Implementing a Surgical Smoke Evacuation Policy and Procedure: A Quality Improvement Project

Energy-generating surgical devices (eg, electrosurgical units, lasers) produce surgical smoke that can cause negative health effects in exposed individuals. In 2019, a review of nursing documentation at an urban teaching hospital revealed that personnel were properly evacuating surgical smoke during less than 0.5% of applicable procedures. To address the noncompliance and reduce exposure to surgical smoke, an interdisciplinary team initiated a quality improvement project to implement a surgical smoke evacuation policy for all smoke-generating procedures. The project included creation and implementation of a smoke evacuation policy, staff member education on the hazards of surgical smoke and proper evacuation device use, and acquisition of the proper smoke evacuation equipment. After instituting the policy in June 2020, results of a three-month chart audit showed that there was nursing documentation confirming personnel used energy-generating devices and the corresponding surgical smoke evacuation devices during 664 of 2,224 procedures, for a compliance rate of 30%.