1. AORN Electrosurgery and Laser Guidelines: Shocking Changes
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

2. Developed and originally presented by Byron L. Burlingame, MS, RN, CNOR
Byron has been a perioperative specialist in AORN’s Nursing Department for 12 years. Byron serves as the lead author for various guidelines, including the Guideline for Safe Use of Energy-Generating Devices, which incorporates AORN’s evidence-based recommendations for safe use of electrosurgical devices, lasers, and phacoemulsification systems. Byron also serves on the Facility Guidelines Institute’s Health Care Guidelines Revision Committee for the Guidelines for Design and Construction of Health Care Facilities and the FDA Surgical Fires Group. Byron has authored Clinical Issues columns and articles published in the AORN Journal and other professional publications. Before coming to AORN, Byron worked as an RN circulator and in various levels of management in large and rural hospitals.
These slides are taken from the webinar AORN Electrosurgery and Laser Guidelines: Shocking Changes, presented August 4, To listen to the webinar, visit THE VIEWS EXPRESSED IN THESE SLIDES ARE THOSE OF THE PRESENTERS AND DO NOT NECESSARILY REPRESENT THE VIEWS OF, AND SHOULD NOT BE ATTRIBUTED TO AORN.

3. Objectives
Explain the difference between electrosurgery, electrocautery, and diathermy.
Describe three safety precautions for all energy-generating devices.
Describe three safety precautions for electrosurgical devices.
Describe three safety precautions for lasers.
Describe two safety precautions for phacoemulsification devices.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

4. Energy-Generating Devices
Combined
Electrosurgery
Laser
Added
Phacoemulsification
The AORN Guideline for Safe Use of Energy-Generating Devices is a combination of the previous guidelines for electrosurgery and for laser safety. These two documents were combined because we found there was a great deal of duplication between the two, and it was difficult to keep both documents current and be certain that the duplicated material always matched. The duplicated material dealt with smoke, fire safety, and electrical safety. We deleted the smoke section from this document because there is now a separate guideline on this topic. Any content on general fire safety and general electrical safety was also eliminated because it is already included in the Guideline for a Safe Environment of Care, Part 1. There is still content in the guideline related to fire safety, but it concerns fire safety precautions that apply only to energy-generating devices. A new recommendation on phacoemulsification, which is an ultrasonic energy-generating device, was added.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

5. Terminology Bovie™ ESU Electrosurgery Electrocautery Diathermy
Dispersive electrode
Active electrode
Before we get into the content of the guideline, we should all be on the same page regarding terms that are used consistently in the document, but may be used differently in your practice setting and in the literature. For consistency between your practice and the guideline, I encourage you to use the terms correctly in practice and not use the slang terms. The first term on this list is Bovie. This term is actually the brand name of one of the first electrosurgical units. In the literature and in many of your operating rooms, you will see this used as a synonym for electrosurgery. This term should only be used if you are referring to that particular brand of product and should not be used to replace the term electrosurgery.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

6. ESU Generator Circuit Accessories
The next term on the list is ESU or electrical surgical unit. This is one term that is used in many different ways, but in the guideline, it refers to the generator that produces a high-frequency current waveform that is delivered to tissues, and it includes the foot switch with cord (if applicable), the electrical plug, cord, and connections. When I think of the electrical circuit I think of a large circle. The electricity flows from the wall to the generator, then it flows through one of the accessories, and then back to the generator, and eventually back to the wall. The electrosurgical accessories include the active electrode with tip(s), dispersive electrode, adapters, and connectors to attach these devices to the electrosurgery generator. You may ask how the electricity gets back to the generator from the active electrode. The answer to that question will be answered when I describe the active and passive electrodes as a portion of the definition of electrosurgery.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

7. Electrosurgery Monopolar Active electrode Dispersive electrode
Current through the patient
There are two types of electrosurgery: monopolar and bipolar. The key to telling them apart is the device used to apply the current to the patient and the accessories required to complete the current pathway. The current pathway for monopolar electrosurgery goes from the generator through the active electrode cord to the active electrode, through the patient to the dispersive electrode, and then through the dispersive electrode cord back to the generator. This illustration only shows the pathway through the patient. The device used to apply the current to the patient is the active electrode, which has only a single point of contact with the patient. The key factor here is that the current travels from the active electrode through the patient to the dispersive electrode.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

8. Electrosurgery Bipolar Active and dispersive electrode
Current flows through tissue
The second type of electrosurgery is bipolar. The current pathway in this device goes from the generator through the cord to one tip of the forceps, through the tissue between the forceps to the other tip as shown here, and then back to the generator. The only tissue that the current flows through is the tissue that is between the tips. You do not need a dispersive electrode for bipolar electrosurgery as you do for monopolar electrosurgery. Bipolar electrosurgery is a good alternative to monopolar electrosurgery if you have devices or implants that will interfere with the flow of the current from the active electrode to the dispersive electrode.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

9. Electrocautery Battery operated No electrode
Current flows through wire
A term that is frequently used incorrectly is electrocautery. Electrocautery is not the same thing as electrosurgery. The electrocautery device is frequently similar to a pencil so it may be referred to as a cautery pencil. The power source in the electrocautery pencil is usually a battery. The current does not flow through the patient at all, only through the wire at the end of the pencil as shown here. This device works through an application of heat and not through the application of electricity to the tissue. As with bipolar electrosurgery, you do not need a dispersive electrode when using electrocautery. In fact, generally there are no cords involved with electrocautery at all.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

10. Diathermy Physical therapists Not in the OR
Used in international literature
In the literature, the term diathermy is frequently used as a synonym for electrosurgery. This is especially true in the international literature. This term is not used in this guideline because in the US, diathermy is a heat treatment that is applied most frequently by physical therapists, and it is not a method to cut skin or coagulate vessels.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

11. Dispersive Electrode Grounding pad Patient plate Return electrode
Inactive electrode
Single use or reusable
In this guideline, we use the term dispersive electrode. In the literature and in the OR, people use the terms that have been around for years to refer to this part of the electrical circuit, including grounding pad, patient plate, return electrode, and inactive electrode. The dispersive electrode may be single use or may be reusable, and one is always required for monopolar electrosurgery. The definition that we use in the guideline is: The accessory that directs electrical current flow from the patient back to the electrosurgical generator—often called the patient plate, return electrode, inactive electrode, or grounding pad.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

12. Active Electrode Bovie™ Bovie pencil ESU pencil Hot electrode
Hand piece
Another term that has several synonyms is active electrode. This is the ESU accessory that touches the patient and delivers the energy to the patient. The terms listed here are all synonyms for the active electrode. I encourage you to use the correct terminology for both of these electrodes and not one of the synonyms, because their use can cause confusion between the OR team members and this could lead to an adverse event.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

13. Layout of the Guideline
Recommendation applying to:
All energy-generating devices
Just electrosurgical devices
IEDs
Precautions for MIS
Laser program
Precautions for lasers
Precautions for phacoemulsification
Precautions for AEC
Glossary
References
As mentioned at the beginning of the presentation, we combined two documents to create this one, and here is the way it is laid out by the main topic of each recommendation. One of the things we added within the section on electrosurgical devices is a section on the care of the patient with an implanted electronic device.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

14. Question Can the scrub person activate the energy device? Yes No
In certain situations during the procedure
During testing of the device before the procedure has begun
The correct answer is D, during testing of the device before the procedure has begun. This is the only point during which the scrub person can have the hand piece in his or her control. This is a practice application of the guideline, which states that the energy-generating device should only be activated by the person who has the hand piece in his or her hands.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

15. All Energy-Generating Devices
Lowest power setting
Activated only by person controlling the hand piece
Inspect
Remove from service
The first recommendation contains interventions and activities that apply to all the different types of energy-generating devices, including electrosurgical units (ESUs), electrocauteries, ultrasonic instruments, and lasers. The devices produce energy that is transferred to the patient by various methods. These include monopolar electrosurgical devices, bipolar devices, advanced bipolar devices (eg, vessel-sealing devices); tripolar devices (eg, plasma knife); class 3 and class 4 laser devices; and ultrasonic devices, such as ultrasonic tissue ablation system, phacoemulsification, and argon-enhanced coagulation (AEC) modalities.
The lowest power setting that will get the job done is the one that should be used. This recommendation has a great deal of strong evidence to support it. The evidence not only applies to monopolar electrosurgery, it also applies to all the other types of energy-generating devices. There are several case reports that involve burns or other injuries to humans. If there is a situation in which the user is requesting a continual increase in the power, the RN circulator and the scrub person should check the integrity of the entire system. For a monopolar electrosurgical device, that would include checking the connection between the hand piece and the active electrode tip, the amount of contact between the surface of the dispersive electrode and the patient, and the cords for the active and dispersive electrodes. If all of the accessories appear to be intact and functioning properly, then the generator itself may be the problem. If that is the case, it will require a change in the generator. This is assuming that the problem is technology related and not related to the person who is controlling the hand piece. The energy-generating device should only be activated by the person who is controlling the hand piece. If the device is activated by another person, then the person controlling the hand piece may inadvertently remove the hand piece from the tissue and not tell the other person to discontinue the delivery of the energy until it is to late. If this happens, there is a potential for a burn to the patient or possibly a fire if the hand piece is in contact with drapes.
All energy-generating devices and all their associated ancillary devices should be inspected before and after use. If the device or the ancillary device is reusable, then it should also be inspected before and after decontamination. If there is a confirmed or suspected problem with the piece of equipment or the ancillary device, it shoud be removed from service. What happens to the item after it is removed from service should be described in your organization’s policy and procedure covering this topic. Also if there is a patient or staff member injury or the piece of equipment fails during use, the energy-generating device should be removed from service and all accessories and packaging should be retained if possible. The adverse event details, including device identification and maintenance and service information, should be reported to the appropriate personnel as described in the health care organization's policy and procedures.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

16. All Energy-Generating Devices
Fire safety
Electrical safety
Accessory cords
Documentation
The fire safety interventions and activities specific to energy-generating devices include using moist sponges near the ignition source,; prohibiting the use of alcohol-soaked sponges on the surgical field; stopping delivery of oxygen or decreasing the percentage to the lowest tolerable level before activating an energy-generating device near the head, face, or neck; using water-soluble lubricants on the patient’s hair near the surgical site; and in predetermined high risk situations, using technologies other than monopolar or laser (these include bipolar, coblation technology, non-energy applying instruments). A situation in which this may apply is that when you open the bowel, you should use a scalpel and not monopolar electrosurgery.
The precautions related to electrocautery devices include applying the protective cap when the cautery is not in use and removing the wire loop before discarding. Applying the plastic cap is equivalent to putting the active electrode of the monopolar system in the holster. Remember, there are other general fire and electrical safety recommendations that can be found in the AORN Guideline for a Safe Environment of Care, Part 1. The electrical safety precautions are unchanged. Containers of liquids should not be placed on energy-generating devices because as we all know, water and electricity do not mix and liquids entering the energy-generating device may cause unintentional activation, device failure, or an electrical hazard. The foot pedal accessories should be encased in a fluid-resistant cover when there is potential for fluid spills. Safety and warning alarms and activation indicators should be operational, audible, and visible at all times.
All energy-generating devices, except possibly the electrocautery device, have a cord. During the procedure, the cords should be secured to the sterile drapes using a non-piercing plastic or other non-conductive device. They should also be secured in a manner that does not crush or damage the cord. The documentation recommendation includes the identification of the device, which can be a serial number or a facility-applied number, and all patient assessments such as skin condition. A recommendation that has been eliminated is the recommendation for the power settings of the device, though before you remove it from your documentation, check with your risk management department to be certain it is ok to remove. If not, ask them the relevance of this information. If the patient gets burned, does it make any difference whether the ESU was set at 10 watts or 20 watts? The patient still has a burn and the facility may be responsible.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

17. Question
When should the patient’s jewelry be removed if monopolar electrosurgery is going to be used?
Always
If it is in the current pathway
If it interferes with positioning
If it interferes with prepping
If it interferes with anesthesia
b, c, d, and e
The correct response is F. The definition of jewelry includes rings, earrings, necklaces, bracelets and all of the various devices connected to the body by piercing and subdermal implants. The decision to remove a patient’s jewelry goes beyond just taking it off to prevent injury related to electrosurgery. A myth is that when you put an adhesive dressing on or over the jewelry, the dressing provides an insulating barrier. The only way this would be true is if you applied electrician tape and that is not what is used on people. The real reason for applying the adhesive dressing over the piece of jewelry is to keep it from falling off during the procedure. If it is a ring that you are taping on, it is also to help keep the stone from falling out and getting lost during the procedure. This truly has nothing to do with electrosurgery.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

18. Electrosurgery Injuries
Alternate-site burns
Antenna coupling
Capacitive coupling
As we all know, the use of electrosurgery results in a burn, but that is intentional. An unintentional burn is known as an alternate-site burn, which is a patient injury caused by an electrosurgical device that occurs away from the active and dispersive electrode site. A cause for the alternate-site burn is antenna coupling, which is radio-frequency energy emitted by a monopolar active electrode and transferred without direct contact through conductive materials (eg, neuromuscular, cardiac monitoring electrode wires). An alternate-site burn can also occur through capacitive coupling, which is the transfer of electrical current from the active electrode through intact insulation to adjacent conductive items (eg, tissue, trocars). Alternate-site burns can also occur between the patient and a metal object. The classic case of this is a burn occurring under a ring because the patient’s hand touched the metal parts of the bed. According to two sources in the literature, these injuries have almost disappeared because of the advances in technology.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

19. Electrosurgery Active Electrode
Fired by only the person in control of the hand piece
Holster use
Wires away from cords
The next portion of the program covers specific parts of the electrical surgical circuit, including the active and dispersive electrodes and the active electrode tips. You have already heard abut the need for the active electrode to only be activated by the person in control of the hand piece. The active electrode should always be placed in the holster when it is not in use. The wires going between the generator and the active electrode should be physically separated by as great a distance as possible from the non-electrical cords, including monitoring cables and other items such as lightsource cords. Separating the cords in this manner will help to reduce the potential for the patient being burned because of antenna coupling. An example of this is to have the lightsource on one side of the table and the ESU generator on the opposite side of the table and the cords coming off each side and not bundled together, which many of us have done to keep the table neat.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

20. Active Electrode Tips Use according to the manufacturer’s instructions
Securely seat into the hand piece
Clean during use
If insulation is present, inspect for insulation failure
Don’t alter (eg, bend)
The active electrode tips are the portion of the hand piece that actually do the work. They should only be used according to the manufacturer’s instructions for use and that includes not altering them, such as bending them, unless it is permitted in the manufacturer’s instructions for use. When connecting them to the hand piece, you need to be certain that a good connection is present and that the tip is securely seated into the hand piece. The tips should be cleaned whenever visible eschar is present, and cleaning should be performed away from the incision. You can use a moistened sponge or instrument wipe for cleaning the nonstick coated electrosurgical tips and an abrasive electrode cleaning pad for cleaning the non-coated electrodes. If you are using the abrasive pad, be sure to include it in your instrument count.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

21. Dispersive Electrode Single use
Reusable, capacitive-coupled dispersive electrode
The dispersive electrode comes in two varieties. They are the single use and the reusable, capacitive-coupled dispersive electrode. They do have some things in common, the first being that they disperse the current over a large area. Both varieties should be used according to the manufacturer's instructions for use. Also both varieties come in more than one size, and the pad to be used on your patient should be of the appropriate size for that patient as described in the manufacturer's instructions for use.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

22. Single-Use Electrosurgery Dispersive Electrode
Locations for placement
Where not to place
When to apply and reapply
Everything in this slide applies to the single-use dispersive electrode. The electrode should be placed on the patient after final positioning and on clean, dry skin which covers a large, well-perfused muscle mass. The application location should be close to the surgical site and on the surgical side when indicated, and located so that there is no metal or no monitoring leads between the dispersive and active electrodes. The electrode should be applied so uniform contact exists between it and the patient’s skin. In other words, there should be no wrinkles in the electrode. When applying the electrode, be sure it is placed away from warming devices and check the electrode for flaws, damage, discoloration, adhesiveness, and dryness before application.
Do not alter the electrode, such as by cutting or folding. Do not place it over bony prominences and potential pressure points, over scar tissue, over an implant containing metal components, over skin folds, on areas with dense hair, or on areas distal to tourniquets. The electrode should not be repositioned or reapplied. The last precaution for the dispersive electrode is that it should be checked for uniform contact if the patient has been moved or repositioned or if any tension has been applied to the dispersive electrode cord. One case study reported a burn on the patient resulting from a dispersive electrode being loosened when the anesthesia professional tripped on the cord.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

23. Reusable, Capacitive-Coupled Dispersive Electrode
Use with a compatible ESU
Use without or with minimal material between the pad and the patient
Clean
Inspect
Repair or replace
Replace on expiration dates
If you are using a reusable, capacitive-coupled dispersive electrode pad, it should be used with minimal or no material between the pad and patient. Between uses, it should be cleaned with a health care facility-approved and Environmental Protection Agency-registered agent in accordance with the manufacturer’s instructions for use. The pad should be checked for tears or breaks in the surface material before and after use and, if damage is found, it should be repaired or replaced. It should also be replaced when it reaches its labeled expiration date.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

24. Question When do you use a magnet with a pacemaker? Always Depends
Only with a single chamber
Always with an old pacemaker
This question opens the section on precautions to take when the patient has an existing implanted electronic device. The correct answer is B. depends, and I will explain that shortly.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

25. Electrosurgery and IEDs
All IEDs
Consultation
Information to be shared
Advice to be given
Now I will describe the steps the perioperative team should take with all implanted electronic devices (IEDs), including gastric and cardiac pacemakers; implantable cardioverter defibrillators; cochlear implants; and deep brain, vagal nerve, sacral nerve, phrenic nerve, spinal cord, and bone stimulators to name a few. The first step the perioperative team should take when caring for a patient with an IED is to consult with the team managing the device. This should be done before surgery. The team members who may be managing a patient with a pacemaker may include a cardiologist, the electrophysiology team, and the manufacturer's representative. If the patient has a cochlear implant, you should consult with the implanting surgeon and the manufacturer's representative. For a neuro-stimulator device, again consult with the implanting surgeon or neurologist. If it is an implanted infusion pump, consult with the implanting surgeon or physician responsible for managing care.
The reason we need to consult with the team managing the IED is that various types of implants and various brands of the same implant may exhibit different responses to the electromechanical interference created by the energy-generating device, such as monopolar electrosurgery. Before the consultation, you should have the following information available: the procedure scheduled, including the site; intraoperative patient positioning; the potential for electromechanical interference based on the type of electrosurgical device to be used (eg, radio-frequency ablation, monopolar, bipolar); the procedure room location (eg, OR, interventional radiology); and post-procedure patient disposition (eg, outpatient, inpatient). Information should also be obtained during the patient assessment or from the patient’s caregivers, the identification card carried by the patient, or the medical record. This information includes type of implanted device, patient’s level of dependence, location of the device and leads (eg, within or outside the path between the active and dispersive electrode), device manufacturer and model, clinical indication for the device, battery life, device settings, and lead placement. If the perioperative team doesn’t have this information, the team managing the IED should have it. This information is important because it will help the management team to determine the interventions that should be taken to manage the patient safely.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

26. Electrosurgery and CIEDs
Additional information for consultation
Now we are discussing just cardiac implanted electronic devices. When you consult with the team managing the cardiac IED, you need all the information expressed in the previous slide plus the following information to assist in making a decision on what interventions should be accomplished: date of the last device interrogation or monitoring; lead polarity (eg, unipolar or bipolar); need for device programming, which is what is accomplished by placing the magnet over the pacemaker; response of the device to a magnet; presence of an alert status on the generator or on the lead; and the last pacing threshold.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

27. Electrosurgery and CIEDs
Interventions to be performed after consultation
Reprogramming (magnet)
Placement of dispersive/active electrode
Use alternate technology
Monitoring methods
Temporary pacer
There are several interventions that you may be instructed to perform for the cardiac IED. These include reprogramming the device by a magnet or use of reprogramming equipment, which will be performed by a qualified person. A magnet is only used in certain situations because all pacemakers do not respond in the same way; for example, use of a magnet on a pacemaker with a low battery may lead to device failure because the power of the battery may become rapidly exhausted. Also the same brand and same type of a pacemaker may react differently based on the age of the device. It has also been reported that the new IEDs are far more resistant to electromechanical interference created by the use of electrosurgery compared with the older ones. There is no magical date and time that would make a cardiac IED classified as an old or new.
When the patient has a cardiac IED, you may want to use alternate technology, including electrocautery, bipolar forceps, ultrasonic technology, or a ferromagnetic surgical system instead of monopolar electrosurgery. When dealing with the cardiac IED, be sure to place the dispersive electrode as close as possible to the surgical site in order to keep the IED out of the current pathway between the active and dispersive electrode. You should also place the active electrode cord away from the pulse generator, use a five-lead ECG system, use a beat-to-beat indicator such as an arterial line pulse oximeter, and have temporary pacing equipment and an external defibrillator readily available. If the pacemaker will respond to a magnet, keep a magnet immediately available and employ continuous cardiac monitoring whenever the pacemaker is deactivated.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

28. Electrosurgery and IEDs
NO TIME FOR CONSULTATION
As you have heard several times now, the perioperative team should consult with the team managing any IED before the procedure. You may be wondering what do I do if there is no time. This step is not really defined in the guideline, but I am covering it here as it supports implementation of the guideline. The first step is to create a policy and procedure, protocol, or reference list. This should be created by a multidisciplinary team including the perioperative team, anesthesia professionals, and representatives of the teams managing the device. This is a good time to get the industry representatives involved, as they may be able to provide you with good overall information. This document should cover the general measures that may apply to the various devices. You should, if at all possible, use an alternative technology for cutting and coagulating to decrease the amount of electromechanical interference.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

29. Electrosurgery and Minimally Invasive Surgery
Trocars
Capacitive coupling
Insulation failure
Inspection
In addition to the precautions already outlined for procedures using electrosurgery, there are a few additional precautions that should be taken during minimally invasive procedures that use electrosurgery. Conductive trocars should be used, and hybrid trocars, which are a combination of plastic and metal, should not be used. Prevent burns from capacitive coupling, which is transfer of electrical current from the active electrode through intact insulation to adjacent conductive items (eg, tissue, trocars). Burns can also result if there is a failure in the insulation. Insulation failure can be detected by direct inspection before and after use on the sterile field and also during the decontamination/sterilization process. Active electrode insulation integrity testers and active electrode monitoring should be used to assist with detecting breaks in the insulation.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

30. Question
Do you need to have a designated person in the OR to operate the laser console.
Yes No
Only in certain situations
The correct answer is C, and I will explain this shortly.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

31. Laser Laser safety program Laser safety committee
Education and competency requirements
Medical exams
A laser safety program is required at all sites where a laser is used. This includes those facilities that only borrow a laser. The complexity of the program will vary depending on how many different types of lasers are used in the facility. The program should create and list the responsibilities for a multidisciplinary laser safety committee and delegate authority and responsibility for supervising laser safety to a laser safety officer (LSO) whose role I will describe shortly. It should also establish the criteria that must be met before use of a particular laser, list the procedures to be followed for all health care personnel working in the laser nominal hazard zones, and identify and list the hazards and injury-prevention criteria for each laser used. This applies to beam and non-beam hazards. An example of a non-beam hazard is when the laser is reflected off a surface and goes a different direction than intended.
The multidisciplinary laser safety committee may be same as a facility-wide safety committee and should be made up of representatives from administration, the LSO, a biomedical engineer and/or clinical biomedical engineer, a physician representative from each specialty group that uses lasers, anesthesia professionals, perioperative services administrators, a perioperative educator, medical staff education/credentialing personnel, quality department personnel, and the laser safety specialist (eg, nurse, technician). The exact makeup of the committee will depend on how many of the positions are present in your facility. If you do not have all these positions, the person who fills the role should be a member of the committee. An example of this would be that the perioperative administrative representative is also the perioperative educator.
The committee should establish requirements for monitoring compliance with applicable administrative, engineering, and procedural control measures and should identify education requirements, such as what is required for competency verification and what is the minimum education and training for the LSO and laser safety specialist. In respect to education, the committee should also define the qualifications for any participating personnel, including any required certifications. This committee should define quality processes, including the who, what, and when for laser safety audits.
Lastly, the committee should identify the type and frequency of medical examinations for personnel. This applies to the eyes and any other part of the body that may be injured during a laser procedure. One thing to note is that medical exams, such as eye exams, are no longer required on a periodic bases, but they are still required after an injury. The frequency and extent of the exams should be defined in the facility occupational health program.
As mentioned, the multidisciplinary team should create the requirements for competency verification and these should be specific to the laser used, procedures performed, and the person’s job responsibilities. The education must include safety precautions for each type of laser used. Examples of safety precautions include personal protective equipment required, window coverings required, type of warning signs and alarms to be used, electrical safety, and fire safety. The education program should also include information on the laser safety program, hazards associated with lasers, how to report adverse events, and emergency laser shut off.
The laser safety committee is also responsible for strategic planning for and acquisition of laser-related technology, which includes performing a technology assessment, cost analysis, product evaluation, and review of marketing information from laser vendors. Probably one of the toughest jobs the laser safety committee has to perform is establishing the requirements for credentialing and verifying that any physician who operates a laser has completed the health care organization-required education on the operation and safety precautions and coursework in basic laser physics, laser-tissue interaction, and clinical applications for the specific laser for which privileges are sought. Finally, the committee establishes requirements for hazard assessment, oversees the laser safety program and laser-related education and competency verification, develops and enforces laser-related policy and procedures, sets staffing requirements, establishes a quality assurance and improvement program, and oversees third-party laser services. As you can tell, this is a very busy committee with many varied responsibilities.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

32. Laser SAFETY PRECAUTIONS Nominal hazard zone Covering windows
Accidental activation
There are several safety precautions to be taken with the laser, and some of them differ with the type of laser being used. Before instituting precautions, be sure to check the manufacturer’s instructions for use to verify what is required. One that is required for all lasers is the creation of a nominal hazard zone. This zone should be developed by the laser safety committee or the laser safety officer. The nominal hazard zone is the space in which the level of direct, reflected, or scattered radiation used during normal laser operation exceeds the applicable maximum permissible exposure. Exposure levels beyond the boundary of the nominal hazard zone should be below the appropriate maximum permissible exposure level of the laser. In the nominal hazard zone, special eye and skin precautions must be enforced; doors should remain closed; and windows, including door windows, should be covered with a barrier that blocks transmission of the beam. The type of window covering that is required will be stated in the manufacturer’s instructions for use.
There are also several precautions that should be implemented to prevent accidental activation or misdirection of laser beams. These precautions include limiting access to the laser keys to authorized personnel who are skilled in laser operation and calibration of the laser before each use as described in the manufacturer's instructions for use. Other recommendations to prevent accidental firing of the laser include placing the lasers in stand-by mode when it is not in active use and placing the laser foot switch in a position convenient to the user and in a position where it will not be confused with other foot pedals. The last precaution is probably the most important, and that is that only the laser user should be activating the device. This is the responsibility of the laser user and not the laser operator or the scrub person.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

33. Laser
Reflective surfaces Laser-related fire precautions Breaking laser fiber
The use of reflective surfaces should be minimized during laser surgery because the laser beam may reflect off surfaces onto non-target tissues and potentially cause skin or eye injury for the patient or the personnel who are in range. What should be used instead of reflective instruments are instruments that have an anodized, dull, nonreflective, or matte finish. Before use, the instruments they should be inspected to ascertain that the finish has not become worn. If a reflective instrument is needed, then it should be covered with materials that will not reflect and will not ignite when exposed to the laser beam, such as saline-saturated radiopaque towels or saturated radiopaque sponges. As we all know, the laser can ignite a fire, so the fire safety precautions as described in Recommendation 1.a and the AORN Guideline for a Safe Environment of Care, Part 1 should be followed. Additional fire safety precautions that apply only to use of the laser include using moistened radiopaque sponges for rectal packing or for covering the anus during perineal surgery, using a laser-resistant endotracheal tube, and inflating the endotracheal tube with normal saline or methylene blue-tinted saline during procedures. One thing that is key here is that the balloon on many laser-resistant tubes is not laser resistant, and it may burst easily if hit by the laser beam. Inflating the tube with saline instead of air makes it less likely to ignite if it is hit by the beam. Moistened packs should be placed around the endotracheal tube and kept moist during the procedure because they can dry out and then also become flammable.
At times, a laser fiber may break during use. To help prevent this from occurring, certain precautions should be implemented, including a multiple step inspection process. The scrub person should inspect the laser catheter sheaths and laser fibers for damage before and after the procedure and if damaged, the sheath should be removed from service. Step two of the inspection includes confirming that the catheter sheath meets the manufacturer’s labeled length and that the laser fiber is of sufficient length to extend beyond the catheter. If the length differs from the manufacturer's stated length, the scrub person should remove it from service. After each removal from the patient, the scrub person should confirm that the catheter sheath and the laser fiber are intact and complete. If not, the scrub person should remove it from service, report the situation to the physician, and implement the organization's policy for retained surgical items.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

34. Laser Protective eyewear Personnel Patients
As mentioned earlier but worth repeating, everyone in the nominal hazard zone must wear appropriate eyewear. The eyewear must meet the laser manufacturer’s protective eyewear specifications, which are based on the wavelength of the laser. The eyewear should also be inspected for damage and scratches before use and if damaged, it should be removed from use. One easy way to tell which protective eyewear goes with which laser is to mark the eyewear with a label that will correspond to a label on the laser.
The eye protection requirements for the patient are based upon the type of anesthesia being given. Patients who remain awake during laser procedures should wear goggles or glasses designated for the type of laser being used. Patients who undergo general anesthesia should be provided with protection including wet eye pads, laser-specific eye shields, or other devices approved by the laser safety officer. Patients who undergoing laser treatments on or around the eyelids should have their eyes protected by metal corneal eye shields that are approved by the US Food and Drug Administration for use during laser procedures.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

35. Laser STAFFING Laser user Laser operator Laser safety officer
Laser safety specialist
The last discussion on lasers covers the staffing requirements for a facility in which a laser is used. When a facility performs procedures that require the use of a laser, the staffing requirements change. The number of people employed may or may not increase, but the number of roles or titles may increase. In these facilities, there should be a laser safety officer, there may or may not be a laser safety specialist, there must be a laser user, and there may or may not be a laser operator based on the type of procedures being performed. You may notice that these titles have changed from the previous versions of the guideline. This is because our key reference, which is the ANSI standards, also changed the titles. One of the hopes is that these new terms will be clearer. Here are the definitions of these four positions:
The laser user is the person employing the laser for its intended purpose within the user's scope of practice, education, and experience. This person is most frequently the physician.
The laser operator is the person who sets up the laser and operates the laser console to control the laser parameters under the supervision of the laser user. This is the person who stands at the laser and turns it on and off during the process of the case. The laser operator cannot have any competing responsibilities that would require leaving the laser unattended during active use. There should be a laser operator assigned for every procedure in which a laser is used. There is one exception to this and that is when the console of the laser is controlled by the laser user. An example of this is during laser eye surgery when the physician is seated at the console of the laser looking through the microscope into the eyes of the patient on the other side of the scope. In this situation there is really no room for a third person to be involved, and the surgeon can manipulate the controls without taking his or her eyes off the patient. The laser operator does not have to be an RN; in fact, in some locations, it may be a surgical technologist or even a biomedical engineer. The key is that the person be knowledgeable about the laser that is being used.
The next role is the laser safety officer who is the person responsible for effecting the knowledgeable evaluation of laser hazards and authorized and responsible for monitoring and overseeing the control of such laser hazards. This person is appointed by the multidisciplinary laser safety committee.
The last title or role is the laser safety specialist. This title is optional and the need for this person is based on the number of areas where lasers are used within the facility. The laser safety specialist is the person designated to oversee safe laser use in each area where a laser is used. This is almost like an assistant laser safety officer. An example of when you may need this person is when you have a main OR and you have an ambulatory surgery center that is not located on the same campus. In this situation, the laser safety specialist would carry out all or some of the duties of the laser safety officer at the surgery center.
These roles and who occupies them is flexible; in fact, the laser operator can be the laser safety specialist or the laser safety officer. In other words, the roles are required, but they can be filled by one person or more than one person depending on the size of the facility. All of these people need education and training commensurate with their job responsibilities, but the education only needs to apply to the types of lasers that are used in your facility. Education should also be provided for the entire perioperative team, including the anesthesia professionals.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

36. Phacoemulsification Continuous irrigation flow Inspect the hand piece
Pre-use testing
New to this guideline is a recommendation on phacoemulsification, which is an example of a ultrasonic device. The steps for safe use of the phacoemulsifier are inspecting the phacoemulsifier hand piece operating tip before and after use, performing pre-use testing according to the manufacturer’s instructions for use, and maintaining a continuous irrigation solution flow. The flow of the irrigation solution can be interrupted for a number of reasons, including that the saline solution bottle is empty or positioned too low; the irrigation tubing, or sleeve, or the probe tip is occluded; the vacuum limit is set too low; the aspiration tubing is crimped; or the phacoemulsification machine cassette is improperly loaded.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

37. AEC or ABC Argon-enhanced coagulation - or - Argon beam coagulation
Use monopolar precautions
Follow manufacturer’s instructions for use
Initiate treatment in case of venous emboli
The final recommendation covers use of argon-enhanced coagulation or argon beam coagulation. AEC or ABC is defined as radio-frequency coagulation from an electrosurgical generator that is capable of delivering monopolar current through a flow of ionized argon gas. In other words, it is monopolar energy that is surrounded by argon gas. An adverse event that can occur during the administration of the argon gas is a venous embolism. This is a gas embolism that is created when the argon gas is forced into the vessels, and this creates effects just like any other type of air embolism. When the AEC is used, the perioperative team should all be aware of this risk and should take precautions as described in the manufacturer’s instructions for use and be prepared to treat any symptoms.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

38. REFERENCES
Guideline for safe use of energy-generating devices. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc.
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.

39. Questions and Answers
Copyright © 2016 AORN, Inc. All rights reserved. Used or adapted with permission.