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RECOMMENDED PRACTICES

Implementing AORNRecommended Practicefor ElectrosurgeryLISA SPRUCE, DNP, RN, ACNP-BC, ANP-BC, ACNS-BC, CNOR;MELANIE L. BRASWELL, DNP, RN, CNS, CNOR

www.aorn.org/CE

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ABSTRACTTechnology is constantly changing, and it is important for perioperative nurcurrent on new products and technologies in the perioperative setting. AORommended practices for electrosurgery” addresses safety standards thaterative personnel should follow to minimize risks to both patients and stafduring the use of electrosurgical devices. Recommendations include howelectrosurgical units and accessories for purchase, how to minimize the popatient and staff member injuries, what precautions to take during minimsive surgery, and how to avoid surgical smoke hazards. The recommendaddress education/competency, documentation, policies and procedures, aassurance/performance improvement. Perioperative nurses should considerchecklists and safety posters to remind staff members of the dangers of elecand the steps to take to minimize the risks for injury. AORN J 95 (March 2012© AORN, Inc, 2012. doi: 10.1016/j.aorn.2011.12.018

Key words: electrosurgery, electrosurgical unit, ESU, active electrode,active electrode, dispersive electrode, monopolar electrosurgery, ultrasovice, argon enhanced coagulation technology, surgical smoke, minimallysurgery, MIS.

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The AORN “Recommended prelectrosurgery” was publishedonline in Perioperative Stand

indicates that continuing education co

are available for this activity. Earn the c

by reading this article, reviewing the pur

objectives, and completing the online Lea

tion at http://www.aorn.org/CE. The co

for this article expire March 31, 2015.

doi: 10.1016/j.aorn.2011.12.018

© AORN, Inc, 2012

s forly 2009nd

Recommended Practices. The purpos

vised recommended practices (RP) d

“provide guidance to perioperative nu

use and care of electrosurgical equip

ing high frequency, ultrasound, and a

modalities.”1(p99) There are 14 practi

mendations that represent what is bel

an optimal level of practice. Hospital

tory patient scenarios representing po

hours

hours

oal and

valua-

ours

safety situations are provided here to exemplify

March 2012 Vol 95 No 3 ● AORN Journal 373

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March 2012 Vol 95 No 3 SPRUCE—BRASWELL

ways that practice recommendationssurgery might be implemented.

WHAT’S NEW?Electrosurgery was introduced in thecommonly used today. However, newtures have been incorporated into cursurgical unit (ESU) and active and delectrode designs. Electrosurgical unipresent risks for patient injury; the mform of patient injury is a burn at theelectrode site.2 In addition to presenfor patient injury, these devices canelectrical shock, or explosions andfere with other critical implanted elmedical devices such as pacemakerdocument updates perioperative nurpractices in electrosurgery.

RATIONALEPatient safety is the number-one prperioperative nurses, and keeping pstaff members safe during the use oessential. Electrosurgical technologvery high risk to the patient and capermanent disfiguring injuries or de

Figure 1. The monopolar electrosurgic

patient, and the patient dispersive electrode

374 AORN Journal

ectro-

s and isty fea-lectro-iveicesommonersivea riske fires,

inter-nicis RPn safe

forts andUs ises aseIn

addition, there is a high degree of rpersonnel, such as shocks and burnpresence of this device.

The generator of the ESU is thesource. The monopolar electrosurgecomposed of the generator, the actithe patient, and the patient dispersi(ie, return electrode) (Figure 1). Thtissue provides impedance, and heaas the electrodes overcome the impground-referenced generators, alternways to the ground may include thestirrups, staff members, and equipming a potential risk of alternate siteIsololated generators minimize thisjury because the preferred pathwayground is through the generator.

This RP document addresses thesures that all perioperative personnto minimize risk to both patients anmembers. The Association for the Aof Medical Instrumentation has estaimum safety and performance standing ESU systems, which have beenthe American National Standards Inthe International Electrotechnical C

uit is composed of the generator, the active electrod

al circ .

for ebeingand

klistsstep

s takefe. Elnd itols sup perionents this

ff meity.ander w

ies. PRN’

differe unare u

otocove sucauseedia

the use ofnitoring.2,5

ed explana-quipment

ask ques-nefits to pa-

e facility sowhich helpsd with theESU use.

er that mini-0) Patientcur. Periop-ble of andiples of ESUeak up andent safetyistently fol-nsider the

ectrosurgical

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RP IMPLEMENTATION GUIDE: ELECTROSURGERY www.aornjournal.org

DISCUSSIONMost perioperative nursing strategiespatient safety while electrosurgery isare task oriented. Working as a teaming patient safety protocols and chechelp remind staff members of the keyelectrosurgical safety. At times, nursegranted that patients are going to be sasurgery is used every day in the OR, ato let one’s guard down. The use of topatient safety poster (Figure 2) can heltive personnel remember the key compelectrosurgery. Developing tools such aindividual practice settings reminds stathat patient safety is a team responsibil

Developing standardized protocolslists for each operating arena is anothreinforce all of the key safety strategand checklists should be based on AOommended practices. An example ofprotocols might be for patients who aing general surgery versus those whogoing minimally invasive surgery. Prpatients undergoing minimally invasiwould have additional safety steps berisks involved with using distention m

Recommendation I“Personnel selecting newand refurbished [ESUs] andaccessories for purchase oruse should make decisionsbased on safety features tominimize risks to patients andpersonnel.”1(p99) Personnelinvolved in purchasing deci-sions should considerthe following:

� The most frequently re-ported injury to patientsis a burn at the site ofthe dispersive electrode.2

Look for a dispersive

E

�

�

�

�

W

electrode that will

nsuringused

follow-wills forfor

ectro-is easych as aopera-s ofone in

mbers

check-ay torotocolss rec-rentdergo-nder-ls forrgery

of the.

minimize this risk, such as throughreturn electrode contact quality mo

� Speak to vendors and get a detailtion of the safety features of the ebeing considered for purchase.

� Form an interdisciplinary group totions and discuss the risks and betients of this type of equipment.

� Standardize equipment across ththere is no variation in practice,ensure that all patients are treatesame safety standards related to

Recommendation II“The ESU should be used in a mannmizes the potential for injuries.”1(p10

injuries, user injuries, and fires do ocerative nurses should be knowledgeadiligent in adhering to the basic princsafety. Perioperative nurses should spchallenge other team members if patiissues arise or strategies are not conslowed. Perioperative nurses should cofollowing steps for creating a safe elenvironment:

� Read and attach the manufacturerthe unit or cart on which the ESU

cational Resources

iop Modules: Electrosurgery. http://www.aorn.org/ucation/Specialty_Education/Periop_Modules.aspx.RN Video Library: Electrosurgery: Function, Practiety. http://cine-med.com/index.php?nav�nursing&subn&id�1937.ioperative Management Resources: Evaluation of Neogy. http://www.aornbookstore.org/.gical Smoke Evacuation Tool Kit. http://www.aornnical_Practice/ToolKits/Surgical_Smoke_EvacuatiolKit/Download_the_Surgical_Smoke_Evacuation_l_Kit.aspx.

te access verified December 12, 2011.

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AORN Journal 375

er when

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at patients wrong.”

oper ac-

he pa-

March 2012 Vol 95 No 3 SPRUCE—BRASWELL

Electrosurgical Safety

It Takes a TEAM to:

Know how to:

Check the machine and accessories before use.

Avoid risks to patient and staff.

Solve simple problems.

Prepare the patient safely.

Assess the patient’s skin before and after elec-trosurgery use.

Understand:

What equipment you are using.

How to minimize risk.

Electrosurgery principles

Importance of letting the prep dry!

Why the active electrode is stored in a holstnot in use.

Every year patients and members of the surgery team are injured during cases where electrotechnology is used. Often times injuries occur due to operator error and not from the equipmself. It takes a team to assure patients and staff are safe from injury! Everyone should underthe risks and take action to prevent a mishap from occurring.

“We want to make surgical procedures around the world something thand surgeons quickly forget because they have gone right rather than

~Sir Liam Donaldson

Consider:

The patient’s weight, fat distribution, and age.

Active implants such as a pacemaker or ICD-patient cleared by cardiology.

Allergies.

The position of the return electrode and metal implants, patient position, operating site, scars and tattoos.

Be aware of:

The ESU has had proper maintenance, is in good working order with prcessories.

The lowest power setting is being used.

The alarms, never silence them!

The potential for injury due to direct or capacitive coupling.

The correct accessories go with the correct machine.

How to report events and near misses.

The danger of activating the ESU while staff are in direct contact with ttient.

Special precautions with argon enhanced coagulation.

Safety doesn’t happen by accident!

Figure 2. A patient safety poster can remind staff members of precautions to take during electrosurgery.

376 AORN Journal

on atected

s anationis ea

enceaccebe d

l humrds ahas ophenong pa

the ouse ttiss

ts ashou

orieslacemther

wer,blemplaceould

properly,r broken,

survey ofakes a min-reparation forurse shouldsurvey andtect patients

and maket use exten-

eld; the cordithoutffic path.10

s in the cord.removing

or cracksor replace-

in a manneries”1(p101)

ive electrode

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RP IMPLEMENTATION GUIDE: ELECTROSURGERY www.aornjournal.org

� Ensure that the ESU is mountedresistant cart or shelf and is proliquids.

� Do not silence alarms—all alarmvation indicators should be operdible, and visible at all times. Itbecome distracted and to experimalization of deviation” (eg, theof activities that would normallyunacceptable). There is a naturatendency to ignore safety standaalarms over time when no eventNurses should be aware of thisand always be diligent in ensurisafety.

� Confirm the power settings withbefore the ESU is activated andest setting to achieve the desiredeffect.2,6-9 If the operator requesued increase in power, the nursecheck the entire ESU and accesscord connections and adequate pthe dispersive electrode.6,10,11 Ifcontinued request to increase pocould indicate that there is a prothe unit, the connections, or theof the grounding pad. Nurses shsume that it is okay toincrease power withoutstopping the procedureand checking the ma-chine and the patient.Surgery should not con-tinue if there is a con-cern that the machine isnot working properly.

Recommendation III“The electrical cords andplugs of the ESU should behandled in a manner thatminimizes the potential forinjury and subsequent patient

R

�

�

�

�

�

W

and user injuries.”1(p101)

tip-from

d acti-al, au-sy to“nor-ptanceeemedanndccurred.menontient

peratorhe low-uecontin-ldforent of

e is athiswithmentnot as-

When cords and plugs are handled imthe insulation can become frayed owhich presents an electrical hazard. Athe ESU physical environment only tute and should be a part of routine pevery procedure. The perioperative ntake the time to perform this criticalconsider the following actions to proand staff members:

� Do not place tension on the cordsure the length is adequate; do nosion cords.10

� Place the ESU near the sterile fishould reach the wall or outlet wstress and without blocking a tra

� Do not allow kinks, knots, or bend� Hold the plug, not the cord, when

the ESU from the outlet.� Keep the cord dry.10

� Check the cord for breaks, nicks,and remove it from use for repairment if needed.10

Recommendation IV“The active electrode should be usedthat minimizes the potential for injur(Figure 3). Incompatibility of the act

ources for Implementation

RN Clinical Answers. http://www.aorn.org/Clinicactice/Clinical_Answers/Clinical_Answers.aspx.RN Nurse Consult Line. 800-755-2676 or 303-755ion 1.R Perioperative Framework. http://www.aorn.org/Cctice/EHR_Periop_Framework/EHR_Perioperativemework.aspx.NurseLink. http://www.aorn.org/ORNurseLink/.ioperative Job Descriptions and Evaluation Tools.w.aorn.org/Secondary.aspx?id�20740&terms�ioperative%20competencies.

te access verified December 12, 2011.

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AORN Journal 377

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March 2012 Vol 95 No 3 SPRUCE—BRASWELL

with the ESU as well as unintentiona

and incomplete circuitry pose safety

patients and staff members.12,13 Perio

nurses should be diligent in monitori

tentional activation, problems arising

ESU, or unsafe practices, and they sh

up when patient safety is threatened.

tant to ensure that electrosurgery not

the presence of gastrointestinal gases

an oxygen-enriched environment.14,18

should be used when activating the

electrode near the head and neck re

the presence of combustible anesthe

The active electrode should be used

as possible from the oxygen source

tive nurses can take the following a

lessen risks:

� Coordinate with the anesthesia pr

minimize the oxygen concentratio

� Always visually inspect the active

Figure 3. The active electrode should b

at the field before use. Look for cord or

378 AORN Journal

vation

ds to

ive

r unin-

the

speak

impor-

ed in7 or in

aution

e

or in

ases.

ar away

opera-

s to

onal to

de

handpiece damage and incompatib

accessories with the ESU.

� Observe the sterile field when the

use and, when necessary, remind

technician, or assistant that the ac

trode should be placed in a nonco

safety holster when it is not in us

� Place the foot pedal near the user

electrode to reduce the risk of un

activation by other team members

� Remove accumulated eschar from

electrode tip away from the incisi

� Follow fire safety measures,23 and

using a checklist to make sure no

following steps are accidentally m

� Do not activate the active elec

presence of flammable agents.

� Time alcohol-based prep age

minimum dry time recommen

manufacturer is allowed to p

d in a manner that minimizes the potential for injurie

not allow the surgical technologist or

until

ing a

s pos

near

imiz

en, ni

line,

ld to

tingu

used

a ma

ries.

ure th

ct wi

sho

the

or sh

uch

ep so

ering

trode

he n

ersiv

patie

as th

ety st

from

is be

shou

des s

ical

ode,

in p

to pr

he following

nd after ESU

sure there is’s tissue.6 IfU alarm willtioning, thus

should bethe elec-

ositioning isuse a newosition a

of dispersivehere aret be folded,

gle-use dis-ening it and

acturer’s expi-he productdamage, dis-

ss, becausect.6,8,11,27

well-perfusedor of elec-, place thet skin on thelose as possi-

bony promi-earing sur-ttoos, or aiquet; or near

the patientnt is reposi-the electrodes skin.

de is a non-

RP IMPLEMENTATION GUIDE: ELECTROSURGERY www.aornjournal.org

surgeon to drape the patient

prep agent has dried.

� Remove suture packets contain

from the sterile field as soon a

� Moisten sponges that are used

tive electrode tip.18,24,25

� Arrange surgical drapes to min

buildup of oxidizers (eg, oxyg

oxide).

� Always have a wet towel, sa

ter available on the sterile fie

guish a fire.

� Be prepared to immediately ex

flames should they occur.

Recommendation V“When monopolar electrosurgery is

persive electrode should be used in

that minimizes the potential for inju

It is extremely important to make s

persive electrode has uniform conta

patient’s skin. The perioperative RN

verify this before surgery begins. If

notes that there is poor contact, he

should institute corrective actions, s

moving any oil, lotion, moisture, pr

or excessive hair that may be interf

contact; moving the dispersive elec

other site; or applying a new pad. T

should not use tape to hold the disp

trode in place.

The nurse should ensure that the

not contact any metal devices such

stirrups, positioning devices, or saf

buckles to prevent a possible burn

rected current. Patient jewelry that

the active and dispersive electrodes

removed. Electrocardiogram electro

be placed as far away from the surg

possible. When removing the electr

nurse should hold the adjacent skin

and peel the electrode back slowly

denuding the skin.

the

lcohol

sible.

the ac-

e the

trous

or wa-

extin-

ish

, a dis-

nner

”1(p104)

e dis-

th the

uld

nurse

e

as re-

lution,

with

to an-

urse

e elec-

nt does

e bed,

rap

di-

tween

ld be

hould

site as

the

lace

event

The nurse also should implement tas part of routine patient care:

� Assess the patient’s skin before ause to assess for any injuries.

� Use dual-foil electrodes to makeno impedance through the patientthe impedance is too high, the ESsound and the ESU will stop funcprotecting the patient from harm.2

� A single-use dispersive electrodecompatible with the ESU. Discardtrode after it has been used. If repneeded, discard the electrode andsingle-use product.11,26 Never repused electrode.

� Make sure to use the correct sizeelectrode for individual patients. Tdifferent sizes, and they should nocut, or altered in any way.

� Identify the expiration date on a sinpersive electrode package before opdo not use it if it is past the manufration date. Check the integrity of tand do not use it if there are flaws,coloration, poor adhesive, or drynethese could prevent adequate conta

� Place the dispersive electrode onmuscle, which is a better conducttricity than adipose tissue.11 Alsoelectrode on clean, dry, and intacsame side as the surgery and as cble to the site.

� Do not place the electrodes overnences, scar tissue, hair, weight-bfaces, potential pressure points, tametal prosthesis; distal to a tourna warming device.

� Place the dispersive electrode onafter final positioning. If the patietioned during surgery, verify thatis still in contact with the patient’

A capacitive coupled return electro

adhesive return electrode that is placed close to

AORN Journal 379

h theatienad isis there isno m

linen,

cautinimalatientatione RNimp

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entallode isergizathwt patsfere thro

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ation

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(ie, c

IS for insu-ot intact, an

d and can-36 There arensulationerent colorsation is af which theisible if the

ive electrodeuous moni-on methodlation failure

atically shut

s of elec-minal pain,them thatge from the

g vessel oc-a mannerries.”1(p108)

ar electrodesetween thethere is noure 4). Onlyelectricaly current orve nurseand bipolar

that properrect cord is. Bipolarostasis be-o tines of

ient.

in a mannerp109) Ultra-al energy. A

March 2012 Vol 95 No 3 SPRUCE—BRASWELL

the patient and forms a capacitor witreturning electrical current from the pto the ESU. If a capacitive coupled pthe nurse should ensure that the padpriate size for the patient and that thequate contact by confirming there areals, such as foam, gel pads, or extrabetween the patient and the pad.

Recommendation VI“Personnel should take additional prewhen using electrosurgery during misive surgery (MIS).”1(p107) Specific pcan occur from direct coupling, insuland capacitive coupling.6 Perioperativshould understand these concepts andprecautions to prevent patient injury.

Direct coupling is the contact of aactive electrode tip with another metor object in the surgical field. This cawhen the surgeon or other user accidvates the ESU when the active electring another metal instrument, thus eninstrument. This energy will seek a pthe ground and can cause a significaninjury. Capacitive coupling is the trantrical current from the active electrodintact insulation to adjacent conductitissue, trocars). This occurs when complastic and metal trocar systems are ucurrent can be generated from the cothe nonconductor and the current canway through the patient’s tissues onreturn electrode.

The following safety measures areincorporate into nursing practice for

� Make sure the gas used for insufflflammable (eg, carbon dioxide).

� Make sure that conductive trocaare being used. This allows theflow safely between the cannuladominal wall.

� Do not use hybrid trocar systems

nation plastic and metal).

380 AORN Journal

patient,t backused,appro-ade-ateri-

onsly inva-injury

failure,s

lement

rgizedtrumentcury acti-touch-

ing thatay toientof elec-ugh

ms (eg,tion8-30 Aor toa path-y to the

rtant to

is non-

temsnt tothe ab-

ombi-

� Examine the electrodes used in Mlation failure. If the insulation is nalternative pathway can be formecause serious patient injuries.28,31

multiple methods used to detect ifailure. One is the use of two diffon the active electrode. The insuldifferent color than the material oactive electrode is made, so it is vinsulation fails, indicating the actshould not be used. Active contintoring systems are another detectithat continuously monitor for insuor capacitive coupling and automdown when a breach is detected.

� Instruct patients to report symptomtrosurgical injury (eg, fever, abdovomiting) after MIS, and remindsymptoms can occur after discharpostanesthesia care unit.

Recommendation VII“Bipolar active electrodes, includincluding devices, should be used inthat minimizes the potential for injuUnlike monopolar electrodes, bipolhave two poles. The current flows btwo poles and back to the ESU, soneed for a dispersive electrode (Figthe tissue grasped is included in thecurrent and there is no chance of straalternative pathways. The perioperatishould make sure that the monopolarplugs on the ESU are differentiated,accessories are used, and that the corplugged in to the correct bipolar plugactive electrodes provide precise hemcause the current runs between the twthe electrode and not through the pat

Recommendation VIII“Ultrasonic devices should be usedthat minimizes potential injuries.”1(

sonic devices do not create electric

generator is used to produce ultrasonic energy

and cand

no nerisk wsonneof ae

ouldmoke

th anlter.

logy (sonneminimype oy thaESUent thgas

to thectuallseful

acture

opolar sur-implementent safety:

line by acti-after moder-d betweenzes the riskould be lim-at achieves

in directfrom patient

re is directforced into

ich could be

or death asology, thefollowing

ufflators haveurizationated. Thef gas inside

urgery unitrode.

RP IMPLEMENTATION GUIDE: ELECTROSURGERY www.aornjournal.org

and mechanical vibrations that cutlate, causing denaturation of proteinformation of a coagulum. There isa dispersive electrode. The biggestultrasonic devices is the risk to perare operating the device. Inhalationgenerated by the ultrasonic ESU shimized by using measures such as suation systems and wall suction wiultra-low penetration air (ULPA) fi

Recommendation IX“Argon enhanced coagulation technoposes unique risks to patient and perand should be used in a manner thatthe potential for injury.”1(p109) This ttechnology is a form of electrosurgerradio-frequency coagulation from ancapable of delivering monopolar currflow of ionized argon gas. The argonthe current from the active electrodeso the active electrode never has to ainto contact with the tissue. This is uhard-to-reach places.

During the use of AEC, all manuf

Figure 4. In bipolar electrosurgery, curwithout the need for a dispersive elect

written instructions should be followed in

oagu-theed forith

l whorosols

be min-evac-

in-line

AEC)l safetyizes

ft usesthat isrough a

carriestissue

y comefor

rs’

to all of the safety measures for mongery. The perioperative nurse shouldthe following actions to promote pati

� Purge the air from the argon gasvating the system before use andate delays between activations anuses. Purging the gas line minimiof gas embolism. The gas flow shited to the lowest level possible ththe desired effect.

� Do not place the active electrodecontact with tissue and remove ittissue after each activation. If thecontact with tissue, the gas can bea vessel and cause gas emboli, whfatal to the patient.

� To prevent potential patient injurya complication of argon gas technperioperative RN should take thesteps as part of care:� Make sure that endoscopic ins

audible and visual over-pressalarms that cannot be deactivAEC is a secondary source o

ows between the two poles and back to the electros

rent fl

addition the patient and can cause a rapid rise in

AORN Journal 381

ibly c

li, spedurin

ical sbe idhe N

ealthto redoke totilatioh in-li

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heir pe type safsurguse rcal Nltrati

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tion orsonnucatioto theaffordate c

AORdeveltionssist ptency

ld includeg diagnosis,and interven-atient’s re-pdated RPse relevanty.developed,essary, andg. New or

nity for col-sonnel from

evelopdures thatnd Proce-es a collec-izable tem-

ve Standardsr quality im-prove patientFor details ons that are spe-this article,ocument.

RIOnderwent ar her leftly 40 min-settingsispersiveleft lateral

on requestedof an inade-

peatedlyed, and thefter the pro-that the dis-ntact with theo be intact

n check, theg in the pa-

March 2012 Vol 95 No 3 SPRUCE—BRASWELL

intra-abdominal pressure, possgas emboli to form.

� Monitor patients for gas embocally end-tidal carbon dioxide,procedure.

Recommendation X“Potential hazards associated with surggenerated in the practice setting shouldand safe practices established.”1(p110) TInstitute of Occupational Safety and Hmends that smoke evacuators be usedpotential adverse effects of surgical smsonnel and patients. Local exhaust ven(eg, smoke evacuator, wall suction witULPA filter) should be used as the primof smoke evacuation. The suction wansmoke evacuation should not be fartheinches from the source of the smoke. Nevaluate the type of LEV needed in tsettings for surgical procedures. ThLEV is based on adequacy to ensurmoval of the anticipated amount ofsmoke. Perioperative nurses shouldtory protection (ie, a fit-tested surgitering facepiece respirator or high-fimask) as secondary protection.

The Final FourThe final four recommendations in eaRP document discuss education/compumentation, policies and procedures,assurance/performance improvement.topics are integral to the implementaAORN practice recommendations. Peshould receive initial and ongoing edcompetency validation as applicableImplementing new and updated RPsexcellent opportunity to create or updtency materials and validation tools.perioperative competencies team hasthe AORN Perioperative Job DescripCompetency Evaluation Tools37 to asative personnel in developing compe

tion tools and job descriptions.

382 AORN Journal

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erioper-evalua-

Documentation of nursing care shoupatient assessment, plan of care, nursinand identification of desired outcomestions, as well as an evaluation of the psponse to care. Implementing new or umay warrant a review or revision of thdocumentation being used in the facilit

Policies and procedures should bereviewed periodically, revised as necreadily available in the practice settinupdated RPs may present an opportulaborative efforts with nurses and perother departments in the facility to dorganization-wide policies and procesupport the RPs. The AORN Policy adure Templates, 2nd edition,38 providtion of 15 sample policies and customplates based on AORN’s Perioperatiand Recommended Practices. Regulaprovement projects are necessary to imsafety and to ensure safe, quality care.the final four practice recommendationcific to the RP document discussed inplease refer to the full text of the RP d

AMBULATORY PATIENT SCENAMs P, a 20-year-old female patient, uroutine excision of a large mass undearm. The procedure took approximateutes. The ESU was in use and initialwere cut/coagulate at 30 watts. The delectrode was placed on the patient’sthigh. During the procedure, the surgethat the settings be increased becausequate desired effect. The physician rerequested that the settings be increaslast setting recorded was 70 watts. Acedure, the circulating nurse noticedpersive electrode was not in good copatient’s skin but the skin appeared tand free of injury.

During a routine postoperative skipostanesthesia care nurse noted a rin

tient’s navel that had not been removed before

injurreveto di

cume

settindyingmon

teps asuch

ase, bapprot sougnd thurn.r analtednectiooblemom thunitto r

ents w

er ofital re

an eng ante cand laph nodless thinimalogyperat

singlew sigbdomnds. Harrheapain,

d an atypicalcess.ascular col-fter surgery.t was deter-laparoscopicnsulated cov-eated a ther-that was un-

ccur in asopic thermalch can occur

reached.40 At of this tis-ccur if therelativelying central

s, surgicalresponsible

l instruments.a defect, it

l it can be.

re in ae technologyative RNsof electrosur-tients andand imple-ntly reducediligentat safetyented in ev-e.

ery. In: Periop-actices. Denver,

Control Riska 16).sks. Perioper

RP IMPLEMENTATION GUIDE: ELECTROSURGERY www.aornjournal.org

surgery and a bright red area of skinaround the ring. Further investigationthat the preoperative nurse had failedthe navel ring even though it was dothat all jewelry had been removed.

Preoperative care in the ambulatorybecome a familiar routine, with the reatients, use of checklists, and use of comment such as the ESU. Often, simple squiries are overlooked because they areof the routine care of patients. In this cthe dispersive electrode did not adhereto the patient’s skin, the electric currenalternate pathway through the patient athe metal on her skin, thus causing a b

When a surgeon repeatedly asks foin settings, the procedure should be hthe circulating nurse inspects the conelectrodes. If all are intact and the prtinues, the unit should be removed frand tagged for inspection, and a newbe brought in for use. It is imperativeber that nurses are advocates for patiunable to speak for themselves.

HOSPITAL PATIENT SCENARIOMr D, a 74-year-old married man, fathand grandfather of 11, underwent a digexam during a routine physical and hadprostate-specific antigen (PSA) screenitive needle biopsy that indicated prostasubsequently underwent a video-assistescopic prostatectomy with pelvic lympsection. His surgery was completed inhours. His estimated blood loss was moperatively, he was admitted to the urofloor to advance to discharge. On postoone, Mr D reported pain at one of theincision sites. This incision did not shoerythematic or purulent drainage. His adistended. He had persistent bowel souported nausea and had vomiting and diever, he did not experience abdominal

white blood count was within normal limits,

yaledscovernted

g canof pa-equip-nd in-a part

ecausepriatelyht an

rough

increasewhilens andcon-

e roomshouldemem-

ho are

four,ctallevatedd a posi-cer. He

aro-e dis-an four

l. Post-unitive daytrocar

ns ofen wase re-. How-his

did not have a fever. Overall, Mr D hapresentation for an intra-abdominal absHowever, Mr D experienced a cardiovlapse from sepsis and died four days a

After an autopsy was performed, imined that during Mr D’s surgery, ainstrument for which the protective iering had worn off was used. This crmal injury to a portion of his boweldetected during the surgery.

A laparoscopic thermal injury may olittle as two seconds.28,39,40 A laparoscinjury is the result of tissue death, whiif a temperature differential of 30° C islaparoscopic thermal injury is the resulsue death. Thermal injuries also may oinsulated covering on an instrument isthin. All perioperative personnel, includsterile supply department staff membertechnologists, surgeons, and nurses, arefor maintaining the integrity of surgicaIf an instrument is suspected of havingmust be removed from circulation untirepaired or replaced to prevent injuries

CONCLUSIONPatients in the perioperative setting ahighly technical, high-risk area. As thevolves, it is imperative that perioperunderstand not only the componentsgery but also the potential risks to papersonnel. Understanding these risksmenting safety practices can significathe chance of injury. Nurses must beabout patient safety and make sure thprecautions and practices are implemery case, for every patient, every tim

References1. Recommended practices for electrosurg

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2. ECRI. Electrosurgery. Healthcare RiskAnalysis. 2007;4(Surgery and Anesthesi

3. Grime B. Essentials of electrosurgery ri

and he Nurs Clin. 2007;2(2):119-125.

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ANP-BC,clinicalDelaware,

this articleed affiliationotential

of this article.

S, CNOR, isspital ofeclared

posing ablication of

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4. ANSI/AAMI HF18:2001. ElectrosurgicaArlington, VA: Association for the AdMedical Instrumentation; 2001.

5. Electrosurgical units. Health Devices. 1996. Electrosurgical safety: conducting a safe

Devices. 2005;34(12):414-420.7. De Marco M, Maggi S. Evaluation of s

frequency radiation emitted by electrosuPhys Med Biol. 2006;51(14):3347-3358

8. ECRI Institute. Electrosurgery checklistRoom Risk Management. 2007;2(Surger

9. Massarweh NN, Cosgriff N, Slakey DPhistory, principles, and current and futuColl Surg. 2006;202(3):520-530.

10. Annex D. The safe use of high-frequenchealth care facilities. In: Health Care Fbook. 10th ed. Quincy, MA: National FAssociation; 2005.

11. ESU burns from poor dispersive electrotion. Health Devices. 1993;22(8-9):422-

12. The patient is on fire! A surgical fires phttp://www.mdsr.ecri.org/summary/detai8197. Accessed November 29, 2011.

13. Misconnection of bipolar electrosurgicaHealth Devices. 1995;24(1):34-35.

14. ECRI Institute. Surgical fire safety. Hea2006;35(2):45-46.

15. Beesley J, Taylor L. Reducing the riskare you assessing the risk? J Perioper P16(12):591-597.

16. Soussan EB, Mathieu N, Roque I, Antoexplosion with colonic perforation durincoagulation for hemorrhagic radiation-inGastrointest Endosc. 2003;57(3):412-41

17. Smith C. Surgical fires—learn not to bu2004;80(1):23-34.

18. Ignition of debris on active electrosurgiHealth Devices. 1998;27(9-10):367-370

19. Smith TL, Smith JM. Electrosurgery inhead and neck surgery: principles, advaplications. Laryngoscope. 2001;111(5):7

20. Electrosurgical airway fires still a hot toDevices. 1996;25(7):260-262.

21. Adverse event report no. 837984: ElectrManufacturer and User Facility Device(MAUDE) Database. http://www.accessscripts/cdrh/cfdocs/cfMAUDE/Detail.CFMID�837984. Accessed November 29, 201

22. Electrosurgery safety issues. PA-PSRS PAdvisory. 2006;3(1):1-3.

23. Recommended practices for a safe encare. In: Perioperative Standards andPractices. Denver, CO: AORN, Inc; 2

24. A report by the American Society of ATask Force on Operating Room Fires. Pfor the prevention and management of ofires. Anesthesiology. 2008;108(5):786-8

25. ECRI Institute. Surgical fires. OperatingManagement. 2006;2(Safety 1):1-18.

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):93-111.it. Health

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ECRI.doc_id�

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Risk

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(MAUDE) Database. http://www.accessscripts/cdrh/cfdocs/cfMAUDE/Detail.CFMID�767284. Accessed November 29, 201

27. Demir E, O’Dey DM, Pallua N. Accideing surgery. J Burn Care Res. 2006;27(

28. Wu MP, Ou CS, Chen SL, Yen EYT, RoComplications and recommended practicegery in laparoscopy. Am J Surg. 2000;179

29. Tucker RD, Voyles CR, Silvis SE. Capstray currents during laparoscopic and etrosurgical procedures. Biomed Instrum26(4):303-311.

30. Wang K, Advincula AP. “Current thoughgery. Int J Gynaecol Obstet. 2007;97(3):2

31. Odell RC. Pearls, pitfalls, and advancemlivery of electrosurgical energy during lProblems Gen Surg. 2002;19(2):5-17.

32. Guidance section: ensuring monopolar esafety during laparoscopy. Health Devic20-26.

33. ECRI. Safety technologies for laparoscoelectrosurgery; devices for managing buDevices. 2005;34(8):259-272.

34. Evaluation of electroscope electroshieldDevices. 1995;24(1):11-19.

35. Dennis V. Implementing active electrodperioperative call. SSM. 2001;7(2):32-38

36. Yazdani A, Krause H. Laparoscopic instion failure: the hidden hazard. J Minimcol. 2007;14(2):228-232.

37. Perioperative Job Descriptions and Comption Tools [CD-ROM]. Denver, CO: AOR

38. Policy and Procedure Templates, 2nd eDenver, CO: AORN, Inc; 2010.

39. Shirk GJ, Johns A, Redwine DB. Compliscopic surgery: how to avoid them and hothem. J Minim Invasive Gynecol. 2006;13

40. Saye WB, Miller W, Hertzmann P. Elecmal injury. Myth or misconception? SurEndosc. 1991;1(4):223-228.

Lisa Spruce, DNP, RN, ACNP-BC,ACNS-BC, CNOR, was the corporatemanager of surgical services, UHS ofInc, King of Prussia, PA, at the timewas written. Dr Spruce has no declarthat could be perceived as posing a pconflict of interest in the publication

Melanie L. Braswell, DNP, RN, CNan advanced practice nurse, Sinai HoBaltimore, MD. Dr Braswell has no daffiliation that could be perceived aspotential conflict of interest in the puthis article.

ence

.8.aorn.org/CE

EXAMINATION

CONTINUING EDUCATION PROGRAM

2wwwImplementing AORN Recommended

Practices for Electrosurgery

mmended

lectrosurgi-

s for

ur conve-e Exami-

PURPOSE/GOAL

To educate perioperative nurses about how to implement the AORN “Recopractices for electrosurgery” in inpatient and ambulatory settings.

OBJECTIVES

1. Identify potential risks involved with the use of electrosurgery.2. Discuss AORN’s practice recommendations for the use and care of e

cal equipment.3. Discuss methods for implementing AORN’s practice recommendation

electrosurgery.

The Examination and Learner Evaluation are printed here for yonience. To receive continuing education credit, you must complete thnation and Learner Evaluation online at http://www.aorn.org/CE.

injury

e site.

gical

ury, rclude

makend 42, 3, a

f members ofety includepatient safety

afety protocols.

nd 42, 3, and 4

or refurbishedperioperative

atures.ode contact

QUESTIONS

1. The most common form of patientthe use of electrosurgery isa. a burn at the dispersive electrodb. a positioning injury.c. a capacitive-coupling injury.d. an injury related to an electrosur

2. In addition to the risk of patient injvolved with using electrosurgery in1. electrical shock.2. explosion.3. fire.4. interference with a patient’s pace

a. 1 and 2 b. 3 ac. 1, 2, and 3 d. 1,

© AORN, Inc, 2012

during

fire.

isks in-

r.

nd 4

3. Activities that can help remind stafthe key steps for electrosurgical saf1. posting an electrosurgery-related

poster.2. developing standardized patient s3. using checklists.4. working as a team.

a. 1 and 3 b. 2 ac. 2, 3, and 4 d. 1,

4. In considering the purchase of newelectrosurgical units or accessories,nurses should1. speak to vendors about safety fe2. avoid products with return electr

quality monitoring.

March 2012 Vol 95 No 3 ● AORN Journal 385

o discnt.dized

nd 42, 3, a

tivatit is in’s dire

(ESUeriope

e stertlet w

the c

cord

e ESU

the acnde at

ofession.r assinductse.

surgeon andate the device

ar the active

2, and 52, 3, 4, and 5

osurgery, ifn the patient’se periopera-

electrode to

re, or prepwith contact.y be interfer-

electrode in

3, and 42, 3, 4, and 5

id trocar sys-minimally

cts of surgical_________od of

acepiece

with consulta-

e Education.

of interest in

March 2012 Vol 95 No 3 CE EXAMINATION

3. form an interdisciplinary group trisks and benefits of the equipme

4. help ensure equipment is standarthe facility.a. 1 and 2 b. 3 ac. 1, 3, and 4 d. 1,

5. It is permissible to disengage the accator on the electrosurgical unit if iwith the ability to hear the surgeonduring surgery.a. true b. false

6. In handling the electrosurgical unitimize the potential for injury, the pnurse shoulda. place the ESU near enough to th

that the cord reaches the wall oustress.

b. tape down any kinks or knots inprevent trips and falls.

c. use an extension cord if the ESUlong enough.

d. hold the cord when removing ththe outlet.

7. To minimize injuries during use ofelectrode, the perioperative nurse ca1. visually inspect the active electro

before it is used.2. coordinate with the anesthesia pr

minimize the oxygen concentrati3. remind the surgeon, technician, o

place the active electrode in a cosafety holster when it is not in u

The behavioral objectives and examination fo

tion from Rebecca Holm, MSN, RN, CNOR,

Ms Retzlaff, Ms Holm, and Ms Bakewell hav

the publication of this article.

386 AORN Journal

uss the

across

nd 4

on indi-terferingctions

) to min-rative

ile fieldithout

ord to

is not

from

tive

the field

onal to

stant toive

4. place the foot pedal between theassistant so that either may activas needed.

5. moisten sponges that are used neelectrode tip.a. 1 and 2 b. 1,c. 3, 4, and 5 d. 1,

8. During the use of monopolar electrthere is not uniform contact betweeskin and the dispersive electrode, thtive nurse should consider1. applying a new pad.2. repositioning the used dispersive

another site.3. removing any oil, lotion, moistu

solution that may be interfering4. removing excessive hair that ma

ing with contact.5. using tape to hold the dispersive

place.a. 3 and 5 b. 1,c. 1, 2, 3, and 4 d. 1,

9. Conductive trocar systems and hybrtems are equally safe for use duringinvasive surgery.a. true b. false

10. To reduce the potential adverse effesmoke to personnel and patients, __should be used as the primary methprotection.a. local exhaust ventilationb. fit-tested surgical N95 filtering f

respiratorsc. high-filtration masks

program were prepared by Kimberly Retzlaff, editor/team lead,

editor, and Susan Bakewell, MS, RN-BC, director, Perioperativ

eclared affiliations that could be perceived as potential conflicts

r this

clinical

e no d

.8.aorn.org/CE

LEARNER EVALUATION

CONTINUING EDUCATION PROGRAM

2wwwImplementing AORN Recommended

Practices for Electrosurgeryne theon proe item

tives o

the u. 5.dation

elec. 5.ORNery.

se yo

objechion fr

2. Nesulttion #

e? (Select all

team regard-

to change/ure.

eeting withand acceptance

evaluate ther intervals

ted as best

e as a resultt all that

t relevant to

teach othersded change.port to make

t we verifythe 2.8 con-68-minute)

This evaluation is used to determito which this continuing educatimet your learning needs. Rate th

described below.

OBJECTIVES

To what extent were the following objeccontinuing education program achieved?

1. Identify potential risks involved withelectrosurgery. Low 1. 2. 3. 4

2. Discuss AORN’s practice recommenthe use and care ofcal equipment. Low 1. 2. 3. 4

3. Discuss methods for implementing Atice recommendations for electrosurgLow 1. 2. 3. 4. 5. High

CONTENT

4. To what extent did this article increaknowledge of the subject matter?Low 1. 2. 3. 4. 5. High

5. To what extent were your individualmet? Low 1. 2. 3. 4. 5. Hig

6. Will you be able to use the informatarticle in your work setting? 1. Yes

7. Will you change your practice as a ring this article? (If yes, answer ques

applicant who successfully completes this program

© AORN, Inc, 2012

extentgrams as

f this

se ofHighs fortrosurgi-High

’s prac-

ur

tives

om thiso

of read-7A. If

7A. How will you change your practicthat apply)1. I will provide education to my

ing why change is needed.2. I will work with management

implement a policy and proced3. I will plan an informational m

physicians to seek their inputof the need for change.

4. I will implement change andeffect of the change at regulauntil the change is incorporapractice.

5. Other:7B. If you will not change your practic

of reading this article, why? (Selecapply)1. The content of the article is no

my practice.2. I do not have enough time to

about the purpose of the nee3. I do not have management sup

a change.4. Other:

8. Our accrediting body requires thathe time you needed to completetinuing education contact hour (1

dentialing Center

eptance of this

ers. Each

no, answer question #7B.) program:

This program meets criteria for CNOR and CRNFA recertification, as well as other continuing education requirements.

AORN is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation.

AORN recognizes these activities as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Creapproves or endorses products mentioned in the activity.

AORN is provider-approved by the California Board of Registered Nursing, Provider Number CEP 13019. Check with your state board of nursing for accactivity for relicensure.

Event: #12507; Session: #0001; Fee: Members $14, Nonmembers $28

The deadline for this program is March 31, 2015.

A score of 70% correct on the examination is required for credit. Participants receive feedback on incorrect answ

can immediately print a certificate of completion.

March 2012 Vol 95 No 3 ● AORN Journal 387