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Surgical Suite

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Surgical Suite Waste Anesthetic Gases Stool Bloodborne Pathogens Cold Sterilant Machine Sterilizer Lasers Latex Allergy Slips, Trips and Falls Compressed Gases Outlet Anesthesia Foot Stool Bloodborne Pathogens

Common safety and health topics:

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Waste Anesthetic Gases

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:
  • Vaporizers of anesthesia machines be turned off when not in use. Proper face masks, sufficiently inflated endotracheal tubes, and the prevention of anesthetic spills will decrease the amount of waste anesthetic gases in the operating room.

  • Inspection and maintenance of anesthesia machines be conducted by factory service representatives or other qualified personnel at least every four months. Leakage of gas should be less than 100 ml/min during normal operation. During normal operation, employee exposure to anesthetic gases in use should not exceed the NIOSH recommended exposure limits.

  • Prior to each day's use, a complete check of all anesthesia equipment (connectors, tubing, etc.) be conducted.

  • Spills of liquid anesthetic agents be cleaned up promptly.

  • Information be provided and a training program implemented in accordance with OSHA's Hazard Communication Standard [29 CFR 1910.1200] for all employees exposed to waste anesthetic gases.

    Book See Healthcare Wide Hazards - Hazardous Chemicals.

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).
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Bloodborne Pathogens (BBPs)

Potential Hazard

  • Occupational exposure to blood and other potentially infectious materials (OPIM) places employees at risk of infection from bloodborne pathogens such as Hepatitis B Virus (HBV), Hepatitis C Virus (HCV) and Human Immunodeficiency Virus (HIV) while performing surgery-related tasks.

Possible Solutions

Among other things, OSHA's 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:

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

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Latex Allergy

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:

Books For additional information, see Healthcare Wide Hazards - Latex Allergy

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Compressed Gases

Within a healthcare facility, compressed gases are usually either fixed piped gas systems or individual cylinders of gases.

Potential Hazard

  • Potential hazards associated with compressed gas will vary based on the chemicals; however, they may include fire, explosion, and toxicity.
Cylinders of compressed gas.
Figure 1. Cylinders of compressed gas.

Possible Solutions

  • Store, handle, and use compressed gases in accordance with 29 CFR 1910.101 and Pamphlet P-1-1965 from the Compressed Gas Association.

  • All cylinders whether empty or full must be stored upright.

  • Secure cylinders of compressed gases. Cylinders should never be dropped or allowed to strike each other with force.

  • Transport compressed gas cylinders with protective caps in place and do not roll or drag the cylinders.
Caution: Keep All Cylinders Chained.
Figure 2. Caution: Keep
All Cylinders Chained.

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).
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Static and Awkward Postures

Medical staff in a surgical setting often assume prolonged awkward postures. Typically, employees vary in height which may require work surfaces at differing heights to minimize awkward postures.

Potential Hazards

  • Standing in static postures continuously during lengthy surgical procedures, causes muscle fatigue and pooling of blood in the lower extremities.

  • Standing on hard work surfaces such as concrete creates trauma and pain to the feet.

  • Awkward postures resulting from prolonged standing, trunk flexion, neck flexion, and arms held higher than the optimal working height.

Possible Solutions

  • Provide stools, where possible.

  • Use shoes with well-cushioned insteps and soles.

  • Provide a footrest bar or a low stool, allowing employees to continually alter their posture by raising one foot.

  • Use height-adjustable work tables and surfaces.

  • Use anti-fatigue mats.

Additional Information:

  • Association of Perioperative Registered Nurses (AORN)
    • Guidance Statement: Safe Patient Handling and Movement in the Perioperative Setting. (2007).
    • Recommended practices for positioning the patient in the Perioperative practice setting. In: Perioperative Standards and Recommended Practices, (2008):497-520.
Books For additional information, see Healthcare Wide Hazards - Ergonomics, Awkward Postures.
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Smoke Plume

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.
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Laser Hazards

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.

Class 2-Laser Sign stating: "Caution. Laser Radiation. Do not stare into beam."
Figure 4. Class 2 Laser Sign stating: "Caution. Laser Radiation. Do not stare into beam."

Class 4 - Laser Sign stating: "Danger. Laser Radiation. Avoid eye or skin exposure to direct or scattered radiation."
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.

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Hazardous Chemicals

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

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Equipment Hazards

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).

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

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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.
Books For additional information, see Healthcare Wide Hazards - Slips/Trips/Falls

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