Hospital eTool: Surgical Suite

The anesthetic gas and vapors that leak out into the surrounding room during medical
and surgical procedures are considered waste anesthetic gases.
They include nitrous oxide and halogenated agents (vapors) such as:

• Enflurane
• Isoflurane
• Sevoflurane
• Desflurane
• Halothane

Potential adverse health effects of exposure to waste
anesthetic gases include loss of consciousness, nausea, dizziness, headaches, fatigue,
irritability, drowsiness, problems with coordination and judgment, as well
as sterility, miscarriages, birth defects, cancer, and liver and kidney
disease.

Potential Hazard

• Exposure to waste anesthetic gases occurs from:

  • Poor work practices during the anesthetization of patients.
  • Leaking or poor gas-line connections.
  • Improper or inadequate maintenance of the machine.
  • Patient exhalation in the recovery room or Post Anesthesia Care Unit (PACU) during off-gassing of surgery patients.

Possible Solutions

OSHA’s
Guidelines for Workplace Exposures
to Anesthetic Gases provide the following recommendations provides the following
recommendations:

• Use appropriate anesthetic gas scavenging systems in
  operating rooms.
  • Appropriate waste gas evacuation
    involves collecting and removing waste gases, detecting and correcting leaks, considering work practices, and effectively ventilating
    the room (Dorsch and Dorsch 1994).
• Provide enough ventilation in the
  surgical suite to keep the room
  concentration of waste anesthetic gases below
  the applicable occupational exposure levels.
  The ventilation design and specifications
  should meet the most current American
  Institute of Architect’s Guidelines for
  Design and Construction of Health Care
  Facilities.
  • To minimize waste anesthetic gas concentrations in the operating room, the recommended air exchange rate (room dilution ventilation)
    is a minimum total of 15 air changes per hour with a minimum of 3 air changes of outdoor air (fresh air) per hour (American Institute of Architects 2006).
• Use a properly designed and operating dilution ventilation system to minimize waste anesthetic
  gas concentrations in recovery room areas.
  • System should provide a recommended minimum total of 6 air changes per hour with a minimum of 2 air changes of outdoor air per
    hour (American Institute of Architects
    2006).
• Conduct periodic exposure monitoring with
  particular emphasis on peak gas levels
  in the breathing zone of nursing
  personnel working in the immediate
  vicinity of the patient’s head.
  • Note: Methods using random room sampling
    to assess ambient concentrations of
    waste anesthetic gases in the recovery
    room are not an accurate indicator of
    the level of exposure experienced by
    nurses providing bedside care. Due to the closeness of the recovery room
    nurse to the patient, such methods would
    consistently underestimate the level of
    waste anesthetic gases in the breathing
    zone of the bedside nurse. Therefore,
    personal sampling is required to
    determine the employee’s overall
    workplace exposure to waste anesthetic
    gases.
• Implement a routine ventilation system maintenance program to keep waste
  anesthetic gas exposure levels to a minimum.

In addition, the

Hospital Investigations: Health Hazards Chapter of the OSHA Technical
Manual recommends that:

Additional Information:

• Anesthetic Gases:
  Guidelines for Workplace Exposures. OSHA,
  (2000, May 18). Provides guidelines and controls to help reduce occupational exposure to waste anesthetic gases.
• Waste Anesthetic Gases.
  OSHA
  Safety and Health Topics Page.
• U.S. Department of Health and Human
  Services (DHHS), National Institute
  for
  Occupational Safety and Health (NIOSH)

• Guidelines for design and
  construction of health care facilities. American Institute of Architects,
  Academy of Architecture for Health, (2006).

• Recommended practices for a safe environment of
  care.
  Association of Perioperative Registered
  Nurses (AORN), In: Perioperative Standards
  and Recommended Practices, (2008):351-374.

• 
  Waste Anesthetic Gases: Information for
  Management in Anesthetizing Areas and the
  Postanesthesia Care Unit (PACU). American
  Society of Anesthesiologists, (2004).

Bloodborne Pathogens Standard requires that:

• Engineering and work practice controls
  be used to eliminate or minimize exposures
  to blood and OPIM.
  [29
  CFR 1910.1030(c),
  29 CFR 1910.1030(d), and
  
  OSHA Directive CPL 02-02-069]

In addition, sharps injuries in the surgical area must be eliminated or minimized through use of measures such as:

• Safer needle/other sharps devices.
  
• Blunt-tip suture needles.
  
• Needleless IV connectors.
  
• Proper containers for sharps.
• “No Pass Zone” for surgical instruments.
• Method for passing equipment safely between surgeon and assistants.
  • The hands-free technique is a work practice whereby a tray or other means are used to
    eliminate simultaneous handling of sharp instruments during surgery.
• Appropriate personal protective
  equipment (PPE) be worn if blood or OPIM exposure is
  anticipated. [29
  CFR 1910.1030(d)(3)] The PPE must be
  impermeable under normal conditions of use
  and for the duration of time it will be
  used. The type of PPE
  depends on the anticipated exposure.
  Appropriate PPE includes, but is not limited
  to, gloves, gowns, face shields or masks,
  and shoe covers. For example:
  • Gloves must be worn when hand contact with blood, mucous membranes, OPIM, or non-intact skin is anticipated, or when handling
    contaminated items or surfaces
    [29
    CFR 1910.1030(d)(3)(ix)].
  • Masks, in combination with eye
    protection devices, must be worn whenever
    splashes, spray, splatter or droplets of
    blood or OPIM may be generated [29
    CFR 1910.1030(d)(3)(x)].
• Contaminated needles and other
  contaminated sharps be discarded immediately or as soon as feasible into appropriate containers [29
  CFR 1910.1030(d)(4)(iii)(A)(1)].
• Sharps containers be located as close as is feasible to the
  immediate where sharps are used or reasonably anticipated to be found [29 CFR 1910.1030(d)(4)(iii)(A)(2)(i)].
• Contaminated needles and other contaminated sharps must not be bent, recapped, or removed except as noted in paragraphs
  
  29 CFR 1910.1030(d)(2)(vii)(A) and
  
  (d)(2)(vii)(B). Shearing or breaking contaminated needles is
  prohibited.
• Employers ensure that handwashing facilities be readily
  accessible,
  [29
  CFR 1910.1030(d)(2)(iii)]
  and that employees wash their hands immediately or as soon as feasible after removal of gloves
  or other personal protective equipment
  [29
  CFR 1910.1030(d)(2)(v)].
  • Hand must be washed with an appropriate
    soap and water, whenever there has been
    occupational exposure to blood or OPIM. If a
    sink is not readily accessible (e.g., in the
    field) for instances where there has been
    occupational exposure, hands may be
    decontaminated with hand cleanser or
    towelette, but must be washed with soap and
    running water as soon as feasible.
  • If there has been no occupational
    exposure to blood or OPIM, use of an
    appropriate antiseptic hand cleanser is
    acceptable.

Additional Information:

• FDA, NIOSH and OSHA Joint Safety Communication: Blunt-Tip Surgical Suture Needles Reduce Needlestick Injuries and the Risk of Subsequent Bloodborne Pathogen Transmission to Surgical Personnel. (May 30, 2012).
• Acceptable use of antiseptic-hand cleansers
  for bloodborne pathogen decontamination and
  as an appropriate handwashing
  practice [1910.1030; 1910.1030(d)(2)(v);
  1910.1030(d)(2)(vi)]. OSHA Standard
  Interpretation, (March 31, 2003).
• Use of Blunt-Tip Suture Needles to Decrease Percutaneous Injuries to
  Surgical Personnel. OSHA and the National Institute for Occupational
  Safety and Health (NIOSH) Publication No. 2008-101, (2007, October). Also
  available as a 281 KB
  PDF, 4 pages. Supersedes NIOSH Publication 2007-132.
• Guideline for Hand Hygiene in Health-Care Settings .
  Centers for Disease Control and Prevention
  (CDC), Morbidity and Mortality Weekly Report
  (MMWR) 51(RR16), (October 15, 2002).
• Workbook for Designing, Implementing, and
  Evaluating a Sharps Injury Prevention
  Program. Centers for Disease Control and
  Prevention (CDC).
• 
  Bloodborne Infectious Diseases: HIV/AIDS, Hepatitis B, and Hepatitis C – Emergency Needlestick Information. National Institute for Occupational
  Safety and Health (NIOSH)
  Workplace Safety and Health Topic.
• Association
  of Perioperative Registered Nurses (AORN)
• B. Stringer, C. Infante-Rivard, J.A. Hanley.
  “Effectiveness of the hands-free techniques
  in reducing operating theatre injuries.”
  Occupational and Environmental Medicine
  59.10(October 2002):703.
• B. Stringer, T. Haines. “Hands-free
  technique: preventing occupational exposure
  during surgery.” Journal of
  Perioperative
  Practice 16.10(October 2006):
  495.
• International Healthcare Worker Safety Center.
  The University of Virginia.

For additional information, see
Healthcare Wide Hazards –
Bloodborne Pathogens, and
Needlestick/Sharps Injuries.

Potential Hazard

• Developing latex allergy from exposure to products that contain latex such as gloves, catheters, and tubing.

Possible Solutions

• Provide appropriate gloves, including
  powderless, hypoallergenic, glove liners, or other similar alternatives to employees who are allergic to the gloves normally provided
  [29
  CFR 1910.1030(d)(3)(iii)].
  Note: Do not
  assume hypoallergenic gloves are non-latex or latex-free.

In addition, good work
practices should be used. These may include:

• Providing a latex-safe work environment.
• Using non-latex gloves and other latex-free products.
• Selecting a low protein, powder-free glove.

Additional Information:

For additional information, see
Healthcare Wide Hazards –
Latex Allergy

Possible Solutions

Additional Information:

• 1910.101, Compressed
  gases.
  OSHA Standard.
• 1910.103, Hydrogen.
  OSHA Standard.
• 1910.104, Oxygen.
  OSHA Standard.
• 1910.105, Nitrous oxide.
  OSHA Standard.
• 
  Compressed Gas and Equipment. OSHA
  Safety and Health Topics Page.
• NFPA 99, Standard for Health Care Facilities, Chapter
  4, Gas and Vacuum Systems. National Fire
  Protection Association, (2005).

Laser or electrosurgical units may be required
during surgical procedures. Smoke byproduct or
“plume” is created when tissue is thermally
destroyed. Smoke plume may contain toxic gases
and vapors such as benzene, hydrogen cyanide,
and formaldehyde, bioaerosols, dead and live
cellular material (including blood fragments),
and viruses.

The research is limited on transmission of
disease through surgical smoke, but the
potential for generating infectious viral
fragments, particularly during treatment of
venereal warts, may exist. Researchers have
suggested that the smoke may act as a vector for
cancerous cells which may be inhaled by the
surgical team and other exposed individuals.

Potential Hazards

• Exposure to high concentrations of smoke may
  cause ocular and upper respiratory tract
  irritation and create visual problems for the
  perioperative team.

• Smoke may contain toxic gases that could have
  the potential for adverse health impacts, such
  as mutagenic and carcinogenic impacts.

Possible Solutions

• Use portable smoke evacuators and room suction systems
  with inline filters.
• Keep the smoke evacuator or room suction hose nozzle inlet within 2 inches of the surgical site to effectively capture
  airborne contaminants.
• Have a smoke evacuator available for
  every operating room where plume is
  generated.
• Evacuate all smoke, no matter how much
  is generated.
• Keep smoke evacuator “ON” (activated) at all times when airborne particles are produced during all surgical or other
  procedures.
• Consider all tubing, filters, and absorbers as infectious waste and dispose of them appropriately. Use
  Universal Precautions as required by
  the OSHA Bloodborne Pathogens Standard when
  contaminated with blood or OPIM [29
  CFR 1910.1030(d)(1)].
• Use new tubing before each procedure
  and replace the smoke evacuator filter as recommended by the manufacturer.
• Inspect smoke evacuator systems regularly to
  ensure proper functioning.
  

Additional Information:

• Laser/Electrosurgery Plume.
  OSHA
  Safety and Health Topics Page.
• Control of Smoke from Laser/Electric
  Surgical Procedures. U.S. Department of
  Health and Human Services (DHHS), National
  Institute for
  Occupational Safety and Health (NIOSH) Publication No. 96-128,
  (March 2, 1998).
• Association of Perioperative Registered
  Nurses (AORN)
  • Recommended practices for a safe environment
    of care. In: Perioperative
    Standards and Recommended Practices,
    (2008):351-374.
  • 
    Recommended practices for electrosurgery. In:
    Perioperative Standards and
    Recommended Practices, (2008):315-329.
  • 
    Recommended practices for endoscopic
    minimally invasive surgery. In:
    Perioperative Standards and Recommended
    Practices, (2008):331-343.

Although there are hundreds of different
types of lasers, only about a dozen laser
systems are found in everyday clinical
use. Nearly all laser products used in
surgery are
Class 4 as they are
designed to deliver laser radiation for
the purpose of altering biological tissue.

When lasers are
introduced into a healthcare environment,
professionals must be prepared to address
safety issues for both the staff and

patient. Safe use of these systems
requires an understanding of the engineering, training, and administrative
requirements for all elements of a healthcare system as well as the risks
associated with use of laser light.

All medical lasers are
regulated and federal
regulations require manufacturers to
classify the medical laser system based
primarily on its ability to cause damage
to the eye and skin. This classification
must be indicated on the laser system’s
label ranging from Class 1 (no hazard) to
Class 4 (serious hazard).

For a more detailed discussion on lasers,
see the

Use of Medical Lasers.

Potential Hazard

Possible Solutions The American National Standard Institute (ANSI) Z136 series of laser safety standards covers lasers in medical settings and provides guidance for the safe use of lasers for diagnostic, cosmetic, preventative and therapeutic applications in healthcare facilities. These guidelines are considered to be the standard for safe practice in the industry and include solutions such as: Use laser protective eyewear that provides adequate protection against the specific laser wavelengths being used. All laser eyewear must be marked with Optical Density (OD) and laser wavelength. Display warning signs conspicuously on all doors entering the Laser Treatment Controlled Area (LTCA), so as to warn those entering the area of laser use. Warning signs should be covered or removed when the laser is not in use. Maintenance on lasers and laser systems must be performed only by facility-authorized technicians trained in laser service. Provide local exhaust ventilation with a smoke evacuator or a suction system with an in-line filter to reduce laser-generated airborne contaminants (LGAC) levels in laser applications. Use an appropriate filter or barrier which reduces any transmitted laser radiation to levels below the applicable Maximum Permissible Exposure (MPE) level, for all facility windows (exterior or interior) or entryways located within the Nominal Hazard Zone (NHZ) of a Class 3B and Class 4 laser system. Figure 3. Goggles. Figure 4. Class 2 Laser Sign stating: “Caution. Laser Radiation. Do not stare into beam.” Figure 5. Class 4 Laser Sign stating: “Danger. Laser Radiation. Avoid eye or skin exposure to direct or scattered radiation.” Ensure that alignment and calibration techniques are used for routine Perioperative checkout of the laser system. Use skin protection if repeated exposures are anticipated at exposure levels at or near the applicable MPE limits for the skin. Provide detailed training in laser safety for healthcare personnel using or working in the presence of Class 3B and Class 4 healthcare laser systems. Ensure credentialing of staff using laser systems. Additional Information: 1926.54, Nonionizing radiation. OSHA Standard. Laser Hazards. OSHA Safety and Health Topics Page. OSHA Technical Manual (OTM). OSHA Directive TED 01-00-015 [TED 1-0.15A], (January 20, 1999). Laser Hazards. Contains information that will assist in the recognition and evaluation of laser hazards. US Department of Health and Human Services, Food and Drug Administration (FDA), Center for Devices and Radiological Health (CDRH) International Electrotechnical Commission IEC 60825-1/A2:2001. Safety of Laser Products – Part 1: Equipment classification, requirements, and user’s guide. IEC 60825-2 IS 01. Interpretation Sheet 1 Laser Institute of America (LIA). The LIA is the secretariat and publisher of the ANSI Z136 series of laser safety standards. They are recognized as a minimum standard for laser safety. ANSI Z136.1-2007. American National Standard for the Safe Use of Lasers. ANSI Z136.3-2005. American National Standard for the Safe Use of Lasers in Health Care Facilities. Recommended practices for laser safety in practice setting. Association of Perioperative Registered Nurses (AORN), In: Perioperative Standards and Recommended Practices, (2008):447-452.

Potential Hazard

• Exposure to possible hazardous chemicals found and used in the surgical area
  typically during mixing, preparation, and in
  the operating room.

  • This may include peracetic acid used in cold
    sterilant machines, Methyl Methacrylate (MMA),
    an acrylic cement-like substance used to
    secure prostheses to bone during orthopedic
    surgery, and
    
    waste anesthetic gases.

Possible Solutions

• Mix methyl methacrylate only in a closed system.
• Carefully read and follow instructions and warnings on labels, (e.g., when using cold sterilant machines for
  sterilizating equipment that cannot be autoclaved, use goggles provided and do not open machine until it is in a
  safe to open mode).
• Consider using disinfectants or other products that are not hazardous.
• Inform employees of chemical hazards and have on hand Material Safety
  Data Sheets, (MSDS) for all hazardous chemicals used in their facilities
  [29 CFR 1910.1200].
• Follow all MSDS instructions regarding safe handling, storage, and disposal of hazardous chemicals.
  

For additional information, see Healthcare Wide Hazards – Hazardous Chemicals and Glutaraldehyde.
See also Central Supply – Ethylene Oxide.

Potential Hazard

• Exposure to burns or shocks from poorly maintained equipment (e.g., autoclaves, warming cabinets, defibrillators) or improperly trained staff.

Possible Solutions

• Create a safety and health program that
  routinely monitors the condition of equipment
  and addresses work practices of employees.
  This program should include practices such as:

• Train employees to correctly and safely use
  and clean equipment.
  
• Maintain adequate working space and access to equipment.
  
• Visually inspect equipment before using.
  • Visually inspect cords. Do not
    use if frayed or damaged.
  • If something does not look right, do not use the machine and call for assistance.
• Ensure that all electrical service
  equipment near sources of water are properly grounded
  [29
  CFR 1910.304].
• Use appropriate personal protective equipment and safe work practices for assessed hazards (e.g., when handling hot items
  use gloves, and do not open autoclaves or sterilizers until items are sufficiently cooled).
  
• Adhere to all manufacturer and
  operator instructions to ensure safe use
  of equipment.

Additional Information:

• Avoiding Hazards with Using Cleaners and
  Disinfectants on Electronic Medical
  Equipment. OSHA, Food and Drug
  Administration (FDA), Centers for Disease
  Control (CDC), and Environmental Protection
  Agency (EPA)
  Public Health Notification, (October 31,2007).

For additional information, see Healthcare Wide Hazards – Electrical, and PPE.

Potential Hazards

• Falling over portable equipment of a color
  that visually
  blends into the floor.

• Slipping on debris (bandages, tubing, blood,
  IV fluids) that had fallen or spilled on the
  floor.

• Tripping on
  electrical cords that may cross floors.

Possible Solutions

• Keep aisles and passageways clear and in good repair, with no obstructions across or in aisles that may create a hazard [29
  CFR 1910.22(a)].
• Provide ceiling or floor outlets for equipment to
  ensure that power cords do not run across pathways.
• Mark mobile equipment (e.g., stools) with a bright color, or a taped “X”,
  making them more visible and distinguishable from the floor.
  Tape should be washable and durable.

For additional information, see Healthcare Wide Hazards – Slips/Trips/Falls