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CONTINUING EDUCATION
Implementing AORNRecommended Practicesfor Laser SafetyDONNA CASTELLUCCIO, MSN, RN, CNOR 2.6www.aorn.org/CE
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Continuing Education Contact Hoursindicates that continuing education contact hours are avail-
able for this activity. Earn the contact hours by reading this arti-cle, reviewing the purpose/goal and objectives, and completingthe online Examination and Learner Evaluation at http://www.aorn.org/CE. A score of 70% correct on the examination isrequired for credit. Participants receive feedback on incorrectanswers. Each applicant who successfully completes this pro-gram can immediately print a certificate of completion.
Event: #12513Session: #0001Fee: Members $13, Nonmembers $26
The contact hours for this article expire May 31, 2015.
Purpose/GoalTo educate perioperative nurses about how to implement theAORN “Recommended practices for laser safety in perioper-ative practice settings” in inpatient and ambulatory settings.
Objectives1. Identify potential risks involved with the use of medical
lasers.2. Discuss AORN’s practice recommendations for the use
and care of laser equipment.3. Discuss AORN’s practice recommendations for providing
a safe environment for patients and health care workers.4. Describe methods for implementing AORN’s practice rec-
ommendations for laser safety.
AccreditationAORN is accredited as a provider of continuing nursing edu-cation by the American Nurses Credentialing Center’s Com-mission on Accreditation.
612 AORN Journal ● May 2012 Vol 95 No 5
pprovalshis program meets criteria for CNOR and CRNFA
ecertification, as well as other continuing educationequirements.
AORN is provider-approved by the California Board ofegistered Nursing, Provider Number CEP 13019. Checkith your state board of nursing for acceptance of this activ-
ty for relicensure.
onflict of Interest Disclosuress Castelluccio has no declared affiliation that could be per-
eived as posing a potential conflict of interest in the publi-ation of this article.
The behavioral objectives for this program were created byimberly Retzlaff, editor/team lead, with consultation fromebecca Holm, MSN, RN, CNOR, clinical editor, and Susanakewell, MS, RN-BC, director, Perioperative Education.s Retzlaff, Ms Holm, and Ms Bakewell have no declared
ffiliations that could be perceived as posing potential con-icts of interest in the publication of this article.
ponsorship or Commercial Supporto sponsorship or commercial support was received for this
rticle.
isclaimerORN recognizes these activities as continuing edu-
ation for registered nurses. This recognition does not im-ly that AORN or the American Nurses Credentialingenter approves or endorses products mentioned in thectivity.
doi: 10.1016/j.aorn.2012.03.001
© AORN, Inc., 2012
RECOMMENDED PRACTICES
Implementing AORNRecommended Practicesfor Laser SafetyDONNA CASTELLUCCIO, MSN, RN, CNORwww.aorn.org/CE
2.6
ABSTRACT
Lasers used in the OR pose many risks to both patients and personnel. AORN’s“Recommended practices for laser safety in perioperative practice settings” identifiesthe potential hazards associated with laser use, such as eye damage and fire- andsmoke-related injuries. The practice recommendations are intended to be used as aguide for establishing best practices in the workplace and to give perioperativenurses strategies for implementing the recommended safety measures. A laser safetyprogram should include measures to control access to laser use areas; protect staffmembers and patients from exposure to the laser beam; provide staff members andpatients with the appropriate safety eyewear for use in the laser use area; and protectstaff members and patients from surgical smoke, electrical, and fire hazards. Mea-sures such as using a safety checklist or creating a laser cart can help perioperativenurses successfully incorporate the practice recommendations. Patient scenarios areincluded as examples of how to use the document in real-life situations. AORN J 95(May 2012) 613-624. © AORN, Inc., 2012. 10.1016/j.aorn.2012.03.001
Key words: AORN recommended practices, laser safety, fire safety, smokeplume, smoke evacuation.
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Laser technology has been evolving for
more than 40 years. AORN mentioned
laser safety in 1985 in the recommended
practices (RP) document about radiation safety,1
and AORN’s recommended practices for laser
safety were originally published in November
1989.2 The RP document has been revised four
times to incorporate new information that has be-
come available over the years.3 The hazards of m
© AORN, Inc., 2012
moke plume were noted in the original 1989 ver-
ion. In 1993, the recommendations stated that a
aser team should be available for each procedure
n which a laser would be used.4 The role of the
aser safety officer (LSO) appeared for the first
ime in 1998.5 The 2004 RP document discussed
stablishing a laser safety program per the Ameri-
an National Standards Institute (ANSI) recom-
endations.6 The most recent laser safety RP was
May 2012 Vol 95 No 5 ● AORN Journal 613
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May 2012 Vol 95 No 5 CASTELLUCCIO
first published electronically in November 2010 inthe AORN Perioperative Standards and Recom-mended Practices.3
The purpose of the laser safety RP document isto “provide guidance to perioperative personnel inthe use and care of laser equipment and to assistpractitioners in providing a safe environment forpatients and health care workers.”3(p125) Theserecommendations apply whether laser equipmentis owned, leased, or borrowed and in any healthcare setting in which medical laser equipment isused. The foundation for all laser safety programsshould be the ANSI standards for class 3 andclass 4 laser devices that are used in health carefacilities, and these standards are the basis forAORN’s recommendations. There are 11 recom-mendations in the current version of the lasersafety RP document.
WHAT’S NEW?The newest RP document contains a number ofsignificant changes. The 2010 iteration expandson what a laser safety program should entail andfurther defines responsibilities of the LSO. A la-ser safety specialist (LSS), also called a laser re-source nurse, appears in the document as a newrole with a unique set of responsibilities. Anothernew recommendation is that a designated laserassistant be assigned to every procedure inwhich a laser is used, and this person shouldhave no competing responsibilities that requireleaving the laser unattended during active use.The hazards of surgical smoke and fire are de-tailed more extensively in this updated docu-ment, reflecting current evidence.
RATIONALELasers are a valuable tool in the OR; however,there are hazards associated with this technol-ogy. Taking proper safety precautions will sig-nificantly reduce the risks to both patients andperioperative personnel.
“Laser” is an acronym for Light Amplification
by the Stimulated Emission of Radiation. Light614 AORN Journal
efers to all the energy on the electromagneticadiation spectrum, whether it is visible or invisi-le. Lasers produce light when energy is added tomedium and causes the release of energy in the
orm of a narrow beam of high-energy light. Thetimulated energy can be a flash-lamp, anotheraser, or a liquid. Laser energy can be infrared,ltraviolet, or visible. Different wavelengths haveifferent effects on tissue, so the wavelength ofhe laser determines the appropriate applicationnd safety measures.
Light can have four interactions with tissue:eflected, scattered, transmitted, and absorbed.
ith reflected and scattered interactions, there ishe danger of light energy being uncontrolled.he reasoning is complicated, but a reflected orcattered beam can hit something reflective andounce off and go anywhere, which is danger-us. Transmission and absorption are the de-ired qualities for a laser; to have an effect onissue, laser light must be absorbed. Light cane transmitted or pass through some tissue witho effect, while other tissue will absorb the en-rgy.7 The thermal effect of the laser is cutting,oagulating, and vaporizing.
Lasers today are being used in all types ofurgeries (eg, ophthalmology, urology, orthope-ics, gynecology) and can be found in hospi-als, ambulatory surgery centers, and office-ased practices. The benefit of using medicalasers is that they seal small blood vessels andecrease edema and pain.
Perioperative nurses must institute control mea-ures to minimize laser hazards:
Laser beams are a source of intense light7-9
and can cause injury to the cornea and retina,either from direct viewing or scattered beams.Eye damage may be temporary but can alsocause blindness.9
Laser radiation can cause irreversible damageto the skin. Lasers are thermal in nature andcan cause burns if there is sufficient intensity
and duration.8
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RP IMPLEMENTATION GUIDE: LASER SAFETY www.aornjournal.org
� Concerns about surgical smoke are mounting.The by-product of the thermal destruction oftissue contains “toxic gases and vapors suchas benzene, hydrogen cyanide, and formal-dehyde, bioaerosols, dead and live cellularmaterial (including blood fragments), andviruses.”10 Surgical smoke should be removedby use of a smoke evacuation system.3,9,11
� Lasers are a potential ignition and fire sourcebecause of the intense heat produced.12
When aware of the risks, perioperative nursescan take the proper precautions to maintain asafe environment.
Several organizations provide guidelines thatare recognized as accepted standards for lasersafety. These agencies, including the OccupationalSafety and Health Administration (OSHA), ANSI,and AORN, promote the proper use, precautions,and maintenance of lasers.
The Joint Commission, as part of a survey,may investigate a facility’s laser program to en-sure adherence to the ANSI Z136.3 standards.11
Figure 1. Laser-specific information should be posted on th
or example, ANSI recommends the use of high-ltration masks during laser use and posting of
aser-specific information on signs (Figure 1) atvery door of the room in which a laser is beingsed. Although ANSI is not a regulatory agency,ts standards are considered to be the gold stan-ard. The Joint Commission will look at laserolicy, training, and credentialing of surgeons.13
Requirements from OSHA include that mea-ures must be taken to provide for a safe environ-ent for staff members, which includes the re-oval of surgical smoke. The AORN Surgicalmoke Evacuation Tool Kit14 offers tools andesources to educate perioperative nurses abouthe hazards of surgical smoke and to help periop-rative personnel research, plan, design, and im-lement a smoke evacuation program. The ECRInstitute also publishes a self-assessment question-aire on laser safety to help identify and manageisks.15 This questionnaire will help perioperativetaff members evaluate their program to ensurehat proper measures are in place.
e signs at every door where a laser is being used.
AORN Journal 615
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May 2012 Vol 95 No 5 CASTELLUCCIO
DISCUSSIONIt is important to establish safety guidelines inany facility in which lasers are used. The AORNrecommended practices for laser safety includeestablishing a laser safety program and a multi-disciplinary laser safety committee and con-trolling measures that are necessary to ensurepatient and staff member safety. Specifically, alaser safety program should include safety mea-sures to control access to laser use areas; pro-tect staff members and patients from uninten-tional exposure to the laser beam; provide staffmembers and patients with the appropriatesafety eyewear for use in the laser use area;and protect staff members and patients againstsurgical smoke, electrical, and fire hazards.
Recommendation I“A laser safety program should be establishedfor all owned, leased, or borrowed laser equip-ment in any location where lasers are used inthe health care organization.”3(p125) A multidis-ciplinary laser safety committee is an essentialelement of this program for any facility, hospi-tal, or ambulatory surgery center in which la-sers are used. The committee can be part of thelarger risk management and safety committee orquality improvement program, but ideally, thecommittee should be in place before a laserprogram is implemented.
The laser safety committee needs to establishadministrative controls (ie, methods to regulatework practice) that assist staff members in mini-mizing risks. The RP document defines whoshould be on the committee and their responsibili-ties, including
� designating an LSO to monitor and overseethe control of laser safety hazards,
� developing and enforcing policies andprocedures,
� verifying physician credentialing,� educating personnel,
� identifying laser hazards, and w616 AORN Journal
ensuring an LSS is available for each area oflaser use when there are multiple sites in ahealth care organization.3
he committee should review recommendationsrom AORN and ANSI, develop a policy, andake sure all the safety components are identi-ed. Establishing a program and then maintaining
t takes time, effort, and dedication; however, it iscrucial component for safe laser use.In a facility that is just starting a laser safety
rogram, it is essential to have administrativeupport to help ensure the success of the program.erioperative nurses may start by meeting with all
he stakeholders, such as perioperative manag-rs, laser accredited surgeons, and risk manage-ent personnel, who will then become the laser
rogram safety committee. Having a laser-redentialed physician champion on the com-ittee who embraces the project and is influen-
ial in getting others to comply with laserafety regulations would be ideal. Then, theealth care organization should select the LSO.he LSO should be qualified through educationnd experience. If no one at the facility hasxperience with a laser safety program, then aerson with an interest should review the litera-ure, become familiar with protocols, and com-lete a laser certification course.16,17
An interested perioperative nurse may start bypproaching his or her manager with the RPs inand to discuss various components of a laserafety program and what needs to be done to cre-te or update an existing program. If there is noxisting committee, this meeting would be thelace to begin creating a committee and the pro-ram. An interested perioperative nurse should lethe manager know that he or she is familiar withhe AORN recommended practices for laser safetynd offer his or her assistance in starting or im-roving a laser safety program. This personhould educate himself or herself by doing someeading on the subject. An educator could help
ith collecting data, but anyone with an interest
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RP IMPLEMENTATION GUIDE: LASER SAFETY www.aornjournal.org
could be of assistance. For an ambulatory surgerycenter or other facility that contracts a laser ser-vice, education, resources, and references may beprovided. Industry representatives or guest speak-ers also may be helpful for educating staff mem-bers. The laser representative may be able tohelp set up a program, answer questions, orrefer staff members to other resources. Staffmembers at other institutions or peers on AORN’sORNurseLink also may have valuable input.
If a laser safety program is already in place, aninterested perioperative nurse should identify thebarriers that might be encountered in trying toimplement new practice recommendations. Aninterested perioperative nurse or the LSO shouldlisten to staff member concerns. If staff membersare asked to provide input, they will be more in-volved in the project and more likely to help withimplementation. If staff members do not adhere tothe recommendations, an interested periopera-tive nurse or the LSO should investigate why.After the challenges are identified, action canbe taken. For example, an interested periopera-tive nurse or the LSO could start a laser safetyawareness campaign and engage everyone(eg, nurses, surgeons, surgical technologists)who has knowledge of lasers to get involved.An interested perioperative nurse or the LSOshould enlist the help of staff members whoregularly participate in laser procedures orwho have an interest and can motivate othersto follow policy. Another option is to make aposter on the effects of surgical smoke, forexample, to get staff members’ attention; mak-ing staff members aware of potential hazardshelps to garner their support in following lasersafety policies.
In a facility in which a program is already inplace, the focus should be on making sure all theelements of the RP document are in place. If acommittee and an LSO are already established,forming the role of an LSS may be the next step.This resource person works with the LSO, is
present in the laser use area, and acts as liaison setween clinicians and the LSO. The LSS trou-leshoots equipment problems and acts as a re-ource to other staff members. Further responsi-ilities can be found in the current RP document.ecause of the risks associated with laser use, a
aser assistant should be assigned to every proce-ure in which a laser is used and should have noompeting duties while the laser is activated. Des-gnating a laser assistant for every laser procedureay prove difficult in a facility that has staffing
ssues, but this role is important for minimizingaser hazards.
The focus of any new or existing program foraser safety will be education. It is vital that ev-ryone who is involved with lasers be educatedn the use and care of laser equipment and onaintaining an environment of safety. The LSO
r perioperative educators should initiate this edu-ation. There are many resources available, andaser Safety in the Perioperative Setting18 from
he AORN Video Library is a good starting point.he LSO at my facility is certified in laser use
rom the Laser Institute of America. She re-iews our policy annually, makes sure we havehe proper equipment and that it is in workingrder, audits problems, and takes a lead in edu-ating staff members. We conduct a mandatory,nnual laser safety inservice program for allerioperative staff members and then about aozen nurses undergo hands-on training as su-er-users/laser assistants. All new staff mem-ers, as part of their orientation, receive laserafety education.
ecommendations II, III, and IVhree practice recommendations address the con-
rol measures necessary for patient and staffember safety, including ensuring that personnel
now where lasers are being used and controllingccess to laser use areas, protecting patients andersonnel from unintentional laser beam exposure,nd ensuring that all people in laser use areasear the appropriate safety eyewear.3 These
tandards must be followed to ensure a safe
AORN Journal 617
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May 2012 Vol 95 No 5 CASTELLUCCIO
environment. Perioperative nurses should read thefull recommendations, create a list of what needsto be done at their institutions to comply with thestandards, and then implement solutions. If ser-vices are contracted, these safety controls may beprovided by the vendor.
The nominal hazard zone—the space in whichthe level of direct, reflected, or scattered radiationused during normal laser operation exceeds the ap-plicable maximum permissible exposure—should beclearly marked with recognizable warningsigns. The laser vendor should be able to sup-ply signs. Each sign must be specific to the la-ser in use and state the eye protection that staffmembers need to wear if they enter the room.
Protecting staff members and patients from unin-tentional laser beam exposure is important becauselasers can cause eye and skin damage.11 Practices toprevent unintentional exposure include
� placing the laser in standby mode when it isnot in use11,19-21;
� placing the foot switch near the operator; and� using anodized, dull, nonreflective, or matte-
finished instruments near the laser site.11,19,20,22
Eyewear specific to each laser, per manufac-turer recommendation, is required in the nominalhazard zone.3,8,9 Glasses must be labeled withappropriate optical density and wavelength.11,20,23
The patient’s eye safety also must be considered:glasses if the patient is awake, wet eye pads if he
CHECK APPROPRIATE SAFETY P
LASER SIGNS POSTED LASER GLASSES AT ALL DOORS SMOKE EVACUATOR SET UP LASER MASKS ON ALL STAFF
FIBER TIP COVERED W/ITH WET 4x4 IN STANDBY 60 mL SYRINGE WITH H2O or NaCl ON MAYO FOR THROAT CAS TRACH TRAY WITH TRACHEOTOMY TUBES FOR ALL THROAT
THE ROOM BASIN OF WATER ON FIELD
Figure 2. Using a checklist of precautions that is part
safety precautions.618 AORN Journal
r she is asleep, or metal corneal shields if thereatment area is around the patient’s eyes.
Laser safety has a lot of components, so in myacility’s OR, the LSO, managers, and I made ahecklist of precautions that is part of our docu-entation (Figure 2). The laser resource nurse
ssigned to the room must complete this checklistefore laser use; hang signs on each door; andnsure the availability of laser-safe instruments,ater, and a fire extinguisher. To help imple-ent laser safety recommendations, perioperative
urses should use the AORN recommendations toreate their own checklists for better compliance.asers: The Perioperative Challenge, 3rd edition,lso has examples of checklists and policies.7
After the list is made, an interested periopera-ive nurse or the LSO should make sure all theecessary elements are available for use, such asaser-safe instruments, proper eyewear, and amoke evacuation system. One author found theumber-one barrier to smoke evacuation was lackf equipment.24 If the necessary safety items areot available, acquiring them is essential. If pur-hasing these safety items is a problem, then theSO or a nurse advocate should approach theppropriate managers and present a well-informedase for their acquisition. Or, perhaps the programeeds to be suspended until the appropriate de-ices are available. If there is any question oroncern that a nurse feels is not being addressed,
UTIONS TAKEN IN ROOM
WET TOWELS FOR DRAPING NON-FLAMMABLE PREP EBONIZED INSTRUMENTS USED HANDPIECE COVERED WITH WET TOWEL IN
STANDBY RECTAL PACK – WET 4x4 LASER SAFE ENDOTRACHEAL TUBE
IN OTHER
FIRE EXTINGUISHER IN ROOM
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he or she has an obligation to report up the chainof command as necessary in a timely fashion forthe safety of patients and personnel. This mayinclude reporting to the committee or risk man-ager or via a facility hotline if one is availableand documenting these reports via an online sys-tem or an internal quality reporting system. Itmay be necessary to get OSHA involved if thereis a continuing problem. If an institution is non-compliant with the laser safety protocols and at-tempts have been made to get the protocols insti-tuted, then whistle blowing may be in order. Thisaction should only be taken after all attempts atresolving the issue through the chain of commandhave been exhausted.
To ensure proper safety measures are imple-mented, perioperative team members can reviewlaser safety precautions in a huddle before thepatient enters the room or at the time out. Atmy facility, the LSO set up a laser cart somost of what we need—such as glasses, signs,attachments, masks, tongue blade, and eyepads—is in one place. We also have a resourcebook with each laser that states
� whether it needs to be tested and, if so, how;� what equipment must be in the room;
Figure 3. A page from a laser resource book might in
during laser use and whether windows need to be coveredwhether windows need to be covered; andthe correct eyewear that should be used (Figure 3).
he resource book also contains pictures of variousaser components and lists directions for how tossemble them. This information helps staff mem-ers comply with our facility laser guidelines.
No matter the type of facility—whether hospi-al or ambulatory surgery center—or whether la-er equipment is owned or rented, the role of theirculating nurse will be the same. The RN circu-ator must be aware of and enforce all laser safetyrecautions, such as correct signage being postedn the doors and the availability of the correctyewear and a fire extinguisher in the room. Aaser assistant should be at the laser console dur-ng use to oversee the safe use of the laser. Estab-ishing an LSS in the area of laser use providesn opportunity for that person to model properrecautions and to reinforce them with the othertaff members in the room. Every laser procedurehen becomes a potential teachable moment.
ecommendation VPotential hazards associated with surgicalmoke generated in the laser practice settinghould be identified and safe practices
details such as what type of eyewear is necessary
clude .AORN Journal 619
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established.”3(p130) The National Institute forOccupational Safety and Health (NIOSH),OSHA, Laser Institute of America, ANSI,AORN, and The Joint Commission recommendthat surgical smoke be filtered and evacuatedthrough the use of room ventilation, smokeevacuators, and room (wall) suction systems.25
The evidence shows that surgical smoke con-tains toxic gases and vapors like cyanide andformaldehyde, as well as bacterial and viralcontaminants.10,11,26,27
In addition to a smoke evacuation system,staff members should wear high-filtration masksto filter particulate matter as a second line ofdefense.9 If compliance with wearing masksand using smoke evacuators is a problem, aninterested perioperative nurse or the LSO couldhave staff members read articles on the hazardsof surgical smoke from NIOSH, AORN, andthe ECRI Institute. The evidence shows “peri-operative nurses experience respiratory symp-toms at a higher rate—sometimes twice therate—as others in the United States.”24(p60) Inone study, nurses experienced more sinus infec-tions and other problems and reported higherrates of allergies, bronchitis, and asthma thanthe general public.24
If this evidence does not improve compliance,an interested perioperative nurse could make staffmembers aware of the surgeon who acquired pap-illomavirus while treating patients with anogenitalcondylomas28 or that 1 g of lasered tissue is equalto smoking three cigarettes in 15 minutes.14 Put-ting this information on a poster or in a newslet-ter or discussing it at a staff meeting may in-crease compliance.
Recommendations VI and VIITwo recommendations are related to protectingstaff members from hazards associated withlaser use, specifically electrical and flammablehazards. During laser use, all basic electricalsafety precautions must be followed, such as
not putting liquids on the console; not using i620 AORN Journal
xtension cords; and checking wires for fray-
ng, cracks, or breaks. Electrical problems are
nly one of many fire hazards, however. All
hree components of the fire triangle (ie, oxidiz-
rs, fuel, ignition sources) are present in the
R, which makes laser use a high risk for sur-
ical fires.29,30 Because of these factors, fire is
he greatest risk of using lasers, and safety
recautions must be followed. Examples of fire
afety precautions during laser use include not
ctivating the laser beam in the presence of
ammable gases and keeping sponges and
rapes near the surgical site moist.
Personnel also should be prepared to immedi-
tely extinguish flames should they occur.12 Sim-
lation exercises that include putting out mock
res and evacuating rooms should be an annual
vent so everyone is prepared. If fire safety ed-
cation is not a mandatory, annual occurrence
t an institution, an interested perioperative
urse should make it happen by taking his or
er concerns to perioperative leaders or the
SO and requesting help with compliance. The
ORN Fire Safety Tool Kit31 is a comprehen-
ive resource that may be used to raise periop-
rative staff member awareness of the inherent
ealities of surgical fires and provide proactive
ools to promote fire prevention, plan effective
esponse strategies, and develop department-
pecific, evidence-based policies and protocols
o protect patients and staff members.
As with the previously discussed recommen-
ations, anyone who works during laser proce-
ures should follow all the steps that are out-
ined in the RP document. If staff members are
ot following policy, an LSO, an LSS, a peri-
perative leader, or a concerned perioperative
taff member should determine why and then
etermine what needs to be done. At my facil-
ty, the LSO and I mounted the fire extin-
uisher and smoke evacuator on the laser cart
o they are always where we need them, mak-
ng compliance easy.
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The Final FourThe final four recommendations in each AORNRP document discuss education/competency, doc-umentation, policies and procedures, and qualityassurance/performance improvement. These fourtopics are integral to the implementation ofAORN practice recommendations. Personnelshould receive initial and ongoing education andcompetency validation as applicable to their roles.Implementing new and updated recommendedpractices affords an excellent opportunity to cre-ate or update competency materials and validationtools. AORN’s perioperative competencies teamhas developed the AORN Perioperative Job De-scriptions and Competency Evaluation Tools32 toassist perioperative personnel in developing com-petency evaluation tools and position descriptions.
Documentation of nursing care should includepatient assessment, plan of care, nursing diagno-sis, and identification of desired outcomes andinterventions, as well as an evaluation of the pa-tient’s response to care. Implementing new orupdated recommended practices may warrant areview or revision of the relevant documentationbeing used in the facility.
Policies and procedures should be developed,reviewed periodically, revised as necessary, andreadily available in thepractice setting. New orupdated recommendedpractices may present anopportunity for collabora-tive efforts with nurses andpersonnel from other de-partments in the facility todevelop organization-widepolicies and procedures thatsupport the recommendedpractices. The AORN Pol-icy & Procedure Templates,2nd edition,33 provides acollection of 15 sample poli-cies and customizable tem-
AORN Re
� Fire Safety� Smoke Eva
Practice/ToSurgical_Sm
� Laser SafetySpecialty_E
� Laser Safety2011). http:
� Ball KA. Laver, CO: AOproduct/pro
Web site acces
plates based on AORN’s
erioperative Standards and Recommended Prac-ices. Regular quality improvement projects areecessary to improve patient safety and to ensureafe, quality care. For details on the final fourractice recommendations that are specific to theP document discussed in this article, please refer
o the full text of the RP document.
MBULATORY PATIENT SCENARIO26-year-old man with condylomata of the geni-
als is scheduled for a laser vaporization proce-ure under general anesthesia. The procedure isxpected to take less than 30 minutes. He has aistory of asthma but is otherwise healthy. Nurseis the laser assistant assigned to the procedure.
urse C uses the laser safety checklist to preparehe room. She hangs the CO2 laser signs on bothoors into the room as well as the appropriatelasses. She tests the laser handpiece, has glassesor everyone in the room, and ensures sterile wa-er and a fire extinguisher are available. She pro-ures the smoke evacuator and gives the scruberson the proper tubing with the wand attach-ent. Nurse C reminds the scrub person to useet towels and sponges and to keep the wand as
lose to the site of surgery as possible to evacuatehe smoke.
rces
Kit. http://www.aorn.org/FireSafety/.n Tool Kit. http://www.aorn.org/Clinical_/Surgical_Smoke_Evacuation_ToolKit/Evacuation_Tool_Kit.aspx.ialty module. http://www.aorn.org/Education/ion/Laser_Safety/Laser_Safety.aspx.e Perioperative Setting [DVD] (Ciné-Med,-med.com/index.php?nav�aorn.
The Perioperative Challenge. 3rd ed. Den-Inc; 2004. http://www.aornbookstore.org//sp?sku�MAN186.
fied January 23, 2012.
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May 2012 Vol 95 No 5 CASTELLUCCIO
The circulating nurse checks that everything isready and brings the patient into the room. Every-one has laser masks on. The physician tells NurseC the settings for the laser and that he is ready togo; she turns on the laser and the smoke evacua-tor. The smoke evacuator does not turn on. NurseC informs the surgeon that he needs to stop whileshe troubleshoots the smoke evacuator, and sheputs the laser in standby mode. The surgeonwants to proceed, saying, “It will only take fiveminutes, it will take longer to get another smokeevacuator.” The surgeon demands that the laserbe turned on. What should Nurse C do?
As the person responsible for safe laser use inthe room, Nurse C should immediately call for anew smoke evacuator. Then she should explain tothe surgeon, as she troubleshoots, the hazards ofsurgical smoke. Nurse C should be able to citepatient and staff member safety, explaining thatthe smoke could irritate the respiratory systemand may exacerbate the patient’s asthma. Byknowing the standards and the rationale, Nurse Ccan be confident and assertive, and she can re-main calm under pressure and thus support bestpractice. Explaining the rationale and not arguingmake for a smooth, safe procedure.
HOSPITAL PATIENT SCENARIOMr G, who is 68 years old, is undergoing a mi-crolaryngoscopy for a vocal cord lesion. NurseA is the laser assistant for the procedure. She
Resources for Implementatio
� AORN Nurse Consult Line. (800) 755-26766300, option 3.
� ORNurseLink. http://www.aorn.org/ORNurs� Perioperative Job Descriptions and Compete
Tools [CD-ROM]. http://www.aorn.org/BookPublications/AORN_Publications/PerioperatDescriptions_and_Competency_Evaluations_
Web site access verified January 23, 2012.
622 AORN Journal
hecks the laser beam for accuracy with theicroscope attachment after taking all general
afety and fire prevention precautions. Sheakes sure the anesthesia professional has a
aser-safe endotracheal (ET) tube; notes thecrub person has a 60-mL syringe of saline;nd sees that the circulating nurse has themergency instruments, tracheotomy tray, andronchoscope outside the door according to fa-ility policy. A basin of sterile water, fire extin-uisher, and laser-safe instruments are all as-embled per policy. The surgeon places a wetottonoid in the patient’s throat. The surgeonegins the procedure. After about three min-tes, a fire erupts and Nurse A yells, “Fire!”hat are the team members’ responsibilities at
his point?The actions of the various team members may
e happening simultaneously:
Surgeon� Stop lasering.� Perform a bronchoscopy to assess the dam-
age after fire is extinguished.Anesthesia professional� Immediately turn off the oxygen.� Remove the ET tube while disconnecting
the ET tube from the breathing circuit.� Check to make sure the ET tube is intact.� Re-establish the airway using air, switch-
ing to oxygen when it has been deter-mined that there is no burning in the
airway.� Perform a bronchos-
copy to assess thedamage after the fireis extinguished if it isnot performed by thesurgeon.
� Scrub person� Pour saline into the
airway.� Remove burning or
flammable drapes or
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RP IMPLEMENTATION GUIDE: LASER SAFETY www.aornjournal.org
� Circulating nurse� Call for help according to established facil-
ity policy.� Assist other team members as needed.
� Nurse A (laser assistant)� Put the laser in standby mode.
Because of the team’s quick response, the patientdid not sustain any injuries. The patient wasreintubated and the surgery was completed with-out incident.
Requiring all perioperative team members toattend regular fire safety inservice programs willhelp ensure they will be able to react instinctivelyin the event of a fire. Having all the precautionsin place and educating staff members can avert apotential catastrophe.
CONCLUSIONLasers are a valuable tool in surgery but alsopresent significant risk. The AORN “Recom-mended practices for laser safety in perioperativepractice settings” is a comprehensive guideline forachieving the optimal level of practice. The RPdocument gives perioperative nurses all the keyelements to ensure industry standards are fol-lowed. The RP document should be the basis fora facility’s policy and procedures wherever lasersare used. There are many safety precautions thatmust be taken, but these precautions, defined inthe RP document, are at the heart of laser safetyand should be a part of every laser program.
For the best outcomes, a solid program shouldbe in place. At a minimum, the scrub person andcirculating nurse should know their roles in laseruse. Other staff members may need the guidanceof an LSO to make them aware of the recom-mended practices.
References1. Recommended practices: radiation safety in the operat-
ing room (including lasers). AORN J. 1985;42(6):920-930.
2. Recommended practices for laser safety in the practicesetting. In: AORN Standards and Recommended Prac-tices for Perioperative Nurses. Denver, CO: The Asso-ciation of Operating Room Nurses, Inc; 1990:111:7-1-
111:7-5.3. Recommended practices for laser safety in perioperativepractice settings. In: Perioperative Standards and Rec-ommended Practices. Denver, CO: AORN, Inc; 2012:125-142.
4. Recommended practices for laser safety in the practicesetting. In: AORN Standards and Recommended Prac-tices. Denver, CO: The Association of Operating RoomNurses, Inc; 1994:191-195.
5. Recommended practices for laser safety in practice set-tings. In: Standards, Recommended Practices & Guide-lines. Denver, CO: AORN, Inc; 1999:267-272.
6. Recommended practices for laser safety in practice set-tings. In: AORN Standards, Recommended Practices &Guidelines. Denver, CO: AORN, Inc; 2004:319-324.
7. Ball KA. Lasers: The Perioperative Challenge. 3rd ed.Denver, CO: AORN, Inc; 2004.
8. American National Standard for Safe Use of Lasers inHealth Care Facilities. Orlando, FL: The Laser Insti-tute of America; 2005.
9. Laser hazards. Occupational Safety and Health Admin-istration. http://www.osha.gov/SLTC/laserhazards/. Ac-cessed January 23, 2012.
0. NIOSH Hazard Control HC11: Control of smoke fromlaser/electric surgical procedures. http://www.cdc.gov/niosh/hc11.html. Accessed January 23, 2012.
1. Z136. 3-2005: Safe Use of Lasers in Health Care Fa-cilities. Washington, DC: American National StandardsInstitute; 2005.
2. New clinical guide to surgical fire prevention. HealthDevices. 2009;38(10):314-332.
3. Absten GT. Medical Laser Safety and CredentialingGuidelines. Professional Medical Education Associa-tion, Inc; 2007:70-101.
4. Surgical Smoke Evacuation Tool Kit. AORN, Inc.http://www.aorn.org/Clinical_Practice/ToolKits/Surgical_Smoke_Evacuation_ToolKit/Surgical_Smoke_Evacuation_Tool_Kit.aspx. Accessed February 14,2012.
5. Laser safety [self-assessment questionnaire 18]. Health-care Risk Control. 2011;1. https://www.ecri.org/Documents/RM/HRC_TOC/SAQ18.pdf. Accessed Janu-ary 23, 2012.
6. L-125 Principles of Lasers and Laser Safety. RockwellLaser Industries. http://www.rli.com/training/course.aspx?CourseID�29. Accessed January 23, 2012.
7. Laser Institute of America. http://lia.org/. Accessed Jan-uary 23, 2012.
8. Laser Safety in the Perioperative Setting [DVD]. Den-ver, CO: AORN, Inc; 2011.
9. Annex D. The safe use of high-frequency electricity inhealth care facilities. In: Health Care Facilities Hand-book. 10th ed. Quincy, MA: National Fire ProtectionAssociation; 2005.
0. Houck PM. Comparison of operating room lasers: uses,hazards, guidelines. Nurs Clin North Am. 2006;41(2):193-218, vi.
1. Patient Safety Authority. Airway fires during surgery.PA-PSRS Patient Safety Advisory. 2007;4(1):1, 4-6.
2. Andersen K. Safe use of lasers in the operating room—what perioperative nurses should know. AORN J. 2004;
79(1):171-188.AORN Journal 623
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23. Occupational Health and Safety Administration. 29CFR § 1910.132-134: General requirements; eye andface protection; respiratory protection; 2008.
24. TJC makes it clear: get surgical smoke out of OR.Same-Day Surgery. 2009;33(6):59-60.
25. Novak DA, Benson SM. Understanding and controllingthe hazards of surgical smoke. Becker’s ASC Review.March 28, 2011. http://www.beckersasc.com/asc-accreditation-and-patient-safety/understanding-and-controlling-the-hazards-of-surgical-smoke.html. Ac-cessed January 23, 2012.
26. ECRI Institute. Smoke evacuation systems, surgical.Healthcare Product Comparison System. November2007.
27. Alp E, Bijl D, Bleichrodt RP, Hansson B, Voss A. Sur-gical smoke and infection control. J Hosp Infect. 2006;62(1):1-5.
28. Waddell AW. Cultivating quality: implementing surgi-cal smoke evacuation in the operating room. Am JNurs. 2010;110(1):54-58.
29. Medical surveillance (rationale). In: EnvironmentalHealth Criteria 23: Lasers and Optical Radiation. Ge-
This RP Implementation Guide is intended to be adocument upon which it is based and is not intenals who are developing and updating organization
ence the full recommended practices document.624 AORN Journal
neva, Switzerland: World Health Organization;1982:132.
0. Oberg T, Brosseau LM. Surgical mask filter and fit per-formance. Am J Infect Control. 2008;36(4):276-282.
1. Fire Safety Tool Kit. AORN, Inc. http://www.aorn.org/FireSafety/. Accessed February 14, 2012.
2. Perioperative Job Descriptions and Competency Evalu-ation Tools [CD-ROM]. Denver, CO: AORN, Inc;2012.
3. Policy & Procedure Templates, 2nd ed [CD-ROM].Denver, CO: AORN, Inc; 2010.
Donna Castelluccio, MSN, RN, CNOR, is anOR educator, Danbury Hospital, Danbury, CT.Ms Castelluccio has no declared affiliation thatcould be perceived as posing a potential con-flict of interest in the publication of this article.
junct to the complete recommended practicesbe a replacement for that document. Individu-
licies and procedures should review and refer-
n added toal po
EXAMINATION
CONTINUING EDUCATION PROGRAM2.6www.aorn.org/CEImplementing AORN Recommended
Practices for Laser Safety
PURPOSE/GOAL
To educate perioperative nurses about how to implement the AORN “Recommendedpractices for laser safety in perioperative practice settings” in inpatient and ambu-latory settings.
OBJECTIVES
1. Identify potential risks involved with the use of medical lasers.2. Discuss AORN’s practice recommendations for the use and care of laser
equipment.3. Discuss AORN’s practice recommendations for providing a safe environment for
patients and health care workers.4. Describe methods for implementing AORN’s practice recommendations for laser
safety.
The Examination and Learner Evaluation are printed here for your conven-ience. To receive continuing education credit, you must complete the Exami-nation and Learner Evaluation online at http://www.aorn.org/CE.
QUESTIONS
1. Perioperative nurses must institute control mea-sures to minimize laser hazards such as1. fire.2. injury to the eye from direct viewing or scat-
tered beams.3. skin damage caused by burns.4. surgical smoke.
a. 1 and 2 b. 3 and 4c. 1, 3, and 4 d. 1, 2, 3, and 4
2. A laser safety program should include safetymeasures to
1. control access to laser use areas.© AORN, Inc., 2012
2. protect staff members and patients from unin-tentional exposure to the laser beam.
3. protect staff members and patients againstelectrical hazards.
4. provide physicians with the clinical componentof their laser training.
5. provide staff members and patients with appro-priate safety eyewear.a. 1 and 2 b. 3, 4, and 5c. 1, 2, 3, and 5 d. 1, 2, 3, 4, and 5
3. Responsibilities of the members of the lasersafety committee include ensuring a laser safetyspecialist is available for each area of laser use.
a. true b. falseMay 2012 Vol 95 No 5 ● AORN Journal 625
1
May 2012 Vol 95 No 5 CE EXAMINATION
4. To implement safety recommendations in a facil-ity in which a laser safety program is already inplace, an interested perioperative nurse or thelaser safety officer should1. consider starting a laser safety awareness
campaign.2. consider making a poster on the effects of sur-
gical smoke to get staff members’ attention.3. listen to staff member concerns about barriers
to implementation.4. enlist the help of staff members who regularly
participate in laser procedures to motivate oth-ers to follow policy.a. 1 and 2 b. 3 and 4c. 1, 3, and 4 d. 1, 2, 3, and 4
5. One of the three practice recommendations thataddress control measures necessary for patientand staff member safety is ensuring that all peo-ple in laser use areas wear the appropriateeyewear.a. true b. false
6. Practices to protect staff members and patientsfrom unintentional laser beam exposure includea. requiring eyewear that is appropriate for multi-
ple lasers.b. placing the foot switch near the operator.c. shutting the laser off when it is not in use.d. using reflective instruments near the laser site.
7. The patient’s eyes should be covered with weteye pads if the treatment area is around the eyes.
a. true b. false626 AORN Journal
8. To implement recommendations for ensuringproper laser safety measures, perioperative teammembers can1. create a resource book with information about
each laser in use at the facility.2. provide pictures of the various laser compo-
nents and directions for how to assemble them.3. review laser safety precautions in a huddle
before the patient enters the room or duringthe time out.
4. set up a laser cart so glasses, signs, masks, andother necessary items are located in one place.a. 1 and 2 b. 3 and 4c. 1, 3, and 4 d. 1, 2, 3, and 4
9. Surgical smoke has been found to contain1. bacterial and viral contaminants.2. cyanide.3. fiberglass.4. formaldehyde.5. polyicynene.6. toxic gases and vapors.
a. 1, 3, and 5 b. 1, 2, 4, and 6c. 2, 3, 4, and 5 d. 1, 2, 3, 4, 5, and 6
0. During laser use, basic electrical and fire safetyprecautions must be followed, including1. checking wires for fraying, cracks, and breaks.2. keeping sponges and drapes near the surgical
site moist.3. not putting liquids on the console.4. using extension cords to minimize the risk of
slips, trips, and falls.a. 1 and 2 b. 3 and 4
c. 1, 2, and 3 d. 1, 2, 3, and 4
LEARNER EVALUATION
CONTINUING EDUCATION PROGRAM2.6www.aorn.org/CEImplementing AORN Recommended
Practices for Laser Safety8
8
8
9
This evaluation is used to determine the extent towhich this continuing education program metyour learning needs. Rate the items as described
below.
OBJECTIVES
To what extent were the following objectives of thiscontinuing education program achieved?
1. Identify potential risks involved with the use ofmedical lasers. Low 1. 2. 3. 4. 5. High
2. Discuss AORN’s practice recommendations forthe use and care of laser equipment.Low 1. 2. 3. 4. 5. High
3. Discuss AORN’s practice recommendations forproviding a safe environment for patients andhealth care workers.Low 1. 2. 3. 4. 5. High
4. Describe methods for implementing AORN’s prac-tice recommendations for laser safety.Low 1. 2. 3. 4. 5. High
CONTENT
5. To what extent did this article increase yourknowledge of the subject matter?Low 1. 2. 3. 4. 5. High
6. To what extent were your individual objectivesmet? Low 1. 2. 3. 4. 5. High
7. Will you be able to use the information from this
article in your work setting? 1. Yes 2. No© AORN, Inc., 2012
. Will you change your practice as a result ofreading this article? (If yes, answer question#8A. If no, answer question #8B.)
A. How will you change your practice? (Select allthat apply)1. I will provide education to my team regard-
ing why change is needed.2. I will work with management to change/
implement a policy and procedure.3. I will plan an informational meeting with
physicians to seek their input and acceptanceof the need for change.
4. I will implement change and evaluate theeffect of the change at regular intervals untilthe change is incorporated as best practice.
5. Other:B. If you will not change your practice as a result
of reading this article, why? (Select all thatapply)1. The content of the article is not relevant to
my practice.2. I do not have enough time to teach others
about the purpose of the needed change.3. I do not have management support to make
a change.4. Other:
. Our accrediting body requires that we verifythe time you needed to complete the 2.6 con-tinuing education contact hour (156-minute)
program:May 2012 Vol 95 No 5 ● AORN Journal 627
