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Air Quality in the Operating Suite Nursing CE Course

1.0 ANCC Contact Hour

About this course:

The purpose of this activity is to enable the learner to identify the dangers of surgical smoke, mitigation methods, compliance improvement efforts, and ways to bring smoke evacuation practices beyond the healthcare facility level.

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Purpose Statement

The purpose of this activity is to enable the learner to identify the dangers of surgical smoke, mitigation methods, compliance improvement efforts, and ways to bring smoke evacuation practices beyond the healthcare facility level.


  • Explore the contents and health hazards of surgical smoke
  • Review case reports of perioperative personnel negatively affected by the poor air quality in operating rooms
  • Explore the risks to patients from poor air quality in operating rooms
  • Understand the key components of a surgical smoke evacuation program
  • Review the Association for PeriOperative Registered Nurses’ Go Clear Award
  • Explore the milestones of surgical smoke evacuation legislation

Poor air quality in the operating room can negatively affect everyone in the operating room suite, including the patient. The primary cause of poor air quality in the operating room is surgical smoke (Fencl, 2017). A concept analysis performed by Vortman et al. (2021) defines surgical smoke as “a visible plume of aerosolized combustion byproducts produced by heat-generating surgical instruments” (p. 1). It contains toxic chemicals as well as bacteria, viruses, and tumor particles that may be inhaled and may obscure the surgical field and dimmish provider visibility (Vortman et al., 2021). Surgical smoke is created from energy-generating devices, such as lasers and electrosurgical units, used within the operating room. Surgical smoke contains biohazardous substances that pose risks to perioperative personnel and patients. More information and research regarding the dangers of surgical smoke are emerging every day, but it is still not common practice to reduce surgical smoke in the operating room. This is primarily due to the lack of knowledge regarding the dangers of surgical smoke and a lack of compliance for using products designed to reduce surgical smoke (Fencl, 2017). Smoke evacuation implementation programs vastly improve the air quality in the operating room. By following a few essential steps (i.e., performing a literature search, identifying barriers, building awareness and gaining buy-in, creating a multidisciplinary team, conducting trials, and establishing policies), operating rooms will have the proper air quality personnel and patients deserve. Recently, legislation has been created to help control surgical smoke (Ball, 2018). Perioperative nurses are responsible for protecting themselves, their colleagues, and patients from the dangers of surgical smoke.

What is Surgical Smoke, and Why is it Dangerous?

Surgical smoke is created when energy-generating devices are activated on organic material, such as human tissue. While it can be seen, surgical smoke is more easily identified by its noxious and malodorous vapor (Spruce, 2020). Studies performed 40 years ago by Tomita et al. (1981) demonstrated surgical smoke’s mutagenic potency. Surgical smoke can contain chemicals, bioaerosols, bacteria, viruses (e.g., HIV and human papillomavirus [HPV]), tissue, blood, nonviable particles, and viable cancer cells (Croke, 2021; Vortman et al., 2021). The hazards of breathing in the contents of surgical smoke include chemical, carcinogenic, mutagenic, respiratory, and cytotoxic concerns (Spruce, 2020). It is currently unknown whether SARS-CoV-2 is transmissible through surgical smoke, but evidence has confirmed the transmission of other viruses; therefore, this risk is certainly possible (Croke, 2021). Researchers hypothesize the aerosolization of SARS-CoV-2 endangers perioperative teams because the virus has been located in the cells that line the respiratory system as well as the gastrointestinal tract (Spruce, 2020). 

The US Occupational Safety and Health Administration (OSHA, 1988) issued a Hazard Information Bulletin regarding the potential associated harm of surgical smoke related to the increased use of carbon dioxide in laser surgery. The regulatory body urged the medical community to consider these hazards carefully within this bulletin. It cited multiple studies indicating the potential contaminants of surgical smoke, including viral particles/DNA and those too small to be filtered out by a standard surgical mask. The bulletin urged operating suites to establish appropriate precautions and referenced the effectiveness of “mechanical smoke vacuuming systems” (OSHA, 1988)

Surgical smoke has been compared to tobacco cigarette smoke due to its similar contents and equivalent risk of harm (Spruce, 2020). Surgical smoke contains over 150 chemicals, including formaldehyde, carbon monoxide, benzene, toluene, acetaldehyde, hydrogen cyanide, and volatile organic compounds (Spruce, 2018). These chemical contents of surgical smoke include 16 US Environmental Protection Agency (EPA) priority pollutants (see Box 1; Hedley, 2018). Cauterizing one gram of tissue with an electrosurgical unit is equivalent to smoking six unfiltered cigarettes in 15 minutes. In context, one gram of tissue is the size of a penny (Dobbie et al., 2017). Conditions and symptoms that may develop from surgical smoke inhalation include coughing, a sore throat, watery eyes, headaches, dizziness, drowsiness, nausea, rhinitis, sneezing, and bad odors absorbed into an individual’s hair (Pennock, 2021; Vortman et al., 2021). 

There have been numerous reports of human disease directly connected with the inhalation of surgical smoke. One case report involves a 28-year-old gynecology operating room nurse who developed a histologically proven recurrent case of laryngeal papillomatosis. The correlation between her diagnosis and surgical smoke was strong because she repeatedly assisted on surgical cases involving the excision of genital condylomas using electrosurgical units and a laser. In a similar case, a 53-year-old gynecologist had a lump on his neck biopsied, which tested positive for human papillomavirus (HPV) type 16 and squamous cell carcinoma. The gynecologist did not have any risk factors for HPV or oropharyngeal cancer except via surgical smoke from more than 3,000 surgical cases involving dysplastic cervical and vulvar lesions (Spruce, 2018). 

Dr. Anthony Hedley, an orthopedic surgeon, seeks to warn others of the dangers of surgical smoke. Hedley was diagnosed with idiopathic pulmonary fibrosis and required a double lung transplant to survive. Environmental pollutants are attributed to idiopathic pulmonary fibrosis, but Dr. Hedley did not smoke cigarettes, and he was not exposed to Agent Orange while in the military. His primary environmental pollutant exposure was surgical smoke (Hedley, 2018). Compared to the general public, perioperative nurses suffer twice as many respiratory-related health issues (Vortman et al., 2021). OSHA estimates that more than 500,000 healthcare workers are exposed to surgical smoke each year (Spruce, 2018). 

Patients are also at risk for adverse health effects from surgical smoke. Risks to patients from surgical smoke include port-site metastasis, carbon monoxide exposure, high levels of carboxyhemoglobin, and extended procedure time due to a reduction in surgical field visibility from the smoke (Vortman et al., 2021). Patients undergoing laparoscopic cholecystectomies were studied to identify the chemical composition of surgical smoke within the body following surgery. A urine sample was collected from each patient upon admission to the hospital to establish a baseline. The patients were anesthetized using the same methods and equipment, and the patients all recovered in the same room postoperatively to reduce variability. Each patient’s first urine sample was collected within 5-12 hours postoperatively and stored at 4° C (39° F) until analyzed. Researchers found over 40 chemicals in the urine with significantly high concentrations of benzene

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and toluene, known human carcinogens. Benzene was three times higher than the preoperative levels (Ball, 2018). 

Another study regarding surgical smoke effects studied patients receiving laparoscopic gynecological procedures. The study had a control group and an intervention group. In the control group, surgeons did not use smoke-generating devices, while surgeons in the intervention group utilized a carbon dioxide laser and an electrosurgical unit. Patients in the control group did not show any changes postoperatively in their pulse oximetry readings, carboxyhemoglobin levels, or intra-abdominal carbon monoxide levels. In contrast, patients in the intervention group showed increased intra-abdominal carbon monoxide levels. This is a significant health concern because it may enter the bloodstream causing hypoxic stress in an otherwise healthy patient. Postoperative blood samples taken from patients in the intervention group demonstrated increased carboxyhemoglobin and methemoglobin levels, which decrease red blood cells’ capability to carry oxygen. Port-site metastasis is another concern with laparoscopic surgery and surgical smoke. This occurs when cancer cells spread to the trocar port sites when the cancer cells become aerosolized. Although this is a concern, scientists acknowledge that more research needs to be done (Ball, 2018).

While there are no specific standards related to surgical plume, OSHA (2021) has two general industry standards related to air quality. The first standard, 1910 Subpart I, involves respiratory protection with the primary goal of controlling occupational harm caused by inhaling contaminated air. The OSHA standard states this is to be achieved through engineering controls, such as room ventilation, equipment, surgical smoke evacuation systems, and respiratory protection. In addition, the standard specifies that surgical masks are not certified as respiratory protection for medical professionals. The second general industry standard, 1910 Subpart Z, covers toxic and hazardous substances. Standard Z states that employers must provide personal protective equipment, including N95 masks, if smoke evacuation systems are unavailable (OSHA, 2021). By reducing surgical smoke in the operating room, perioperative nurses and nurse leaders can improve the health and safety of perioperative personnel and surgical patients. OSHA’s hierarchy of controls should be utilized to do this (Croke, 2021). The OSHA hierarchy entails smoke evacuation systems, room ventilation, and personal protective equipment, such as N95 masks, for added respiratory protection (OSHA, 2021). 

Implementing a Smoke Evacuation Program

Healthcare facilities across the nation are considered smoke-free environments. Sadly, this does not usually apply to the facility’s operating room. Perioperative personnel and patients deserve the same protection as the rest of the healthcare facility (Croke, 2021). The creation of a surgical smoke evacuation program involves multiple steps. The first step is to perform a literature search to gain evidence that surgical smoke is harmful and determine how to minimize the risks of surgical smoke inhalation. The next steps are identifying barriers, building awareness, educating, and gaining buy-in. Next, assembling a multidisciplinary team and trialing and evaluating equipment and devices should be performed. The last step is creating a policy to ensure consistent use of equipment that will provide the best air quality in the operating room (Vortman et al., 2021). 

Literature Search

A literature search can supply key information regarding surgical smoke and how to mitigate it. This will build the necessary evidence to validate perioperative nurses trying to create change within the operating room and provide a rationale for investing in a surgical smoke evacuation program. It is imperative to use evidence-based research and qualified sources when conducting this literature search. Organizations that provide evidence and recommendations for surgical smoke evacuation include the American National Standards Institute, the Association of periOperative Registered Nurses (AORN), the National Institute of Occupational Safety and Health, and OSHA (Croke, 2021; Vortman et al., 2021). 

Identifying Barriers

Diverse barriers affect the air quality in the operating room. Common barriers perioperative nurses face are surgeon refusal, limited or no access to smoke evacuation equipment, the noise of existing equipment options, staff competency, and a lack of leadership/policy (Vortman et al., 2021).

Building Awareness and Gaining Buy-In

Identifying and addressing knowledge gaps of perioperative personnel is an essential step in the process. Providing an educational in-service education to staff will spread awareness of the dangers of surgical smoke. This may encourage other perioperative staff to address air-quality issues within the operating room. Gaining buy-in from key personnel in the healthcare facility and the operating room will increase support for and interest in a surgical smoke evacuation program. By building awareness through education, perioperative personnel may come forward to aid in the surgical smoke evacuation program. An engaged team will be more apt to accept change and utilize the necessary equipment (Croke, 2021).

Creating a Multidisciplinary Team

Creating a multidisciplinary team can allow medical leadership to establish and maintain a surgical smoke evacuation program (Dobbie et al., 2017). The team may consist of perioperative nurses, surgical technologists, surgeons, anesthesia providers, a perioperative nurse manager, a perioperative department director, and a member of the supply chain, among others. A multidisciplinary team approach will ensure appropriate representation. Surgeon champions must appear on this team, as they are often instrumental to the change process and can help combat the surgeon refusal barrier. This team should set a goal date for achieving a smoke-free operating room and share this date with the perioperative department. This allows the perioperative staff to work toward a common target. In addition, having a clear goal date may increase teamwork, morale, and engagement (Croke, 2021). 

Trialing and Evaluating Equipment

In addition to room ventilation, a surgical smoke evacuator is the first line of defense against surgical smoke inhalation (Fencl, 2017). Many options for smoke evacuation systems are available; therefore, it is ideal to trial a few systems to find the one that works best for the entire perioperative department. The multidisciplinary team can research the options available and make selections. Trialing and evaluating systems will help users decide which system they prefer to purchase. Each system will come with product representatives for guidance and assistance during setup and use. They educate the perioperative team on setting up and using the smoke evacuation system and answer any questions or concerns the team may have. Everyone in the perioperative department who works directly in the operating room should be encouraged to participate in these trials and evaluations. The evaluations offer each team member the opportunity to document their insights, preferences, and rationale for liking or disliking a certain device (Croke, 2021). 

All evaluations shall be tallied at the end of the trials to determine the surgical smoke evacuation system that received the most votes. Depending on the budget, a perioperative department may purchase different systems based on surgeon preference. To increase compliance, it would be wise to add the smoke evacuator system and cautery pencils to each surgeon’s preference card so they are not overlooked when preparing for a surgical case. The cautery pencils may also be added to custom procedure packs to promote seamless use (Croke, 2021). 

Establishing Policies and Monitoring Compliance

Policies regarding air quality in the operating room should be developed to standardize the smoke evacuation process. Clear and comprehensive policies can guide perioperative teams and ensure compliance. The policies should contain information including, but not limited to, positioning the smoke evacuation cautery pencil as close to the surgical site as possible, indicating when the smoke evacuation systems are required (i.e., ideally for all surgical smoke-producing cases), wearing respiratory protection (N95 mask or alternative) for high-risk procedures, and meeting requirements for competency and education. These policies must be routinely assessed and updated as needed. In addition, staff should perform quality-assurance audits for compliance with current policies and proper use of the equipment. Medical leadership should be open and honest with the perioperative staff regarding the audit results and remind them that (a) the air quality in the operating room affects everyone and (b) surgical smoke evacuation is an important safety measure to protect the health of the staff, providers, and patients (Croke, 2021). 

AORN’s Go Clear Award Program 

The AORN created the Go Clear Award Program to establish smoke-free operating rooms and acknowledge facilities that complete the program for their commitment to safety. The goals of the Go Clear Award Program are to protect patients and perioperative personnel from the dangers of surgical smoke, educate perioperative personnel on the health hazards of surgical smoke and mitigation efforts, increase surgical smoke evacuation system compliance, and aid healthcare facilities in attracting and retaining perioperative personnel by providing a smoke-free work environment (Croke, 2020). 

Participants in the program must follow a series of steps, including: 

  • making a commitment to a smoke-free operating room and obtaining leadership support, 
  • assembling an implementation team, 
  • conducting a gap analysis to determine whether smoke evacuators are being utilized (if the facility has any), 
  • creating a plan of action and a goal date of becoming smoke-free, 
  • creating an implementation plan and sharing it with leadership and perioperative staff, 
  • educating the perioperative department, and 
  • auditing and monitoring compliance using the CLEAR (Check, Learn, Evaluate, Assess, and Report) tool (Croke, 2020). 

To be considered for the award, participants must perform audits for 3 months before submitting their compliance data to AORN. Recertification can be applied for after 3 years, and the requirements entail that newly hired staff must complete the program’s education modules, all perioperative personnel must retake the program’s posttest, and facility leaders must conduct 3 months of compliance audits. The award has three classifications: gold, silver, and bronze. The criteria for award designation are based on the availability of surgical smoke evacuation systems in the operating room and the facility’s compliance and educational performance regarding surgical smoke evacuation. Award recipients are listed on AORN’s website, acknowledged at the AORN Global Surgical Conference and Expo, receive a plaque, and gain access to the Go Clear Award media kit (Croke, 2020).


Since 2018, perioperative personnel and professional organizations throughout the United States (e.g., AORN, state associations representing nurse anesthetists, state nursing associations) have driven the pursuit of surgical smoke evacuation legislation. As a result, more smoke evacuation milestones are being reached. As of 2021, several states have enacted surgical smoke evacuation legislation, including Rhode Island in 2018, Colorado in 2019, and Kentucky in 2021. Currently, nine state legislatures are considering surgical smoke evacuation legislation, including Georgia, Tennessee, Illinois, Iowa, Connecticut, and New Jersey. These acts require state-licensed ambulatory surgery centers and hospitals to use surgical smoke evacuation systems during all smoke-generating procedures (Pennock, 2021; Vortman et al., 2021). 

The COVID-19 pandemic has accelerated all discussions related to air purification legislation and heightened the focus on respiratory health and safety. Perioperative personnel are getting creative with their tactics to demonstrate the importance of surgical smoke evacuation legislation. For example, a member of AORN in Georgia surgically cut into a piece of cow steak to simulate the smoke produced when cutting into human tissue. He asked legislators to imagine the smoke coming from the steak was instead coming from a patient with a communicable disease. Similarly, surgical smoke evacuation discussions in Oregon were occurring in tandem with the wildfires; advocates for surgical smoke legislation asked legislators if they were comfortable standing outside during the fires. Work for legislation will continue until surgical smoke in operating rooms is as unacceptable as cigarette smoke on airplanes (Pennock, 2021).  


Ball, K. (2018). Protecting patients from surgical smoke. AORN Journal, 108(6), 680-684. http://doi.org/10.1002/aorn.12436

Croke, L. (2020). The AORN Go Clear Award Program recognizes facilities working to eliminate surgical smoke. AORN Journal, 111(4), 5. https://doi.org/10.1002/aorn.13025

Croke, L. (2021). Implementing a surgical smoke evacuation program. AORN Journal, 113(3), 5-8. https://doi.org/10.1002/aorn.12052

Dobbie, M. K., Fezza, M., Kent, M., Lu, J., Saraceni, M. L., & Titone, S. (2017). Operation clean air: Implementing a surgical smoke evacuation program. AORN Journal, 106(6). https://doi.org/10.1016/j.aorn.2017.09.011

Fencl, J. L. (2017). Guideline implementation: Surgical smoke safety. AORN Journal, 105(5). 488-497. https://doi.org/10.1016/j.aorn.2017.03.006

Hedley, A. (2018, February). Surgical smoke nearly killed me. Outpatient Surgery. https://www.aorn.org/outpatient-surgery/articles/outpatient-surgery-magazine/2018/february/surgical-smoke-nearly-killed-me 

Occupational Safety and Health Administration (1988). OSHA hazard information bulletins: Hazard of laser surgery smoke. https://www.osha.gov/publications/hib19880411

Occupational Safety and Health Administration (2021). Laser/electrosurgery plume. https://www.osha.gov/laser-electrosurgery-plume/standards

Pennock, J. (2021, June). Surgical smoke legislation gaining traction across the country. The Joint Commission. https://www.jointcommission.org/resources/news-and-multimedia/blogs/leading-hospital-improvement/2021/06/surgical-smoke-legislation-gaining-traction-across-the-country/

Spruce, L. (2018). Back to basics: Protection from surgical smoke. AORN Journal, 108(1), 24-32https://doi.org/10.1002/aorn.12273 

Spruce, L. (2020). Preventing exposure to surgical smoke. AORN Journal, 112(6), 709-710http://doi.org/10.1002/aorn.13265

Tomita, Y., Mihashi, S., Nagata, K., Ueda, S., Fujiki, M., Hirano, M., & Hirohata, T. (1981). Mutagenicity of smoke condensates induced by CO2-laser irradiation and electrocauterization. Mutation Research, 89(2), 145–149.

Vortman, R., McPherson, S., & Wendler, M. C. (2021). State of the science: A concept analysis of surgical smoke. AORN Journal, 113(1), 41-51. http://doi.org/10.1002/aorn.13271

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