Hospital eTool: Surgical Suite

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

Common safety and health topics:

Virtual Tour

Review the hazards below and then tour the virtual reality room.

The anesthetic gas and vapors that leak out into the surrounding room during medical
and surgical procedures are considered waste anesthetic gases.
They include nitrous oxide and halogenated agents (vapors) such as:

  • Enflurane
  • Isoflurane
  • Sevoflurane
  • Desflurane
  • Halothane

Potential adverse health effects of exposure to waste
anesthetic gases include loss of consciousness, nausea, dizziness, headaches, fatigue,
irritability, drowsiness, problems with coordination and judgment, as well
as sterility, miscarriages, birth defects, cancer, and liver and kidney

Potential Hazard

  • Exposure to waste anesthetic gases occurs from:

    • Poor work practices during the anesthetization of patients.
    • Leaking or poor gas-line connections.
    • Improper or inadequate maintenance of the machine.
    • Patient exhalation in the recovery room or Post Anesthesia Care Unit (PACU) during off-gassing of surgery patients.

Possible Solutions

Guidelines for Workplace Exposures
to Anesthetic Gases
provide the following recommendations provides the following

  • Use appropriate anesthetic gas scavenging systems in
    operating rooms.

    • Appropriate waste gas evacuation
      involves collecting and removing waste gases, detecting and correcting leaks, considering work practices, and effectively ventilating
      the room (Dorsch and Dorsch 1994).
  • Provide enough ventilation in the
    surgical suite to keep the room
    concentration of waste anesthetic gases below
    the applicable occupational exposure levels.
    The ventilation design and specifications
    should meet the most current American
    Institute of Architect’s Guidelines for
    Design and Construction of Health Care

    • To minimize waste anesthetic gas concentrations in the operating room, the recommended air exchange rate (room dilution ventilation)
      is a minimum total of 15 air changes per hour with a minimum of 3 air changes of outdoor air (fresh air) per hour (American Institute of Architects 2006).
  • Use a properly designed and operating dilution ventilation system to minimize waste anesthetic
    gas concentrations in recovery room areas.

    • System should provide a recommended minimum total of 6 air changes per hour with a minimum of 2 air changes of outdoor air per
      hour (American Institute of Architects
  • Conduct periodic exposure monitoring with
    particular emphasis on peak gas levels
    in the breathing zone of nursing
    personnel working in the immediate
    vicinity of the patient’s head.

    • Note: Methods using random room sampling
      to assess ambient concentrations of
      waste anesthetic gases in the recovery
      room are not an accurate indicator of
      the level of exposure experienced by
      nurses providing bedside care. Due to the closeness of the recovery room
      nurse to the patient, such methods would
      consistently underestimate the level of
      waste anesthetic gases in the breathing
      zone of the bedside nurse. Therefore,
      personal sampling is required to
      determine the employee’s overall
      workplace exposure to waste anesthetic
  • Implement a routine ventilation system maintenance program to keep waste
    anesthetic gas exposure levels to a minimum.

In addition, the

Hospital Investigations: Health Hazards
Chapter of the OSHA Technical
Manual recommends that:

Additional Information:

  • Anesthetic Gases:
    Guidelines for Workplace Exposures
    . OSHA,
    (2000, May 18). Provides guidelines and controls to help reduce occupational exposure to waste anesthetic gases.
  • Waste Anesthetic Gases.
    Safety and Health Topics Page.
  • U.S. Department of Health and Human
    Services (DHHS), National Institute
    Occupational Safety and Health (NIOSH)
  • Guidelines for design and
    construction of health care facilities.
    American Institute of Architects,
    Academy of Architecture for Health, (2006).

  • Recommended practices for a safe environment of
    Association of Perioperative Registered
    Nurses (AORN), In: Perioperative Standards
    and Recommended Practices, (2008):351-374.

  • Waste Anesthetic Gases: Information for
    Management in Anesthetizing Areas and the
    Postanesthesia Care Unit (PACU)
    . American
    Society of Anesthesiologists, (2004).

Potential Hazard

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

Possible Solutions

Among other things, OSHA’s

Bloodborne Pathogens Standard
requires that:

  • Engineering and work practice controls
    be used to eliminate or minimize exposures
    to blood and OPIM.
    CFR 1910.1030(c)
    29 CFR 1910.1030(d), and

    OSHA Directive CPL 02-02-069
  • In addition, sharps injuries in the surgical area must be eliminated or minimized through use of measures such as:

    • Safer needle/other sharps devices.
    • Blunt-tip suture needles.
    • Needleless IV connectors.
    • Proper containers for sharps.
    • “No Pass Zone” for surgical instruments.
    • Method for passing equipment safely between surgeon and assistants.
      • The hands-free technique is a work practice whereby a tray or other means are used to
        eliminate simultaneous handling of sharp instruments during surgery.
  • Appropriate personal protective
    equipment (PPE) be worn if blood or OPIM exposure is
    anticipated. [29
    CFR 1910.1030(d)(3)
    ] The PPE must be
    impermeable under normal conditions of use
    and for the duration of time it will be
    used. The type of PPE
    depends on the anticipated exposure.
    Appropriate PPE includes, but is not limited
    to, gloves, gowns, face shields or masks,
    and shoe covers. For example:

    • Gloves must be worn when hand contact with blood, mucous membranes, OPIM, or non-intact skin is anticipated, or when handling
      contaminated items or surfaces
      CFR 1910.1030(d)(3)(ix)
    • Masks, in combination with eye
      protection devices, must be worn whenever
      splashes, spray, splatter or droplets of
      blood or OPIM may be generated [29
      CFR 1910.1030(d)(3)(x)
  • Contaminated needles and other
    contaminated sharps be discarded immediately or as soon as feasible into appropriate containers [29
    CFR 1910.1030(d)(4)(iii)(A)(1)
  • Sharps containers be located as close as is feasible to the
    immediate where sharps are used or reasonably anticipated to be found [29 CFR 1910.1030(d)(4)(iii)(A)(2)(i)].
  • Contaminated needles and other contaminated sharps must not be bent, recapped, or removed except as noted in paragraphs

    29 CFR 1910.1030(d)(2)(vii)(A)

    . Shearing or breaking contaminated needles is
  • Employers ensure that handwashing facilities be readily
    CFR 1910.1030(d)(2)(iii)
    and that employees wash their hands immediately or as soon as feasible after removal of gloves
    or other personal protective equipment
    CFR 1910.1030(d)(2)(v)

    • Hand must be washed with an appropriate
      soap and water, whenever there has been
      occupational exposure to blood or OPIM. If a
      sink is not readily accessible (e.g., in the
      field) for instances where there has been
      occupational exposure, hands may be
      decontaminated with hand cleanser or
      towelette, but must be washed with soap and
      running water as soon as feasible.
    • If there has been no occupational
      exposure to blood or OPIM, use of an
      appropriate antiseptic hand cleanser is

Additional Information:

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

Potential Hazard

  • Developing latex allergy from exposure to products that contain latex such as gloves, catheters, and tubing.

Possible Solutions

  • Provide appropriate gloves, including
    powderless, hypoallergenic, glove liners, or other similar alternatives to employees who are allergic to the gloves normally provided
    CFR 1910.1030(d)(3)(iii)
    Note: Do not
    assume hypoallergenic gloves are non-latex or latex-free.

In addition, good work
practices should be used. These may include:

  • Providing a latex-safe work environment.
  • Using non-latex gloves and other latex-free products.
  • Selecting a low protein, powder-free glove.

Additional Information:

For additional information, see
Healthcare Wide Hazards –
Latex Allergy

Within a healthcare

facility, compressed gases are usually
either fixed piped gas systems
or individual cylinders of

Potential Hazard

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

Cylinders of compressed gas.
Figure 1. Cylinders of compressed gas.

Possible Solutions

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

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

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

  • Transport compressed gas cylinders with
    protective caps in place and do not roll or
    drag the cylinders.

Caution: Keep All Cylinders Chained.
Figure 2. Caution: Keep
All Cylinders

Additional Information:

  • 1910.101, Compressed
    OSHA Standard.
  • 1910.103, Hydrogen.
    OSHA Standard.
  • 1910.104, Oxygen.
    OSHA Standard.
  • 1910.105, Nitrous oxide.
    OSHA Standard.

  • Compressed Gas and Equipment
    . OSHA
    Safety and Health Topics Page.
  • NFPA 99, Standard for Health Care Facilities, Chapter
    4, Gas and Vacuum Systems. National Fire
    Protection Association, (2005).

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

Potential Hazards

  • Standing in static postures
    continuously during lengthy surgical
    procedures, causes muscle fatigue and pooling of blood in the lower extremities.
  • Standing on hard work surfaces such as
    concrete creates trauma and pain to the feet.
  • Awkward postures
    resulting from prolonged standing, trunk
    flexion, neck flexion, and arms held
    higher than the optimal working height.

Possible Solutions

  • Provide stools, where possible.
  • Use shoes with well-cushioned insteps and soles.
  • Provide a footrest bar or a low stool, allowing employees
    to continually alter their posture by raising one foot.
  • Use height-adjustable work tables and surfaces.
  • Use anti-fatigue mats.

Additional Information:

  • Association
    of Perioperative Registered Nurses (AORN)

    • Guidance Statement: Safe Patient Handling and Movement
      in the Perioperative Setting.

    • Recommended practices for positioning the patient in the
      practice setting.

      In: Perioperative Standards and Recommended Practices, (2008):497-520.

For additional information, see
Healthcare Wide Hazards –
Ergonomics, Awkward Postures

Laser or electrosurgical units may be required
during surgical procedures. Smoke byproduct or
“plume” is created when tissue is thermally
destroyed. Smoke plume may contain toxic gases
and vapors such as benzene, hydrogen cyanide,
and formaldehyde, bioaerosols, dead and live
cellular material (including blood fragments),
and viruses.

The research is limited on transmission of
disease through surgical smoke, but the
potential for generating infectious viral
fragments, particularly during treatment of
venereal warts, may exist. Researchers have
suggested that the smoke may act as a vector for
cancerous cells which may be inhaled by the
surgical team and other exposed individuals.

Potential Hazards

  • Exposure to high concentrations of smoke may
    cause ocular and upper respiratory tract
    irritation and create visual problems for the
    perioperative team.

  • Smoke may contain toxic gases that could have
    the potential for adverse health impacts, such
    as mutagenic and carcinogenic impacts.

Possible Solutions

  • Use portable smoke evacuators and room suction systems
    with inline filters.
  • Keep the smoke evacuator or room suction hose nozzle inlet within 2 inches of the surgical site to effectively capture
    airborne contaminants.
  • Have a smoke evacuator available for
    every operating room where plume is
  • Evacuate all smoke, no matter how much
    is generated.
  • Keep smoke evacuator “ON” (activated) at all times when airborne particles are produced during all surgical or other
  • Consider all tubing, filters, and absorbers as infectious waste and dispose of them appropriately. Use
    Universal Precautions
    as required by
    the OSHA Bloodborne Pathogens Standard when
    contaminated with blood or OPIM [29
    CFR 1910.1030(d)(1)
  • Use new tubing before each procedure
    and replace the smoke evacuator filter as recommended by the manufacturer.
  • Inspect smoke evacuator systems regularly to
    ensure proper functioning.

Additional Information:

  • Laser/Electrosurgery Plume.
    Safety and Health Topics Page.
  • Control of Smoke from Laser/Electric
    Surgical Procedures
    . U.S. Department of
    Health and Human Services (DHHS), National
    Institute for
    Occupational Safety and Health (NIOSH) Publication No. 96-128,
    (March 2, 1998).
  • Association of Perioperative Registered
    Nurses (AORN)

    • Recommended practices for a safe environment
      of care
      . In: Perioperative
      Standards and Recommended Practices,

    • Recommended practices for electrosurgery
      . In:
      Perioperative Standards and
      Recommended Practices, (2008):315-329.

    • Recommended practices for endoscopic
      minimally invasive surgery
      . In:
      Perioperative Standards and Recommended
      Practices, (2008):331-343.

Although there are hundreds of different
types of lasers, only about a dozen laser
systems are found in everyday clinical
use. Nearly all laser products used in
surgery are
Class 4 as they are
designed to deliver laser radiation for
the purpose of altering biological tissue.

When lasers are
introduced into a healthcare environment,
professionals must be prepared to address
safety issues for both the staff and

patient. Safe use of these systems
requires an understanding of the engineering, training, and administrative
requirements for all elements of a healthcare system as well as the risks
associated with use of laser light.

All medical lasers are
regulated and federal
regulations require manufacturers to
classify the medical laser system based
primarily on its ability to cause damage
to the eye and skin. This classification
must be indicated on the laser system’s
label ranging from Class 1 (no hazard) to
Class 4 (serious hazard).

For a more detailed discussion on lasers,
see the

Use of Medical Lasers

Potential Hazard

Possible Solutions

The American National Standard Institute (ANSI)
Z136 series of laser safety standards covers lasers in
medical settings and provides guidance for the
safe use of lasers for diagnostic, cosmetic,
preventative and therapeutic applications in
healthcare facilities. These guidelines are
considered to be the standard for safe practice
in the industry and include solutions such as:

  • Use laser protective
    eyewear that provides adequate protection
    against the specific laser wavelengths
    being used. All laser
    eyewear must be marked with Optical Density (OD) and laser
  • Display warning signs conspicuously

    on all doors entering the Laser
    Treatment Controlled Area (LTCA), so as to
    warn those entering the area of laser use.
    Warning signs should be covered or removed
    when the laser is not in use.

  • Maintenance on lasers and laser systems
    must be performed only by facility-authorized
    technicians trained in laser service.
  • Provide local exhaust ventilation with a
    smoke evacuator or a suction system with an
    in-line filter to reduce

    laser-generated airborne
    contaminants (LGAC)
    levels in laser
  • Use an appropriate filter or barrier which reduces
    any transmitted laser radiation to levels
    below the applicable Maximum Permissible
    Exposure (MPE) level, for all facility windows (exterior or interior) or
    entryways located within the Nominal
    Hazard Zone (NHZ) of a
    Class 3B and
    Class 4
    laser system.

Figure 3.

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

Class 4 - Laser Sign stating: "Danger. Laser Radiation. Avoid eye or skin exposure to direct or scattered radiation."
Figure 5.
Class 4 Laser Sign stating: “Danger.
Laser Radiation. Avoid eye or skin exposure
to direct or scattered radiation.”

  • Ensure that alignment and calibration
    techniques are used for routine Perioperative
    checkout of the laser system.
  • Use skin protection if repeated exposures
    are anticipated at exposure levels at or near
    the applicable MPE limits for the skin.
  • Provide detailed
    training in laser safety
    for healthcare personnel using or working in
    the presence of Class 3B and Class 4 healthcare laser systems.
  • Ensure
    credentialing of staff using laser

Additional Information:

  • 1926.54, Nonionizing radiation.
    OSHA Standard.

  • Laser Hazards
    Safety and Health Topics Page.

  • OSHA Technical Manual (OTM)
    . OSHA
    Directive TED 01-00-015 [TED 1-0.15A],
    (January 20, 1999).

    • Laser Hazards.
      Contains information that will assist in the recognition and
      evaluation of laser hazards.
  • US Department of Health and Human
    Services, Food and Drug Administration
    (FDA), Center for Devices and Radiological
    Health (CDRH)
  • International Electrotechnical

    • IEC 60825-1/A2:2001. Safety of Laser
      Products – Part 1: Equipment classification,
      requirements, and user’s guide.
    • IEC 60825-2 IS 01. Interpretation Sheet
  • Laser Institute of America (LIA). The
    LIA is the
    secretariat and publisher of the ANSI Z136
    series of laser safety standards. They are
    recognized as a minimum standard for laser

    • ANSI Z136.1-2007. American
      National Standard for the Safe Use of
    • ANSI Z136.3-2005. American National Standard for the Safe Use of Lasers
      in Health Care Facilities.
  • Recommended practices for laser safety
    in practice setting
    . Association of
    Perioperative Registered
    Nurses (AORN), In: Perioperative Standards and Recommended
    Practices, (2008):447-452.

Potential Hazard

  • Exposure to possible hazardous chemicals found and used in the surgical area
    typically during mixing, preparation, and in
    the operating room.

    • This may include peracetic acid used in cold
      sterilant machines, Methyl Methacrylate (MMA),
      an acrylic cement-like substance used to
      secure prostheses to bone during orthopedic
      surgery, and

      waste anesthetic gases

Possible Solutions

  • Mix methyl methacrylate only in a closed system.
  • Carefully read and follow instructions and warnings on labels, (e.g., when using cold sterilant machines for
    sterilizating equipment that cannot be autoclaved, use goggles provided and do not open machine until it is in a
    safe to open mode).
  • Consider using disinfectants or other products that are not hazardous.
  • Inform employees of chemical hazards and have on hand Material Safety
    Data Sheets, (MSDS) for all hazardous chemicals used in their facilities
    [29 CFR 1910.1200].
  • Follow all MSDS instructions regarding safe handling, storage, and disposal of hazardous chemicals.

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

Potential Hazard

  • Exposure to burns or shocks from poorly maintained equipment (e.g., autoclaves, warming cabinets, defibrillators) or improperly trained staff.

Possible Solutions

  • Create a safety and health program that
    routinely monitors the condition of equipment
    and addresses work practices of employees.
    This program should include practices such as:

    • Train employees to correctly and safely use
      and clean equipment.
    • Maintain adequate working space and access to equipment.
    • Visually inspect equipment before using.
      • Visually inspect cords. Do not
        use if frayed or damaged.
      • If something does not look right, do not use the machine and call for assistance.
    • Ensure that all electrical service
      equipment near sources of water are properly grounded
      CFR 1910.304
    • Use appropriate personal protective equipment and safe work practices for assessed hazards (e.g., when handling hot items
      use gloves, and do not open autoclaves or sterilizers until items are sufficiently cooled).
    • Adhere to all manufacturer and
      operator instructions to ensure safe use
      of equipment.

Additional Information:

  • Avoiding Hazards with Using Cleaners and
    Disinfectants on Electronic Medical
    . OSHA, Food and Drug
    Administration (FDA), Centers for Disease
    Control (CDC), and Environmental Protection
    Agency (EPA)
    Public Health Notification, (October 31,2007).

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

Potential Hazards

  • Falling over portable equipment of a color
    that visually
    blends into the floor.

  • Slipping on debris (bandages, tubing, blood,
    IV fluids) that had fallen or spilled on the

  • Tripping on
    electrical cords that may cross floors.

Possible Solutions

  • Keep aisles and passageways clear and in good repair, with no obstructions across or in aisles that may create a hazard [29
    CFR 1910.22(a)
  • Provide ceiling or floor outlets for equipment to
    ensure that power cords do not run across pathways.
  • Mark mobile equipment (e.g., stools) with a bright color, or a taped “X”,
    making them more visible and distinguishable from the floor.
    Tape should be washable and durable.

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

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