Perioperative team members and patients face a risk of exposure to surgical smoke on a daily basis. Surgical smoke is a by-product released in the air after vaporization and tissue disruption by the energy-generating health care equipment (lasers, powered instruments, electrosurgical units) (Fencl, 2017). In 2018 the Occupational Safety and Health Administration (OSHA) estimated that more than 500,000 healthcare workers were exposed to surgical smoke every year (Occupational Safety and Health Administration [OSHA], as cited in Spruce, 2018).
Surgical smoke creates multiple hazards to patient’s and nursing personnel’s health. Firstly, it contains volatile carcinogenic molecules, such as acrylonitrile (a cyanide precursor) and carbon monoxide (Abbas et al., 2020). In addition, inhalation of surgical smoke increases the risk of infection, respiratory diseases, and strokes (Karjalainen et al., 2018). Therefore, the perioperative nursing personnel and hospital leadership must be aware of health-related risks that surgical smoke creates in order to develop and implement prevention measures.
Background of the Study
Surgical smoke has confirmed hazardous properties; however, in time of the COVID-19 pandemic, it is extremely important to raise additional awareness in perioperative nursing personnel. Several scientific societies, such as the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) and the European Society for Endoscopic Surgery (EAES), recommended the implementation of filtering systems in operating theatres (Campanile & Campanile, 2020).
Therefore, the surgeons and perioperative team members cannot ignore the matter of surgical smoke awareness any longer. Hospital leadership should evaluate the personnel’s awareness of surgical smoke’s harmful effects and promote knowledge about existing air filtering technologies and solutions.
Problem Statement
The fundamental problem lies in insufficient information regarding the awareness of surgical smoke’s harmful effects among the perioperative teams of the Regency Specialist Hospital in Johor. Even if team members have the necessary knowledge, it is still unknown whether they use it to mitigate possible risks for health.
In addition, the lack of awareness among the personnel might cause a lack of necessary equipment for a surgical smoke evacuation since hospital leadership might be unaware as well. Therefore, the nursing personnel’s awareness of surgical smoke’s harmful effects must be evaluated and raised in case of necessity. The hospital leadership should pay attention to the awareness evaluation results and invest in measures of adequate protection from surgical smoke.
Research Questions
- Do the perioperative team members of the Regency Specialist Hospital possess theoretic knowledge about harmful effects of the surgical smoke?
- Do the perioperative team members of the Regency Specialist Hospital experience harmful effects of the surgical smoke in operating room?
- Do the perioperative team members of the Regency Specialist Hospital use their theoretic knowledge to protect themselves from the surgical smoke hazard?
Research Objectives
The proposed research will focus on completing the following key objectives:
- General Objective: identification of awareness level among the perioperative team members towards surgical smoke hazard;
- Specific Objective: verification of knowledge level within perioperative team members towards surgical smoke hazard and working experience
Completing these research objectives would allow to provide the hospital leadership with the necessary information and implement adequate protection measures against the surgical smoke hazard.
Hypotheses of the Study
- H1: Since the Regency Specialist Hospital conducts a significant amount of surgeries, the staff will have a necessary theoretic knowledge about the surgical smoke hazard;
- H2: It will be found, that the staff uses protective measures to mitigate consequences of exposure to surgical smoke; however, the level of exposure and the adequacy of protective measures are yet unknown.
Significance of the Study
The study will have a significant favorable influence on the hospital, perioperative team members, and the patients. First of all, the Regency Specialist Hospital in Johor would be able to obtain evidence of the personnel awareness towards the surgical smoke hazard and implement the necessary measures of protection. In addition, the Regency Specialist Hospital would be able to improve its image among the perioperative professionals. As a result, the hospital could possibly increase the quality of health care services in comparison to other organizations.
The research will also be beneficial for the perioperative team members since its results could raise the awareness of hospital leadership and lead to improvement of the protective equipment. The possible improvement of protection against surgical smoke would positively impact perioperative team members’ health condition. As nursing personnel directly involved in the activity of operating theatre, perioperative team members would greatly benefit from the improvements in occupational safety.
Finally, the research would help the patients since they are also exposed to surgical smoke and all its adverse effects. If the hospital leadership and perioperative team members raise their awareness, the patients would be able to receive safer, better-quality health care. After all, the hospital exists to provide health care for the people, so the patient’s well-being should always remain one of the most important considerations.
Definitions
The research uses the following definitions for different kinds of surgical smoke and equipment, which produces them.
- Smoke — by-products of combustion that pose a chemical hazard;
- Vapor — suspended particles that pose a biological hazard;
- Plume —by-products of combustion and non-combustion process.
- Electrosurgical unit (ESU) — surgical equipment that uses high-frequency electric current for cutting or destroying tissue.
Literature Review
The idea behind this research proposal is based on scholarly articles, which explore the harmful effects of surgical smoke and present the arguments for the use of protective equipment and smoke evacuation systems. The knowledge from those articles provides an insight into the importance of surgical smoke hazard awareness among the perioperative team members and hospital leadership. The topics of articles on surgical smoke hazards can be separated into three groups: harmful chemical components, protective measures, and
Several pieces of research focused on listing the harmful chemical particles contained in surgical smoke. York and Autry (2018) mentioned that surgical smoke includes volatile organic compounds, which can be carcinogenic for humans. Karjalainen et al. (2018) added that surgical smoke contains airborne particles, which can penetrate the defensive mechanism of the upper respiratory tract and cannot be stopped by a standard surgical mask. In general, those authors stress the necessity of raising awareness among the nursing personnel due to the multiple negative health implications.
Another important topic of researches is protective measures from the negative impact of surgical smoke. For instance, Spruce (2018) provided the essential guidelines and takeaways for the surgical smoke evacuation. Fencl (2017) listed all necessary practices for perioperative teams, such as education and competency verification, smoke evacuation, and quality assurance. Michaelis et al. (2020) shared practical experience from the German operating rooms and suggested that surgeons and assistant staff should be better informed about the possible health risks of surgical smoke its prevention.
Finally, Swerdlow (2020) stated that anesthesia providers do not apply knowledge about the surgical smoke hazard to their daily working practices. Overall, the articles from that group provide an overview of the existing protective measures and suggest the necessary working practices for the nursing personnel.
Some articles focused on the exploration of the particular smoke evacuation devices. For instance, Campanile & Campanile (2020) noted the lack of technical competence among the perioperative nursing personnel in light of the COVID-19 pandemic and provided a detailed classification of filters and filtering mechanisms. Hahn et al. (2017) conducted a study of the built-in filter trocar effectiveness and came to a conclusion that simple filtration presents a cost-efficient way of protection from the surgical smoke hazard. Therefore, those articles proved that even the basic equipment could effectively deal with the surgical smoke issue, and the most critical problem remains in personnel awareness.
Finally, the last of the reviewed articles provided significant insight into the possible methodology of this research. Abbas et al. (2020) conducted qualitative research on surgical smoke awareness among hospital workers in Karachi, Pakistan. Their work was based on a questionnaire of six questions, which revealed the awareness of surgical smoke hazards and the common symptoms of exposure. In that regard, the research by Abbas et al. served as a source of inspiration for this proposal since the researchers managed to create relatively simple yet effective instrumentation.
Theoretical Framework
The lack of surgical smoke hazard awareness among the perioperative team members is harmful in two ways. Firstly, the exposure to chemical particles in smoke, vapor, and plume produced by the ESU might lead to cancer, infections, and respiratory diseases among the nursing personnel and the patients. Secondly, the unaware personnel will not be able to express their concerns to the hospital’s leadership. According to Michaelis et al. (2020), operating room nurses can play an active role as advocates for their health. Without sufficient personnel awareness, the hospital leadership will not receive necessary feedback and improve occupational safety.
To address these problems, we propose to conduct questionnaire-based qualitative research among the perioperative team members in Regency Specialist Hospital. This research would allow collecting the qualitative data necessary to evaluate the awareness level and health conditions among the personnel. The gathered and analyzed data can be further submitted to the hospital leadership. Due to an actual understanding of the situation, the leadership would be able to decide whether the personnel and patients are adequately protected against the surgical smoke hazard. If the protection level is insufficient, the hospital leadership would have evidence in favor of improvement of the existing protective measures.
Methodology
This chapter focuses on the practical aspects of the proposal, such as research design, study setting, population and sampling, instrumentation, ethical considerations, validity, reliability, and the process and method of data collection. The result should be sufficient for the evaluation of personnel awareness. Furthermore, the gathered information will be presented to the hospital leadership so that it could decide if any extra protective measures against surgical smoke are necessary.
Research Design
The research will utilize a quantitative descriptive method and include two major stages. Firstly, the respondents from the perioperative personnel of the Regency Specialist Hospital will have to fill out a questionnaire. That stage will serve for gathering the data regarding the surgical smoke hazard awareness among the personnel. After that, the data will be analyzed with a Statistical Package for Social Science (SPSS) software. A Gantt’s chart provides a list of the key milestones, which must be achieved throughout the research process.
Table 1: Gantt’s Chart.
Study Setting
The research will be focused on perioperative personnel of the Regency Specialist Hospital in Johor. This private medical facility has served over 1 million patients since 2009 and has conducted over 10000 surgeries in the last three years (Regency Specialist Hospital, 2021). Nowadays, the hospital employs over 700 staff members and treats over 170,000 patients annually (Regency Specialist Hospital, 2021).
Therefore, the perioperative teams have to face a risk of exposure to surgical smoke constantly. The practical part of the research will take place from July 2021 until the end of September 2021 on the approval of the Acting Director of Nursing and the Head of the Operation Theatre Department. The gathered data will be analyzed and prepared for presentation by the end of December 2021.
Population and Sampling
The research population will include the whole staff of the Regency Specialist Hospital’s Operation Theatre Department. In total, this will make 70 respondents: 41 nurses, 24 surgeons, and 5 anesthetists. A small sample would not allow to evaluate the awareness level of personnel properly. Furthermore, the inclusion of all available personnel in the research population will create a necessary reserve if some team members refuse to participate. In addition, the selected sample would allow to evaluate the awareness of surgical smoke hazards among the different types of perioperative professionals.
Sample Size Calculation
This research does not require any specific formula for sample size calculation, since the whole staff will be included in the default research population for the reasons, listed in the section 3.3.
Inclusion & Exclusion Criteria of the Sample
- Inclusion Criteria: whole staff of the Regency Specialist Hospital’s Operation Theatre Department is included in the research sample by default;
- Exclusion Criteria: the only exclusion criteria from the sample is an explicit disagreement to provide a written consent for participation.
Instrumentation
The main instrument for this research will be a questionnaire for the perioperative personnel. The questionnaire is based on the one used by Abbas et al. (2020) in their research of Pakistani hospitals. The reason for choosing that design is its complex nature, which encompasses both demographic and professional aspects.
- Part A includes four questions related to demographics: age, gender, the surgical specialty of respondents, and their length of service in operation theatre;
- Part B includes ten questions related to professional experience and awareness about surgical smoke hazards.
Ethical Considerations
The research will be conducted ethically and respect all possible considerations. First of all, permission for conducting the study will be obtained from the Acting Director of Nursing and the Head of the Operation Theatre Department of the Regency Specialist Hospital. Secondly, a written consent will be obtained from the respondents, and they will have a right not to participate in the research if they wish so.
The respondents will receive an explanation regarding the nature and purpose of the study. All information obtained from the perioperative personnel will be used solely for research purposes and remain strictly confidential. In addition, all participants will be attributed with a unique code in order to ensure confidentiality. After the final results are ready, the information related to the procedure of research will be destroyed.
Validity and Reliability
The validity of the research mostly depends on the accuracy of the questionnaire or, to be precise, the honesty of the participants. Before conducting the research, a consultation with an expert will be held in order to understand whether the questions require reformatting. The approached expert will be selected among the perioperative professionals from the Regency Specialist Hospital. However, Abbas et al. (2020) proved that a similar research method works for perioperative personnel awareness evaluation. Therefore, a modified questionnaire of a similar style will be used for the initial gathering of research data.
The research reliability will be ensured via conducting the pilot study among the randomly pre-selected perioperative personnel of the Regency Specialist Hospital. In addition, several members of the pilot group will be surveyed in two weeks after the ending of the initial study, and a Cronbach’s alpha coefficient will be calculated for their responses. Therefore, the possible contradictions and discrepancies might be revealed before conducting the full scope research. Overall, this procedure would allow the polishing of the research instrumentation in case of necessity.
Data Collection Method and Process
The research data will be collected according to the following procedure:
Pilot Study and Data Analysis Plan
The pilot study group will consist of 10 perioperative professionals of the Regency Specialist Hospital. The members will be randomly pre-selected after the approval of the proposal from the hospital leadership. In total, the pilot group will consist of 6 nurses, 3 surgeons, and 1 anesthetist. The questionnaire will be distributed among the pilot group members, and the initial results will be evaluated with a Cronbach’s alpha coefficient. If the questionnaire proves to be unreliable, it will be modified until the reliable Cronbach’s alpha is achieved. Therefore, the ultimate goal of the pilot study is the development of reliable instrumentation suitable for conducting research in the main test group.
After the questionnaire stage, the gathered data will be analyzed with the most recent version of SPSS software available. Mean and standard deviation will be calculated for the quantitative variables. Frequencies and percentages will be calculated for the representation of the qualitative variables. Finally, the data will be stratified in order to compare the knowledge and awareness level of the different groups within the perioperative professionals.
Conclusion
Surgical smoke is constantly present in the operating rooms since ESU produces it during the surgeries by disrupting or evaporating the tissues. The smoke contains multiple harmful components, such as volatile organic compounds and airborne particles, which can cause cancer and respiratory diseases. Therefore, surgical smoke poses a threat to the health of the perioperative professionals and patients, so the hospital leadership should implement adequate protective measures against it. The most obvious solution would be installing protective filtering systems; however, that measure should be implemented in connection with educational activities for the personnel.
It is highly important to evaluate the knowledge of the perioperative team members before undertaking any other steps. The hospital might purchase and install expensive filtering and evacuation equipment. However, those systems will be operated by perioperative personnel, and if the employees lack the awareness of surgical smoke hazards, they will fail to use the equipment to its full potential. On the other hand, the knowledgeable and aware team members will be able to provide valuable feedback to the hospital leadership and facilitate the implementation of the necessary protective measures. Therefore, evaluation and subsequent raising of awareness levels among the perioperative staff should become a priority in resolving the surgical smoke problem.
References
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Campanile, F. C., & Campanile, L. F. (2020). Smoke evacuation filters after the COVID-19 pandemic: technical awareness for safety. Annals of Surgery, 272(4), e266-e268. Web.
Fencl, J. L. (2017). Guideline implementation: surgical smoke safety.AORN Journal, 105(5), 488-497. Web.
Hahn, K. Y., Kang, D. W., Azman, Z. A. M., Kim, S. Y., & Kim, S. H. (2017). Removal of hazardous surgical smoke using a built-in-filter trocar: a study in laparoscopic rectal resection. Surgical Laparoscopy Endoscopy & Percutaneous Techniques, 27(5), 341-345. Web.
Karjalainen, M., Kontunen, A., Saari, S., Rönkkö, T., Lekkala, J., Roine, A., & Oksala, N. (2018). The characterization of surgical smoke from various tissues and its implications for occupational safety.PloS One, 13(4), 1-4. Web.
Michaelis, M., Hofmann, F. M., Nienhaus, A., & Eickmann, U. (2020). Surgical smoke — hazard perceptions and protective measures in German operating rooms.International Journal of Environmental Research and Public Health, 17(2), 1-16. Web.
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Swerdlow, B. N. (2020). Surgical smoke and the anesthesia provider.Journal of Anesthesia, (34) 575-584. Web.
York, K., & Autry, M. (2018). Surgical smoke: Putting the pieces together to become smoke‐free.AORN Journal, 107(6), 692-703. Web.