Free? Thousands of hospitals make that claim Let’s advocate to make the Perioperative Setting Smoke-free as well. Protect our Patient-Our Colleagues-Ourselves from the Hazards of Surgical Smoke In summary, the message to healthcare workers is make sure that our surgical environments are smoke-free today! On the front door of a hospital, there’s a sign that says “No Smoking.” But what about the surgical smoke in the OR? We must protect our patients, our colleagues, and ourselves by making sure that our operative and invasive procedure areas are also smoke-free. We have the knowledge, technology, and passion, so let’s ensure all surgical smoke is evacuated.

Notice/Copyright Notice AORN Smoke Tool Kit 2013 Notice/Copyright Notice The content in this publication is provided on an “as is” basis.  TO THE FULLEST EXTENT PERMITTED BY LAW, AORN, INC. DISCLAIMS ALL WARRANTIES, EITHER EXPRESS OR IMPLIED, STATUTORY OR OTHERWISE, INCLUDING BUT NOT LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY, NON-INFRINGEMENT OR THIRD PARTIES RIGHTS, AND FITNESS FOR A PARTICULAR PURPOSE. Copyright AORN’s training and educational materials are protected under federal copyright and trademark law. Only registered students may use our materials.  Any unauthorized use of our materials is strictly prohibited. Violations of these requirements or of our valuable intellectual property rights may incur substantial penalties, including statutory damages of up to $150,000 for a single willful violation of AORN’s copyrights. Presentation/Speaker Information Faculty are responsible for their content and for obtaining permission to use any copyrighted material. AORN recognizes the sessions as continuing education for RNs. This recognition does not imply that AORN or the American Nurses Credentialing Center’s Commission on Accreditation approves or endorses products mentioned in the activity. AORN is not responsible for and does not assume any liability.

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