OSHA shelves plan to issue bulletin on surgical smoke
OSHA shelves plan to issue bulletin on surgical smoke
Nurses stunned by request for more evidence
After years of working on a document about surgical smoke, the U.S. Occupational Safety and Health Administration has decided to shelve its "technical information bulletin" until more scientific evidence becomes available.
The decision stunned several nursing organizations that had lobbied for a guideline or bulletin based on animal studies and information about the content of surgical smoke. The National Institute for Occupational Safety and Health issued a hazard alert in 1998, and the American National Standards Institute (ANSI) issued standards in 1996 calling for the evacuation of laser and electrosurgical smoke.
"I was devastated," says Brenda Ulmer, RN, MN, CNOR, president of the Association of periOperative Registered Nurses in Denver. "For the last two years, OSHA has said consistently that the document was going to be out momentarily."
In fact, last November, Ulmer recalls OSHA Assistant Secretary Charles Jeffress telling representatives of nursing organizations that the bulletin would be out within a month. "I have a letter from him stating it had taken longer than they thought, but they did expect release of a surgical smoke document," says Ulmer.
Ulmer and her colleagues suspect that OSHA has become more timid after facing intense opposition to its proposed ergonomics standard and other regulations. For example, earlier this year, OSHA officials hastily backed down from statements about how regulations applied to home offices after a political firestorm erupted.
However, OSHA officials simply say that they need more evidence of a link between the smoke and ailments that afflict operating room staff. "We need a scientific demonstration that the potentially hazardous material that is in surgical smoke actually leads to medical harm," an OSHA spokesperson said.
Laser standards call for smoke evacuation
When human tissue burns, either in electrosurgery or laser procedures, cells burst and tiny particles become airborne in a noxious plume. Operating room nurses report suffering from nausea, abdominal cramps, and respiratory problems after hours of breathing the surgical smoke.1 (For more information on surgical smoke and evacuation devices, see Hospital Employee Health, April 2000, p. 37.)
For decades, the smoke produced by electrosurgery received little attention. But with the advent of lasers, organizations such as ANSI incorporated smoke evacuation into their guidelines. AORN standards also call for smoke evacuation.
Still, in many hospitals, smoke is routinely evacuated from lasers but not from electrosurgery units (ESUs), which are used in 75% to 80% of all surgical procedures. Nursing leaders say a document from OSHA would influence many hospitals to provide better smoke evacuation from electrosurgical as well as laser procedures. (Normal room ventilation is considered inadequate; several different types of devices are available to remove the smoke directly from the surgical site.)
"The reason that nurses will report they’re not evacuating smoke is that their hospitals are waiting for something from OSHA," says Ulmer.
Just how dangerous is surgical smoke? Past studies of surgical smoke content have identified particulate matter small enough to pass through surgical masks and toxic chemicals such as benzene, toluene, and acrolein. In one case, a surgeon contracted laryngeal papillomatosis with human papillomavirus DNA types that were identical to be those of patients he had treated with laser therapy. The virus may have been transmitted through the laser plume, the treating otorhinolaryngologists concluded.2
OSHA looks for actual harm’
But OSHA also would like to see studies that link prolonged exposure to surgical smoke to a rise in illness or injury among operating room staff. "OSHA must be able to ascertain that surgical smoke is a definite health hazard," says a spokesperson. "To do that, we need not have people who were actually harmed by the substance. A definite health hazard’ can be demonstrated by other means, such as epidemiology studies."
NIOSH’s review of literature on surgical smoke found only anecdotal evidence of actual health effects. Still, NIOSH issued a bulletin about "hazard control" in 1998 recommending the evacuation of surgical smoke.3
"There are some real issues there, but I don’t know if anyone has conclusively shown that there’s a major health hazard," says Gene Moss, a NIOSH health physicist. He adds, "We’re trying to minimize a hazard by using control measures."
Nursing organizations say there is another issue as well: politics. Rule-making has become more difficult for OSHA as it faces political pressure and legal challenges to regulations, says Kae Livsey, RN, MPH, public policy and advocacy manager for the American Association of Occupational Health Nurses in Atlanta. While the surgical smoke issue wouldn’t involve a new regulation, Livsey suspects that OSHA has become gun-shy.
"We’re disappointed that they can’t even get an information bulletin out," says Livsey. "Our groups are going to reconvene to look at ways that we can get additional scientific evidence or other ways that we can help raise this issue in a variety of venues [such as the Joint Commission on Accreditation of Healthcare Organizations]," she says.
Meanwhile, nurses have been calling OSHA to share their personal experience with the effects of surgical smoke. And nursing leaders are considering a new round of congressional lobbying, says Kay Ball, RN, MSA, CNOR, FAAN, a perioperative educator and consultant in Columbus, OH. OSHA began investigating surgical smoke after Rep. Carlos Romero-Barcelo (D-Puerto Rico) and a number of his colleagues signed a letter urging action on the issue in 1996.
"I think it’s just that they don’t understand the true hazards and they’re calling for more research," Ball says of OSHA. "If they would just go and work a day with a nurse in a smoky environment, they would understand."
References
1. Ball K. Surgical smoke: Is it safe to breathe? Today’s Surgical Nurse 1996; 18:16-21.
2. Hallmo P, Naess O. Laryngeal papillomatosis with human papillomavirus DNA contracted by a laser surgeon. Eur Arch Otorhinolaryngol 1991; 248:425-427.
3. National Institute for Occupational Safety and Health. NIOSH Hazard/Controls: Control of Smoke from Laser/Electrical Surgical Procedures. DHHS (NIOSH) Publication No. 96-128. March 1998.
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