At the LRI, the status of equipment is recorded by a member of staff in a log book. The author has undertaken these checks and recognizes the need to be able to justify decisions as specified in the HPC (2008) section 1a.6. The diathermy machine is generally then positioned at the foot of the bed and as advised by the NATN (1998), is mounted on a wheeled stand that is tip resistant and has freedom of movement. If any problems in obtaining a functional electrical circuit are found, this would need to be immediately reported to the Theatre manager and the Biomedical Engineering Department.
The Association for Perioperative Practice (AFPP 2002) advises against the use of alcohol-based preparations, instead recommending that aqueous solutions are used to reduce the risk of fire. Wicker (2000) also advises to ensure that excess prep solution is removed prior to the use of diathermy as ignition can occur if these come into contact with active forceps. Cunnington (2006) discusses an incident in which a spark from the forceps created a burn at the edge of the incision. The instrument was removed from use, the wound made good and an incident report filed. The steps undertaken were in line with AFPP (2002) guidelines but Cunnington (2006) goes on to discuss how this incident illustrates that even with protocols designed to prevent harm, the practitioner still needs to apply understanding to translate their intention into safe practice.
Even when standards are met on a professional level, there’s still an ethical dilemma when accidents occur. For example, some of the risks involved with pacemakers are often unknown by their recipients as Marsh (2008) explains. She discusses the need for the theatre team to be aware of all the implications at the earliest possible stage whilst providing a high standard of care using all the available evidence. Early awareness of a pacemaker allows for advice to be sought from a patients cardiologist and therefore making the team aware of any equipment requirements as early as possible. It is too late when the patient is in the anaesthetic room, which can lead to cancellations or possible negligence claims if something goes wrong. So it is important to prepare the diathermy device correctly and in good time, according to the patient’s clinical status. This relates to the HPC’s (2008) section 2b.3 requirement to formulate specific and appropriate management plans including the setting of timescales.
Prior to commencement of surgery, the scrub practitioner will confirm that forceps and leads are appropriate and functioning properly. If using monopolar, a diathermy plate electrode must be applied to the patient, usually on the thigh area, which must also be shaved prior to application to prevent burning. Positioning the device involves applying the quiver to the drapes in an accessible area for the surgeon. This meets the requirements of the NATN (1998) which states that the diathermy forceps should be housed in an insulated container and kept well away from the operative field during surgery. It is also the scrub practitioner’s responsibility to ensure that the diathermy equipment is used correctly throughout the procedure. However, The NATN’s (1998) section on ‘safe practice’ also stipulates that the activation of the forceps is the responsibility of the operating surgeon.
For example, Wicker (1992) explains how accidents can occur due to staff not being duly attentive. He explains that activating the forceps before they are touching anything will flood the room with radio frequency current. These radio waves are trying to return to the diathermy pad electrode but may take a detour via another object or quite possibly, a person. If they happen to be touching a towel clip which has pierced the drape and is in contact with the patient’s skin, there is the potential for a burn at the point of contact, as the current takes its journey back to the Diathermy plate electrode.
Accountability
There is shared responsibility with the surgeon; often a grey area in theatre. Fulbrook (1998) discusses the role of the ODP in relation to their duty of care and equipment. In theatres, there are several professional groups practicing and it follows that where diathermy is to be utilized, there is a question over who is accountable for negligence if the patient is harmed in any way? Fulbrook (1998) suggests that whoever prepares the diathermy is ultimately responsible, under The Health and Safety at Work Act (1974) but also argues that this doesn’t relinquish the surgeon’s duty because they will be using the equipment and the preparation is just part of the procedure for which the surgeon is ultimately responsible. The HPC (2008) section 2c.2 stipulates that the practitioner should “understand the principles of quality control and quality assurance” and also, “be able to maintain an effective audit trail and work towards continued improvement”. For example, the author has previously used a plastic ‘A’ set with diathermy forceps missing which temporarily held up the operation whilst more were sent for. The author made a note of this so as to alert the staff in the sterile services department.
Continued Education
The NATN (1998) outlines the need for regular audits in order to identify areas for improvement. Constant education and assessment is encouraged, as described by the NATN (1998) as the greatest precaution against accidental burns. An ethos of constant learning naturally extends to the student, who, from module one, is involved with the use of the diathermy machine. The HPC standards of proficiency (2008) section 2b.4 dictates that practitioners should; “be able to conduct appropriate diagnostic or monitoring procedures, treatment, therapy or other actions safely and skilfully.” For the student in their role as circulator, they need to know, for example, where to find spare forceps to continue an operation as soon as possible and generally meet the (HPC) policy in section 2b.4 on being able to undertake appropriate surgical interventions.
The Smoke plume
The NATN (1998) recommends that dedicated smoke evacuation machines must be used where a risk is identified. There seems to be a situation of limbo here because people can only respond to the information that is displayed in front of them and no substantial risk has yet been comprehensively identified. Anderson (2005) discusses the parallels with cigarettes and how a state of ignorance once surrounded this harmful toxin. When discussing problem areas in theatre, it is important to investigate the subject of accountability and how the individual can expand one’s role, and assume the legal and professional responsibility which follows (Fulbrook 1998). But how far can a student take their individual concerns? The HPC (2008) section 1a.6 states that practitioners should,” know the limits of their practice and when to seek advice or refer to another professional“.
One requirement of the HPC (2008) section 2b.1 is that practitioners are “able to engage in evidence-based practice, evaluate practice systematically, and participate in audit procedures.” Scott, Beswick and Wakefield (2004) discuss the results of questionnaires sent out to senior practitioners by a group of theatre staff at Rotherham District General Hospital (RDGH), asking questions relating to health risks of diathermy smoke and current practice. These investigations failed to produce any quantified data so they employed the help of the Health and Safety Laboratory (HSL) in Sheffield who, after chemical analysis, concluded that, “the atmospheric sampling had not identified anything hazardous for patient, scrub or circulating team.” The HSL (2004) indicate that they were limited by the methods employed which suggest ‘cost’ being their biggest barrier. There seems to be a lot of bureaucracy surrounding this subject, especially when we look at other health associations abroad. Scott et al (2004) suggests that we can’t make comparisons with countries like the USA as their standards for operating rooms are different to the UK. However, both the USA and Australia have set out clear guidance on the management of the surgical plume in their own theatres (AFPP 2009). They acknowledge that there has to be some level of risk in breathing in chemicals like carbon monoxide, ethane, methane and phenol and provide staff with the necessary protection. What is interesting is that from the questionnaires taken by RDGH, 60% said they did not offer specialized masks to staff when diathermy was in use. This is certainly the case at the LRI. The author has never been offered any specialized protective equipment and has only witnessed the use of a smoke evacuator once, during an abdominoplasy. The author questioned this and was told that cost was the issue. A conmed evacuation filter costs £150 whilst only being functional for eight hours (cunnington 2006). The British Occupational Hygiene society (2006) has issued guidelines on surgical smoke to be used by managers in the National Health Service but it appears that until the long term effects are known, there will be no definite action taken. A change in approach must occur, however and knowledge shared if we are to affect change. For example, I’ve been advised to secure the diathermy lead through a drape which avoids potential burns or loss of current (due to the forceps coming into contact with an isolated conductor). Through research, I can see this is logical step and I feel confident in adopting this practice. The presence of inbuilt ventilation alone is not a satisfactory precaution against surgical smoke. There seems to be a gap between the precautions taken for staff and those taken for patients. Practitioners wear masks which are designed to prevent droplets from the health care professional reaching the patient but do not prevent against the smaller particles present in surgical smoke (Biggins & Renfree 2002).
Conclusion
When analyzing diathermy, comparisons have been made with cigarettes and how lessons from the past are not being learned. The main question I posed was whether the present guidelines are consistently followed? Currently, I don’t believe they are with the main reason being that smoke evacuators are not compulsory, and if diathermy is used without one, legally, there isn’t an issue. Guidelines are met more consistently when patient safety is concerned but the same standards aren’t always maintained in relation to staff safety. So, it is in the practitioner’s best interests to educate themselves to help bring the health risks of diathermy to the forefront of debate. With cost being an issue, pressure needs to be applied through the appropriate channels so that the gap between best practice and action is narrowed. It is the ODP’s ethical and professional obligation to understand the value of reflection on practice and to share that knowledge with fellow professionals. Health care practitioners are a vital source of information in the investigation of this issue so they must strive to equip themselves with the relevant information so as they are able to influence future practice for the benefit of the patients and their fellow professionals alike.
References
Anderson, E (2005). Surgical Smoke – is there a fire? American Association of Occupational Health Nurses Journal. 53 (3) 104
The British Occupational Hygiene society (2006), cited by the Association for Perioperative Practice (2009), (poster).
The Association for perioperative practice. (2009). Surgical smoke: What we know. (poster). The Association for perioperative practice.
The Association for perioperative practice. (2002). The electrosurgery team. Together everyone avoiding mistakes. (policy). The Association for perioperative practice
Biggins, J. Renfree, S. (2002). The hazards of surgical smoke. Not to be sniffed at! British journal of perioperative nursing, 12 (4) 136-142.
Cunnington, J. (2006). Facilitating benefit, minimizing risk: Responsibilities of the surgical practitioner during electrosurgery. Clinical Feature JPP, 16 (4), 195-201.
The Health and Safety at Work Act,1974, cited by Fulbrook, 1998:p40
Fulbrook, S. (1998). Medico legal insights. A nurses scope of practice, control, and diathermy in theatres. British journal of theatre nursing, 8 (1), 39-41.
Health Professions Council. Standards of proficiency. (2008). Operating department practitioners. (Policy). Health professions council.
Marsh, A. (2008). Pacemakers: Some of the risks and complications you are not warned about. Provenance and Peer review, 18 (10), 443-447.
The National association of theatre nurses. (1998). Topics for inclusion in a local policy. (policy). The National association of theatre nurses.
Private Healthcare UK. (2006). Submucous diathermy to the inferior turbinates (SMD). http://www.http://www.privatehealth.co.uk/private-operations/ear-nose-and-throat/submucous-diathermy-to-the-inferior-turbinate/ - A Patient's Guide.mht, 27/07/10.
Scott, E. Beswick, A. and Wakefield, K. (2004). The hazards of diathermy plume part 1. The literature search. British journal of perioperative nursing. 14 (9) 409-414
Scott, E. Beswick, A. and Wakefield, K. (2004). The hazards of diathermy plume part 2. Producing quantified data. British journal of perioperative nursing. 14 (10) 452-456
Wicker, P. (2000). Electrosurgery in perioperative practice. British journal of perioperative nursing, 10 (4), 221-226
