Surgical Smoke Plume Evacuation System Equipment and Policies

Section 250.1325  Surgical Smoke Plume Evacuation System Equipment and Policies a) To protect patients and health care workers from the hazards of surgical smoke plume, hospitals shall adopt policies to ensure the elimination of surgical smoke plume by use of a surgical smoke plume evacuation system for each procedure that generates surgical smoke plume from the use of energy-based devices, including, but not limited to, electrosurgery and lasers. (Section 6.32(b) of the Act) 1)         The facility's surgical department shall perform a risk assessment to identify all procedures that are performed with energy-based surgical devices (e.g. lasers, electrosurgical instruments, and ultrasonic devices) that generate a surgical smoke plume and will require the use of a surgical smoke plume evacuation system. 2)         All surgical team members shall be trained on the methods for mitigating the hazards and minimizing exposure to surgical smoke plume, positioning and operating surgical smoke plume evacuation pursuant to the manufacturer's instructions, and the requirements in facility policies and procedures for management of surgical smoke plume. 3)         Staff shall wear appropriate respiratory protection when needed as secondary protection against residual smoke in accordance with the hospital's respiratory protection plan. 4)         To protect against potential smoke hazards, the facility’s policy and procedure shall minimally include: A)        During utilization of the smoke evacuator, the suction nozzle inlet shall be positioned as close to the surgical site as possible to maximize capture of airborne contaminants. B)        The smoke evacuator shall be “ON” (activated) at all times when airborne particles are produced during all surgical or other procedures C)        New tubing shall be used before each procedure and the smoke evacuator filter shall be replaced as recommended by the manufacturer. Consider all tubing, filters and absorbers as infectious waste and dispose of appropriately in accordance with OSHA bloodborne pathogens standards. D)        Inspection of smoke evacuator systems regularly, including inspection immediately prior to use, to ensure proper functioning. b) The hospital shall report to the Department that policies required under subsection (a) have been adopted .  The hospital shall provide the Department a letter identifying the date of the adoption of the facility's policy for utilization of smoke evacuation system. (Section 6.32(c) of the Act)