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Research and Standards involving the Use of Electrosurgical

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on 7 May 2014

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Transcript of Research and Standards involving the Use of Electrosurgical

Quality & safety in health care organisations is governed under the NSQHS Standards created by the Australian Commission for Safety and Quality in Health Care [ACSQHC] (2011).

There is no specific standard with direct relation to the safe management of electrosurgical equipment.

The use of electrosurgical equipment needs to be adapted to the NSQHS governance standards, which stipulates it is the responsibility of the health care organisation to implement procedures, policies and protocols which govern the practices within its setting (ACSQHC 2011).

The NSQHSS's governance of safety & quality is in-line with strategies to prevent health care acquired infections.

It further states the health care organisation must comply with relevant industry and legislative standards.
National Safety & Quality Health Service Standards
Australian College of Operating Room Nurses 2012-2013,
ACORN Standards for Perioperative Nursing
, ACORN, Adelaide.

Australian Commission on Safety and Quality in Health Care 2011, '
National Safety and Quality Health Service Standards
', ACSQHC, retrieved 25 March 2012, <http://www.safetyandquality.gov.au/wp-content/uploads/2011/09/NSQHS-Standards-Sept-2012.pdf>

Ball, K 2012, ‘Compliance with surgical smoke evacuation guidelines: implications for practice’,
ORNAC Journal
, Vol. 30, no. 1, pp. 14-37, doi: 10.1016/j.aorn.2010.06.002

Feldman, LS, Fuchshuber, P, Jones, DB, Mischna, J, Schwaitzberg, SD 2012, 'Surgeons don't know what they don't know about the safe use of energy in surgery',
Surgical Endoscopy
, Vol. 26, no. 10, pp. 2735-2739,
doi: 10.1007/s00464-012-2263-y

Spruce L & Braswell, M.L 2012, ‘Implementing aorn recommended practices for electrosurgery’,
AORN Journal
, Vol. 95, no. 3, pp. 373-382, doi: 10.1016/j.aorn.2011.12.018

Victorian Legislation and Parliamentary Documents 2004,
Occupational Health and Safety Act 2004
, retrieved 25 March 2014, <http://www.legislation.vic.gov.au>
* The Australian College of Operating Room Nurses

* ACORN History

* ACORN Considered Gold Standard

* Patient safety is our number 1 priority and S5 addresses measures that all perioperative nurses should use to minimise risks
Introduction to NSQHHS - Lauren
Research and Standards involving the Use of Electrosurgical Equipment
Introduction to ACORN Standards -Taissa
Introduction to Policy
Introduction to Research - Casey
ACORN Standards
Summary of ACORN Standards

Feldman et al suggests ESE so potentially dangerous that it is important that a register should be created for surgeons and anaesthetists.
Surgeon needs to demonstrate correct handling and usage, as well as knowledge in possible side effects of incorrect use
Anaesthetists need to demonstrate understanding in ESE effects on medical implanted devices such as a pace maker
This could perhaps be done as an annual hospital competency (such as the hand hygiene, fire and emergency competency training)
(Feldman et al. 2012)

JBI strongly recommends that prior to ESE use personnel need a thorough understanding of the principles surrounding electrosurgery including electrophysiology
(Moola 2013)

When the research is collated it suggests that the benefits outweigh negatives BUT great care needs to
be taken when using ESE.

Common adverse effects include
Burns – Prep pooling, poor/ faulty insulation
Electric shock
Rare but possible due to complications; Death

Less discussed issues with ESE include:
Toxicity during laparoscopic cases (Tissue nacrosis, carcenogenic)
Airway fire (ENT and Thoracic cases)
Hazardous surgical plume (If not used in conjunction with smoke evacuators)

(Spruce & Braswell 2012)

Current employer does not:
Have a hospital policy dedicated to electrosurgery
Use smoke evacuators in conjunction with diathermy
Have a competency record for those using ESE, instead relying on colleagues to teach other
colleagues on the job

Current employer does:
Encourage the checking of all insulated equipment for defects or damage
Attempt to prevent prep pooling and the use of alcohol based prep

Overall I’ve found that my employer does not follow the majority of recommendations from ACORN, NSQHSS and other reputable sources.
Does your current employer?


Electrosurgical equipment (ESE), such as diathermy, has been around since the early 1920’s.

Since it’s introduction there has been a significant improvements in positive patient outcomes, this can be contributed to the improvement of haemostasis and reduction in scar tissue formation.

All benefits come with negatives, this is no different. Electrosurgical equipment has significant safety issues/ concerns attached to it’s use.
(Moola 2013; Spruce & Braswell 2012)

Joanna Briggs Institute – Best Practise
Peer reviewed journal from within 5 years

Overall strong correlation/ integration between my research and NSQHSS, ACORN/AORN and hospital policies

Research Reviewed

Casey Muscat

Feldman, LS, Fuchshuber, P, Jones, DB, Mischna, J & Schwaitzberg, SD 2012, 'Surgeons don’t know what they don’t know about the safe use of energy in surgery', Surgical Endoscopy, vol. 26, no. 10, pp. 2735-9.
Moola, S 2013, 'Electrosurgery in the Perioperative Setting: Safe Use of Active Electrode', The Joanna Briggs Institute, pp. 1-9.
Moola, S 2013, 'Electrosurgical Unit in the Perioperative Setting: Creating a Safe Environment.', The Joanna Briggs Institute, pp. 1-8.
O'Riley, M 2010, 'Electrosurgery in perioperative practice', Journal of Perioperative Practice, vol. 20, no. 9, pp. 329-33.
Spruce, L & Braswell, ML 2012, 'Implementing AORN Recommended Practices for Electrosurgery', AORN Journal, vol. 95, no. 3, pp. 373-87.


Regulatory Bodies
2. Worksafe Victoria
3. National Safety & Quality Health Service Standards
4. ACORN Standards
5. Hospital Procedure, Policy & Protocols

1. Occupational Health & Safety Act 2004
The Occupational Health & Safety Act 2004 [OHS Act 2004], and Worksafe Victoria (2013) are legislative bodies which must be adhered to (Victoria Legislation and Parliamentary Documents 2004).

The Act states the employer must eliminate or minimise the risk to health and safety to the best of their ability.

The employer and employee has a duty of care to themselves and persons (patients/colleges) to maintain a safe working environment which is free from hazards (Victoria Legislation and Parliamentary Documents 2004).

The Australian College of Operating Room Nurses [ACORN] standards outlines guidelines with relation to the use of elcelrosurgical equipment, and surgical plume (ACORN 2012-2013).

The NSQHSS creates an over arching framework for which health care organisations must follow. The health care organisation must consider and adhere to the standards guided by the OHS Act 2004, Worksafe Victoria (2013) and ACORN Standards(2012-2013) to create workplace policy and procedures that effectively manage safety and the risk of utilising electrosurgical equipment.
Managing the Risk
The standards, guidelines and research suggests health care providers implement existing, or create hospital procedures, policies and protocols to safely manage the risks associated with the use of electrosurgical equipment (Ball, 2012).

The Society of American Gastrointestinal and Endoscopic Surgeons [SAGE] conducted a study on surgeons knowledge of management and safe use of electrosurgical equipment. Of the 48 respondents tested, the average score was 59 percent (Feldman, Fuchshuber, Jones, Mischna, Schwaitzberg 2012). In response to the findings, an educational program called the Fundamental Use of Surgical Energy [FUSE] was created to prevent knowledge gaps.

Literature suggests staff should be competently trained and educated in health, safety and utlisation aspects of electrosurgical devices (Spruce & Braswell 2012).

Training could include education on Association of periOperative Registered Nurses [AORN] Electrosurgery Practice Recommendations (Spruce & Braswell 2012).
Recommendation one: Surrounds consulting suppliers for information on the equipment, safety assessment and standardising the purchasing of the devices (Spruce & Braswell 2012).

Recommendation two: Discusses training, educating staff, and reading manufacturers specifications and recommendations prior to use (Spruce & Braswell 2012).

Recommendation three: Provides information on assessing for damage and safe handling methods to protect the integrity of the equipment (Spruce & Braswell 2012).

Recommendation four: Cautions on the potential for electrosurgical equipment to cause electrocution, or ignite when coming into contact with flammable substances (Spruce & Braswell 2012).

Recommendation five: Encompasses patient positioning and patient safety when utlilising the equipment. This includes placement and use of the dispersive electrode (Spruce & Braswell 2012).

Recommendation six: Advises adhering to manufactures instructions when utilising Argon equipment and following specified safety precautions with regards to its use (Spruce & Braswell 2012).
Australian College of Operating Room Nurses 2012, ‘Electrosurgical Equipment’, in ACORN Standards for Perioperative Nursing, Adelaide, S5, pp. 1-4.
Australian College of Operating Room Nurses 2012, ‘Surgical Plume’, in ACORN Standards for Perioperative Nursing, Adelaide, S20, pp. 1-6.
Ball, K 2010, ‘Compliance with surgical smoke evacuation guidelines: Implications for practice’, AORN, vol. 92, no. 2, pp. 142-149, doi: 10.1016/j.aorn.2010.06.002
Gilmour, D 2005, ‘Perioperative Care’, in R Pudner (ed.), Nursing the Surgical Patient, 2nd edition, Elsevier Health, Philadelphia USA, pp. 17-34.
Hospital X 2011, ‘Electrosurgical Use in the Operating Room’, Hospital X, retrieved 15 March 2014.
Spruce, L & Braswell, ML 2012, ‘Implementing AORN Recommended Practices for Electrosurgery’, vol. 95, no. 3, pp. 373-387, doi: 10.1016/j.aorn.2011.12.018

ACORN (2012) outlines recommendations for the management of surgical plume during surgery, which aims to protect health these standard statements as outlined care personnel in the Perioperative setting.

There is evidence that surgical smoke plume is a serious health hazard to staff (Ball 2010, p. 142)
Hospital policies should also reflect management of surgical plume, or link to the relevant policy, as it is highly relevant to the use of electrosurgical equipment.

For example, Hospital X (2011), has devised a comprehensive hospital policy which covers
The purpose of the policy
Defines electrosurgery
Education and training
Outlines the equipment required
Lists staff responsibilities and nursing considerations
Details precautions and special precautions


Comparison of various hospital policies and procedures found that some were more comprehensive than others.

The hospital policies used for comparison all identified the purpose of the policy, defined electrosurgery, as well as acknowledge and reference the ACORN standard for electrosurgical equipment.

However, some policies failed to describe the potential risks associated and neglect to outline hospital specific procedures to minimise these risks.

ACORN (2012) recommends that relevant personnel
Understand the potential risks and dangers that are associated with the use of electrosurgical equipment
Undertake education for the use of electrosurgical equipment,
Needs to be regular maintenance of electrosurgical equipment, and routine checking of equipment prior to use, to ensure safety to patients and staff.
Documentation of use of electrosurgical equipment in the patient’s Perioperative record.


There is evidence to suggest that electrosurgical equipment in the operating room has the potential to cause injury to the patient, operating room staff (Gilmour 2005, p. 25).

The development and implementation of safety standards are designed to minimise the risk of potential harm from electrosurgical use in the operating room.

Hospital policies outline recommended practices that staff should adhere to, to reduce the potential risks and dangers to staff members and patients (Spruce & Braswell 2012, pp. 373)


By Samantha Lay

ACORN Standard 5 provides perioperative nurses guidance for the use of electorsurgical equipment under the following standard statements:
SS 1
All personnel using equipment should be aware of risk associated with electrosurgical use
SS 2
An education program shall be established for the instruction of all personnel invoed in the application and use of electrosurgical equipment
Electrosurgical equipment will be routinely checked before use and undergo preventative maintenence
The use of electrosurgical equipment shall be documented
ACORN used four distinct references for Standard 5:

Perioperative Nursing Introductory Text

Standards Australia. New Zealand Standards

Victorian Surgical Consultative Council- The Use of Quivers in Surgical Settingings

Valleylab - Principles of Electrosurgery
How ACORN Arrived at the 4 Standard Statements
Association of Registered Perioperative Nurses 2009, 'Reccomended practices for electrosurgery', AORN, Denver, CO, pp. 245-259

Australian College of Operating Roon Nurses 2012, 'Electrosurgical Equipment', in ACORN standards for perioperative nurses, S5, pp. 1-4

Hamlin, L, Richardson-Tench, M & Davies, M 2009, Perioperative nursing: an introductory text, Elsevier:Australia, Chatswood

Spruce, L & Braswell, M 2012 'Implementing AORN Recommended Practices for Electrosurgery', AORN Journal, vol. 95. no. 3, doi: 10.1016/j.aorn.2011.12.018

Standards Australia, New Zealand Standards 2004, 'Guide to safe use of electricity in patient care', 4th Ed., Standards Australia, Sydney

Victorian Surgical Consultative Council 2008, ' The use and care of quivers in the surgical setting-laparscopic surgery', VSCC, Melbourne

ValleyLab 2005, 'Principles of Electrosurgery', ValleyLab inc

AORN's Electrosurgery Practice Recommendations
Background on ACORN Standards
(ACORN, 2012) (AORN, 2009)
(ACORN, 2012)
Lauren Bauer
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