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Electrocautery smoke consists of volatile compounds and organic material.[[1]] The nature of the smoke depends on the type of surgery performed, the type of tissue cauterised, and the instrument used.[[1,2]] Smoke from muscle contains ethylbenzene and styrene which are carcinogenic, and toluene, which is mutagenic.[[3]] Other carcinogens found in surgical smoke include hydrogen cyanide, butadiene and benzene.[[1,2,4,5]] Human papilloma virus has been detected in surgical smoke.[[6]] One study found that the amount of smoke produced in a plastic surgery operating room in a day was equivalent to 27 to 30 cigarettes.[[7]] For these reasons, surgical smoke may be considered an occupational health hazard.[[8]]

Exposure to surgical smoke has been linked to acute adverse health effects in healthcare workers including headaches, nausea, cough, and irritation of the eye, nose and throat.[[9,10]] Data on the long-term effects of surgical smoke are lacking;[[1]] however, almost 10 years ago, a UK research report concluded that “taking into account the published studies included in this review, there is sufficient published evidence to consider the use of surgical smoke evacuation devices and their effectiveness in reducing the levels of smoke exposure”.[[11]]

How to manage surgical smoke remains controversial. One survey of 4533 operating theatre personnel found that only 14% always used a mobile smoke evacuation system in their theatre.[[9]] Some states in the USA have taken a legislative approach by enacting surgical “smoke-free” legislation.[[12]] In Aotearoa New Zealand, the Health and Safety at Work Act 2015 imposes a duty on a person who “has, or would reasonably be expected to have, the ability to influence and control the matter to which the risks relate: (a) to eliminate risks to health and safety, so far as is reasonably practicable; and (b) if it is not reasonably practicable to eliminate risks to health and safety, to minimise those risks so far as is reasonably practicable”.[[13]] Currently, there is no specific requirement for the control of surgical smoke in New Zealand.[[14]]

In the lead up to the 2021 United Nations General Assembly, a group of medical journals released a joint statement in which they said that “the greatest threat to global public health is the continued failure of world leaders to keep the global temperature rise below 1.5°C and to restore nature”.[[15]] The healthcare system is one of the world’s largest polluters, contributing 4.4% of global carbon emissions.[[16]] This means that in any healthcare issue, such as surgical smoke, environmental (planetary health[[17]]) as well as the human (occupational health) perspectives must be taken. Therefore, given the concerns in the literature, the variation in practice, and the larger environmental problems in healthcare, we were interested to learn how theatre workers view surgical smoke and the purported “solution” of a smoke-free policy.

The aims of this study were to discover what healthcare workers thought about the problem of surgical smoke and the idea of a smoke-free policy, and to formulate ideas on how the matter could be approached in an environmentally and socially responsible way. We hypothesised that the people who were exposed to surgical smoke in their jobs would have valuable insights into how to address the problem.

Methods

This study received approval from the Auckland DHB Research Office. The settings were the operating theatre suites of a children’s hospital and an adjoining adult hospital. Smoke evacuation devices are available in the operating rooms, but their use is not mandatory. The survey was developed using the REDCap electronic data capture tools hosted by the Faculty of Medical and Health Sciences at The University of Auckland. REDCap (Research Electronic Data Capture) is a secure, web-based software platform designed to support data capture for research studies.[[18]]

Survey design

The survey consisted of 23 questions asking for demographic details, perceived risk of surgical smoke, current measures used to minimise surgical smoke within the operating theatre, estimated exposure to surgical smoke when not using a smoke evacuation device, barriers to using a smoke evacuator, and support or not for a surgical smoke-free policy. Free text fields gave respondents the opportunity to provide more information if desired. Questions were devised in a meeting held with all authors and adapted from similar questionnaires and published data on the negative effects of surgical smoke.[[19,20]] Please refer to Appendix 1 for a copy of the survey questions, including a broad definition of a smoke-free policy.

Participants

This was a cohort survey aiming to reach as many healthcare workers who might be exposed to surgical smoke as possible. Email lists of perioperative nurses, anaesthetic technicians, anaesthetists, and surgeons were obtained from the hospital administration. The exclusion criterion was anyone who did not work in the operating theatre. A sample size calculation was not performed.

Distribution

The survey was distributed by email to 1,234 recipients. We sent the first email invitation on 17 April 2021. Periodic reminder emails were sent to non-responders, and the final invitation was sent on 28 May 2021. Invitation emails contained the link to the REDCap survey. Using only official hospital email addresses and the REDCap system made multiple participation by participants unlikely. While the survey was not anonymous, confidentiality was maintained through the secure REDCap platform and the University based password protected file storage.

Quantitative analysis

For statistical analysis we used the statistical program, R.[[21]] Exposure to surgical smoke was analysed by converting estimated exposure (<20%, 20–40%, 40–60%, 60–80%, >80%) to an ordinal factor, then performing a cumulative link model in which rage, gender, professional role, and work-place were explanatory variables. Perceived risk of smoke was analysed in a linear model in which age, gender, role, and workplace were explanatory variables. Support for smoke-free policy was analysed using a generalised linear model in which age, gender, perceived risk of smoke, role, and workplace were explanatory variables. Log odds were exponentiated to odds ratios (OR) and reported with their 95% confidence intervals (CI). Missing data were handled by omission.

Qualitative analysis

Qualitative data from text responses in the survey were analysed using reflexive thematic analysis.[[22–24]] Braun and Clarke[[24]] have clearly described how to do reflexive thematic analysis making it accessible to those of us with less experience in qualitative research and aiding reproducibility for those performing similar studies in the future. The theoretical flexibility of reflexive thematic analysis allowed us to choose our epistemological approach and to interpret data both inductively (data driven) and deductively (theory driven).

Theoretical framework

We chose a constructionist theoretical approach in order to view the issues surrounding surgical smoke as social constructs. We felt this was the best framework in which to achieve our aim of developing concepts on how to approach the surgical smoke problem. The constructivist epistemology takes a critical, as opposed to experiential, orientation to what participants had written in the survey. In coding and theme formation, we started inductively, forming codes from what the data “said”, then deductively, formulating our final themes by using a pre-existing theoretical framework.

Researcher’s reflexivity

The researchers are healthcare workers within Starship Children’s Hospital (two nurses, two paediatric surgical registrars and one paediatric surgeon). As such, the researchers are located within the research setting, i.e., we work within the health system we are studying. We try to take an overtly environmental perspective on healthcare, and on life in general.

Data processing

The online version of Taguette[[25]] was used for coding. Researchers read and re-read the texts, tagged comments, and coded the tagged comments. These tagged and coded data extracts formed the data units of the study.

Data analysis

Coding and theme review were a recursive process involving review of the data, review of relevant literature, and deep reflection, in an iterative process. We first read the data set, reflected on the ideas, and presented these at a theatre management meeting. In Taguette, we highlighted data extracts and made codes for each. Next, we grouped codes together into initial themes then, after further reflection and review, refined and renamed themes. We then reflected on the social constructs that the themes evoked, looking to the literature and our own understandings and experiences. We finished by merging the themes we developed from the data with a previously reported Planetary Health Education Framework,[[26]] thus drawing on the wider literature as well as our data set.

Results

Response rate and demographics

From 1,234 invitations, we received 463 responses (38%) of which one was excluded because no fields were completed, leaving 462 for analysis.

The highest response rate was from anaesthetists (62%). Almost half of the surgical consultants responded (49%). Response rates by professional group are shown in Appendix 2, Table S1. Demographics of responders and their specialty areas are shown in Table 1.

The median perceived risk of surgical smoke on a 0–100 scale was 71. Surgeons and anaesthetists perceived less risk than nurses (estimate -23, 95%CI -29 to -17; p<0.001; and -16, 95%CI -23 to -10; p<0.001, respectively). Those identifying as male gender perceived less risk than females (estimate -5, 95%CI -10 to -0.4; p<0.05) as shown in Figure 1.

Estimated exposure and risk of surgical smoke

Almost half (48%) of the nurses reported exposure to surgical smoke in >60% or more cases in which diathermy was used without a smoke evacuation device; almost one quarter (23%) reported exposure in >80% of cases. Estimated exposure was lower amongst surgeons (OR 0.55; 95%CI 0.31 to 0.98; p<0.05) and anaesthetists (OR 0.16; 95%CI 0.08 to 0.32; p<0.001) compared to nurses (Table 2).

Support for a smoke-free policy

All professional groups supported the implementation of a smoke-free policy. Support was strongest amongst nurses (171/180; 95%), anaesthetic technicians (45/47; 96%), and anaesthetists (81/88; 92%). Most surgeons supported a smoke-free policy (108/139; 78%). In the generalised linear mod-el, the most powerful predictor of support for a smoke-free policy was the perceived risk of surgical smoke (estimate 1.07, 95%CI 1.05 to 1.10; p<0.001). Support was lower amongst males compared to females (estimate 0.2, 95%CI 0.05 to 0.84; p<0.05). Although fewer surgeons supported a smoke-free policy than other professions, this was not statistically significant when the perceived risk of smoke was included in the model. Age, nursing level, and surgical specialty were not significant predictors of support for a smoke-free policy.

Perceived risks and management of smoke

Most participants found surgical smoke unpleasant (82%). Over three quarters thought it was potentially carcinogenic (76.7%). One third thought it was potentially teratogenic (35.1%). Commonly cited disadvantages included cough, eye irritation, headache and nausea (Table 3). Participants saw better staff health as the main advantage of a surgical-smoke-free policy (92.9%) (Table 4).

Answers to the following questions are shown in Appendix 2, Tables S2–S6: “In what percentage of cases do you think you are exposed to diathermy smoke without the use of a smoke evacuation device?”; “When using diathermy, what smoke evacuation method/s do you usually use?”; “How should diathermy smoke be best managed?”; and “What reasons are there against the use of smoke evacuation diathermy?”

Thematic analysis

One hundred and sixty participants (35%) wrote comments in free-text fields of the survey. From these, we tagged 200 comments from which we developed 18 codes. In the first round of coding, we developed eight initial themes along with 14 sub-themes. After reviewing the initial themes, refinement and renaming, we developed three broad themes, nature, society (including the economics theme), and technology, with a total of ten sub-themes, as shown in Figure 2. Finally, we reflected on the themes through a constructionist lens, bringing published literature and our own under-standing to bear on the study question of how the problem of surgical smoke could be approached in an environmentally and socially responsible way. The nature theme was not as strongly supported in terms of number of comments from our dataset but was a strong overarching concept in planetary health literature.[[26,27]] Many of our participants commented on aspects of human health as reflected in the sub-themes, including health and feeling valued. This also fitted into a planetary health concept, in which earth and its ecosystems, including human health, takes a higher order than the constructs that society functions within (see Figure 3).

For a detailed explanation of the themes and sub-themes, along with exemplar data extracts, please see Appendix 3, Supplementary Results.

View Tables & Figures.

We propose that all three sub-themes need addressing to bring about change. The healthcare system is situated within the constructs. Steps to address an issue in healthcare are as follows:

1. What are the implications for the planet?

2. What are the implications for society’s constructs?

• Technology—scientific evidence, engineering, devices, machines, information

• Economics—financial cost, efficiencies, opportunity cost

• Governance—movement-building and systems change, equity and justice

3. Consider the interconnection within nature—employ systems-thinking, integrated problem-solving and a collaborative approach.

Discussion

This study analysed an issue of concern in medicine, surgical smoke, through the opinions of front-line workers. Using mixed methods, we have been able to show the many facets of the issue. There was majority support for a surgical smoke-free policy across all professions. Thematic analysis revealed nuances that were not apparent at first, which allowed the issue to be viewed from social, economic, and technical perspectives within a planetary health framework.

To construct an environmentally sustainable health system, MacNeill et al.[[27]] outlined three principles: reduce demand for healthcare, match supply of health services to demand, and optimise the environmental performance of healthcare delivery. The third principle suggests healthcare workers should look at health through a different lens, one of planetary health. Guzmán et al.[[26]] proposed a Planetary Health Education Framework consisting of five domains: interconnection within nature, the anthropocene and health, systems thinking and complexity, equity and justice, and movement building and systems change. Brundiers et al.[[28]] defined the competencies for sustainability in education as values-thinking, systems-thinking, future-thinking, interpersonal, strategic-thinking, integrated problem solving, and implementation. Our concern was for the health system, not the education system; however, the education frameworks provide a good template. In the present paper we propose a Planetary Health Healthcare Framework that we hope will stimulate systems thinking about healthcare issues.

How could our proposed framework guide the management of surgical smoke? One insight gained from the present study was the need not to simply pursue a “policy”. A smoke-free policy, while widely supported by theatre workers in our institution, will be only one piece of the answer.

Environmental concerns of waste and emissions would come to the forefront in the framework. How can we reduce, reuse and recycle the devices? Can we find a supplier that complies with an environmental reporting standard?

Social issues take high priority. Is it fair that staff who do not have control over the use of smoke evacuation devices have to be exposed to smoke? Social justice must be addressed in order to tack-le planetary health crisis, but if we cannot address social justice in our own healthcare workplaces, how can we address it globally?

The framework acknowledges technology and the tools we use. Do we need open a diathermy device for every operation? What are the alternatives? Following this piece of work, our paediatric operating rooms removed diathermy handpieces from the standard setup, only opening diathermy when required.

The framework also acknowledges economics. Changing the ways that we do things could bring efficiencies (although focusing on efficiency can paradoxically increase consumption).[[29]] Do our economists use environmental accounting practices?

This framework could be applied to other aspects of healthcare, targeting issues of justice and management of resources. It is a tool to get one thinking about the wider effects of our decision making within the healthcare setting with the hope of establishing a comprehensive, integrated, and environmentally sound response to health challenges.

Limitations

The present study was limited by an overall response rate of just over one third. This may have been influenced by our wide invitation list that included some healthcare professionals who no longer worked in the operating theatre, which would be supported by the lower response rate from nurses and surgical trainees compared to anaesthetist and surgeons. Response might also have been influenced by people’s level of concern about the issue, their engagement with the hospital system, or simply time constraints. Almost one half of consultant surgeons responded. It would be interesting to survey a sample of those who did not respond to determine any differences in demographics or attitudes. Although support for a smoke-free policy was impressive, the results of the survey cannot be considered a mandate given the limited response rate and voluntary response bias.

The qualitative component of the study was based on written responses in optional text field in the survey. Greater depth of understanding might be gained from interview studies. We took a constructionist paradigm in which the researchers themselves are seen as integral to the study, not impartial observers. This could be construed as bias by some or as a strength by others.[[24]]

The framework did not arise solely from our data but also from our thinking and reading. The framework takes earth and its ecosystems as an overarching consideration, but few data extracts went into the environmental theme. The proposed framework represents a hypothesis which needs to be tested in future studies. Whether or not it would be useful for other healthcare issues remains to be determined.

Conclusions

Although smoke-free policies form part of the solution to surgical smoke, they are not the whole solution. Qualitative analysis allowed a more nuanced plan than simply mandating smoke evacuation devices. Further research could help clarify whether mixed methods analysis of survey data within a planetary health healthcare framework could lead to more ecologically and socially sound approaches to healthcare.

View Appendices.

Summary

Abstract

Aim

The smoke generated from electrocautery machines may be harmful to health. Healthcare in general, and surgery in particular, has a large environmental footprint. The aims of this study were to discover what healthcare workers thought about the problem of electrocautery smoke, the idea of a surgical smoke-free policy, and to formulate ideas on how the matter could be approached in an environmentally and socially responsible way.

Method

Operating room personnel in a tertiary referral hospital were invited to complete a survey about electrocautery smoke: perceived risks, current exposure, and measures to minimise exposure. Quantitative data were analysed in a generalised linear model, and qualitative data by reflexive thematic analysis within a constructivist theoretical framework.

Results

The survey response rate was 463/1234 (38%). Most supported a smoke-free policy (89%). Support for a policy was positively correlated with the perceived risk of electrocautery smoke (p<0.001. Sup-port was lower amongst males (p<0.05). Themes from the qualitative analysis developed around nature, society and technology. A framework was developed consisting of earth and its ecosystems, human health, governance, economics, society, and the interconnected of these systems.

Conclusion

Although smoke-free policies form part of the solution to electrocautery smoke, they are not the whole solution. Healthcare issues, in this case the issue of electrocautery smoke, could be tackled within a planetary health healthcare framework, promoting a systems approach. Applicability of the framework requires confirmation by further research.

Author Information

Lucy Barber: Surgical Registrar, Starship Children’s Health, Auckland, New Zealand. Rosemary Lane: Surgical Registrar, Starship Children’s Health, Auckland, New Zealand. Linda Holmes: Theatre Staff Nurse, Starship Children’s Health, Auckland, New Zealand. Ngaire Murray: Theatre Nurse Manager, Starship Children’s Health, Auckland, New Zealand. James K Hamill: Paediatric Surgeon, The University of Auckland, Auckland, New Zealand.

Acknowledgements

Correspondence

James Hamill: Department of Paediatric Surgery, Starship Children’s Health, Park Road, Private Bag 92024, Auckland 1042, Aotearoa New Zealand. Ph.: +6421753081

Correspondence Email

jamesh@adhb.govt.nz

Competing Interests

Nil.

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2) Georgesen C, Lipner SR. Surgical smoke: risk assessment and mitigation strategies. J Am Acad Dermatol. 2018;79(4):746-755.

3) Yeganeh A, Hajializade M, Sabagh AP, Athari B, Jamshidi M, Moghtadaei M. Analysis of electrocautery smoke re-leased from the tissues frequently cut in orthopedic surgeries. World J Orthop. 2020;11(3):177.

4) Moot AR, Ledingham KM, Wilson PF, et al. Composition of volatile organic compounds in diathermy plume as de-tected by selected ion flow tube mass spectrometry. ANZ J Surg. 2007;77(1‐2):20-23.

5) Bree K, Barnhill S, Rundell W. The dangers of electrosurgical smoke to operating room personnel: a review. Work-place Health Saf. 2017;65(11):517-526.

6) Fox-Lewis A, Allum C, Vokes D, Roberts S. Human papillomavirus and surgical smoke: a systematic review. Occup Environ Med. 2020;77(12):809-817.

7) Hill D, O’Neill J, Powell R, Oliver D. Surgical smoke–a health hazard in the operating theatre: a study to quantify ex-posure and a survey of the use of smoke extractor systems in UK plastic surgery units. J Plast Reconstr Aesthet Surg. 2012;65(7):911-916.

8) Lindsey C, Hutchinson M, Mellor G. The nature and hazards of diathermy plumes: a review. AORN J. 2015;101(4):428-442.

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Electrocautery smoke consists of volatile compounds and organic material.[[1]] The nature of the smoke depends on the type of surgery performed, the type of tissue cauterised, and the instrument used.[[1,2]] Smoke from muscle contains ethylbenzene and styrene which are carcinogenic, and toluene, which is mutagenic.[[3]] Other carcinogens found in surgical smoke include hydrogen cyanide, butadiene and benzene.[[1,2,4,5]] Human papilloma virus has been detected in surgical smoke.[[6]] One study found that the amount of smoke produced in a plastic surgery operating room in a day was equivalent to 27 to 30 cigarettes.[[7]] For these reasons, surgical smoke may be considered an occupational health hazard.[[8]]

Exposure to surgical smoke has been linked to acute adverse health effects in healthcare workers including headaches, nausea, cough, and irritation of the eye, nose and throat.[[9,10]] Data on the long-term effects of surgical smoke are lacking;[[1]] however, almost 10 years ago, a UK research report concluded that “taking into account the published studies included in this review, there is sufficient published evidence to consider the use of surgical smoke evacuation devices and their effectiveness in reducing the levels of smoke exposure”.[[11]]

How to manage surgical smoke remains controversial. One survey of 4533 operating theatre personnel found that only 14% always used a mobile smoke evacuation system in their theatre.[[9]] Some states in the USA have taken a legislative approach by enacting surgical “smoke-free” legislation.[[12]] In Aotearoa New Zealand, the Health and Safety at Work Act 2015 imposes a duty on a person who “has, or would reasonably be expected to have, the ability to influence and control the matter to which the risks relate: (a) to eliminate risks to health and safety, so far as is reasonably practicable; and (b) if it is not reasonably practicable to eliminate risks to health and safety, to minimise those risks so far as is reasonably practicable”.[[13]] Currently, there is no specific requirement for the control of surgical smoke in New Zealand.[[14]]

In the lead up to the 2021 United Nations General Assembly, a group of medical journals released a joint statement in which they said that “the greatest threat to global public health is the continued failure of world leaders to keep the global temperature rise below 1.5°C and to restore nature”.[[15]] The healthcare system is one of the world’s largest polluters, contributing 4.4% of global carbon emissions.[[16]] This means that in any healthcare issue, such as surgical smoke, environmental (planetary health[[17]]) as well as the human (occupational health) perspectives must be taken. Therefore, given the concerns in the literature, the variation in practice, and the larger environmental problems in healthcare, we were interested to learn how theatre workers view surgical smoke and the purported “solution” of a smoke-free policy.

The aims of this study were to discover what healthcare workers thought about the problem of surgical smoke and the idea of a smoke-free policy, and to formulate ideas on how the matter could be approached in an environmentally and socially responsible way. We hypothesised that the people who were exposed to surgical smoke in their jobs would have valuable insights into how to address the problem.

Methods

This study received approval from the Auckland DHB Research Office. The settings were the operating theatre suites of a children’s hospital and an adjoining adult hospital. Smoke evacuation devices are available in the operating rooms, but their use is not mandatory. The survey was developed using the REDCap electronic data capture tools hosted by the Faculty of Medical and Health Sciences at The University of Auckland. REDCap (Research Electronic Data Capture) is a secure, web-based software platform designed to support data capture for research studies.[[18]]

Survey design

The survey consisted of 23 questions asking for demographic details, perceived risk of surgical smoke, current measures used to minimise surgical smoke within the operating theatre, estimated exposure to surgical smoke when not using a smoke evacuation device, barriers to using a smoke evacuator, and support or not for a surgical smoke-free policy. Free text fields gave respondents the opportunity to provide more information if desired. Questions were devised in a meeting held with all authors and adapted from similar questionnaires and published data on the negative effects of surgical smoke.[[19,20]] Please refer to Appendix 1 for a copy of the survey questions, including a broad definition of a smoke-free policy.

Participants

This was a cohort survey aiming to reach as many healthcare workers who might be exposed to surgical smoke as possible. Email lists of perioperative nurses, anaesthetic technicians, anaesthetists, and surgeons were obtained from the hospital administration. The exclusion criterion was anyone who did not work in the operating theatre. A sample size calculation was not performed.

Distribution

The survey was distributed by email to 1,234 recipients. We sent the first email invitation on 17 April 2021. Periodic reminder emails were sent to non-responders, and the final invitation was sent on 28 May 2021. Invitation emails contained the link to the REDCap survey. Using only official hospital email addresses and the REDCap system made multiple participation by participants unlikely. While the survey was not anonymous, confidentiality was maintained through the secure REDCap platform and the University based password protected file storage.

Quantitative analysis

For statistical analysis we used the statistical program, R.[[21]] Exposure to surgical smoke was analysed by converting estimated exposure (<20%, 20–40%, 40–60%, 60–80%, >80%) to an ordinal factor, then performing a cumulative link model in which rage, gender, professional role, and work-place were explanatory variables. Perceived risk of smoke was analysed in a linear model in which age, gender, role, and workplace were explanatory variables. Support for smoke-free policy was analysed using a generalised linear model in which age, gender, perceived risk of smoke, role, and workplace were explanatory variables. Log odds were exponentiated to odds ratios (OR) and reported with their 95% confidence intervals (CI). Missing data were handled by omission.

Qualitative analysis

Qualitative data from text responses in the survey were analysed using reflexive thematic analysis.[[22–24]] Braun and Clarke[[24]] have clearly described how to do reflexive thematic analysis making it accessible to those of us with less experience in qualitative research and aiding reproducibility for those performing similar studies in the future. The theoretical flexibility of reflexive thematic analysis allowed us to choose our epistemological approach and to interpret data both inductively (data driven) and deductively (theory driven).

Theoretical framework

We chose a constructionist theoretical approach in order to view the issues surrounding surgical smoke as social constructs. We felt this was the best framework in which to achieve our aim of developing concepts on how to approach the surgical smoke problem. The constructivist epistemology takes a critical, as opposed to experiential, orientation to what participants had written in the survey. In coding and theme formation, we started inductively, forming codes from what the data “said”, then deductively, formulating our final themes by using a pre-existing theoretical framework.

Researcher’s reflexivity

The researchers are healthcare workers within Starship Children’s Hospital (two nurses, two paediatric surgical registrars and one paediatric surgeon). As such, the researchers are located within the research setting, i.e., we work within the health system we are studying. We try to take an overtly environmental perspective on healthcare, and on life in general.

Data processing

The online version of Taguette[[25]] was used for coding. Researchers read and re-read the texts, tagged comments, and coded the tagged comments. These tagged and coded data extracts formed the data units of the study.

Data analysis

Coding and theme review were a recursive process involving review of the data, review of relevant literature, and deep reflection, in an iterative process. We first read the data set, reflected on the ideas, and presented these at a theatre management meeting. In Taguette, we highlighted data extracts and made codes for each. Next, we grouped codes together into initial themes then, after further reflection and review, refined and renamed themes. We then reflected on the social constructs that the themes evoked, looking to the literature and our own understandings and experiences. We finished by merging the themes we developed from the data with a previously reported Planetary Health Education Framework,[[26]] thus drawing on the wider literature as well as our data set.

Results

Response rate and demographics

From 1,234 invitations, we received 463 responses (38%) of which one was excluded because no fields were completed, leaving 462 for analysis.

The highest response rate was from anaesthetists (62%). Almost half of the surgical consultants responded (49%). Response rates by professional group are shown in Appendix 2, Table S1. Demographics of responders and their specialty areas are shown in Table 1.

The median perceived risk of surgical smoke on a 0–100 scale was 71. Surgeons and anaesthetists perceived less risk than nurses (estimate -23, 95%CI -29 to -17; p<0.001; and -16, 95%CI -23 to -10; p<0.001, respectively). Those identifying as male gender perceived less risk than females (estimate -5, 95%CI -10 to -0.4; p<0.05) as shown in Figure 1.

Estimated exposure and risk of surgical smoke

Almost half (48%) of the nurses reported exposure to surgical smoke in >60% or more cases in which diathermy was used without a smoke evacuation device; almost one quarter (23%) reported exposure in >80% of cases. Estimated exposure was lower amongst surgeons (OR 0.55; 95%CI 0.31 to 0.98; p<0.05) and anaesthetists (OR 0.16; 95%CI 0.08 to 0.32; p<0.001) compared to nurses (Table 2).

Support for a smoke-free policy

All professional groups supported the implementation of a smoke-free policy. Support was strongest amongst nurses (171/180; 95%), anaesthetic technicians (45/47; 96%), and anaesthetists (81/88; 92%). Most surgeons supported a smoke-free policy (108/139; 78%). In the generalised linear mod-el, the most powerful predictor of support for a smoke-free policy was the perceived risk of surgical smoke (estimate 1.07, 95%CI 1.05 to 1.10; p<0.001). Support was lower amongst males compared to females (estimate 0.2, 95%CI 0.05 to 0.84; p<0.05). Although fewer surgeons supported a smoke-free policy than other professions, this was not statistically significant when the perceived risk of smoke was included in the model. Age, nursing level, and surgical specialty were not significant predictors of support for a smoke-free policy.

Perceived risks and management of smoke

Most participants found surgical smoke unpleasant (82%). Over three quarters thought it was potentially carcinogenic (76.7%). One third thought it was potentially teratogenic (35.1%). Commonly cited disadvantages included cough, eye irritation, headache and nausea (Table 3). Participants saw better staff health as the main advantage of a surgical-smoke-free policy (92.9%) (Table 4).

Answers to the following questions are shown in Appendix 2, Tables S2–S6: “In what percentage of cases do you think you are exposed to diathermy smoke without the use of a smoke evacuation device?”; “When using diathermy, what smoke evacuation method/s do you usually use?”; “How should diathermy smoke be best managed?”; and “What reasons are there against the use of smoke evacuation diathermy?”

Thematic analysis

One hundred and sixty participants (35%) wrote comments in free-text fields of the survey. From these, we tagged 200 comments from which we developed 18 codes. In the first round of coding, we developed eight initial themes along with 14 sub-themes. After reviewing the initial themes, refinement and renaming, we developed three broad themes, nature, society (including the economics theme), and technology, with a total of ten sub-themes, as shown in Figure 2. Finally, we reflected on the themes through a constructionist lens, bringing published literature and our own under-standing to bear on the study question of how the problem of surgical smoke could be approached in an environmentally and socially responsible way. The nature theme was not as strongly supported in terms of number of comments from our dataset but was a strong overarching concept in planetary health literature.[[26,27]] Many of our participants commented on aspects of human health as reflected in the sub-themes, including health and feeling valued. This also fitted into a planetary health concept, in which earth and its ecosystems, including human health, takes a higher order than the constructs that society functions within (see Figure 3).

For a detailed explanation of the themes and sub-themes, along with exemplar data extracts, please see Appendix 3, Supplementary Results.

View Tables & Figures.

We propose that all three sub-themes need addressing to bring about change. The healthcare system is situated within the constructs. Steps to address an issue in healthcare are as follows:

1. What are the implications for the planet?

2. What are the implications for society’s constructs?

• Technology—scientific evidence, engineering, devices, machines, information

• Economics—financial cost, efficiencies, opportunity cost

• Governance—movement-building and systems change, equity and justice

3. Consider the interconnection within nature—employ systems-thinking, integrated problem-solving and a collaborative approach.

Discussion

This study analysed an issue of concern in medicine, surgical smoke, through the opinions of front-line workers. Using mixed methods, we have been able to show the many facets of the issue. There was majority support for a surgical smoke-free policy across all professions. Thematic analysis revealed nuances that were not apparent at first, which allowed the issue to be viewed from social, economic, and technical perspectives within a planetary health framework.

To construct an environmentally sustainable health system, MacNeill et al.[[27]] outlined three principles: reduce demand for healthcare, match supply of health services to demand, and optimise the environmental performance of healthcare delivery. The third principle suggests healthcare workers should look at health through a different lens, one of planetary health. Guzmán et al.[[26]] proposed a Planetary Health Education Framework consisting of five domains: interconnection within nature, the anthropocene and health, systems thinking and complexity, equity and justice, and movement building and systems change. Brundiers et al.[[28]] defined the competencies for sustainability in education as values-thinking, systems-thinking, future-thinking, interpersonal, strategic-thinking, integrated problem solving, and implementation. Our concern was for the health system, not the education system; however, the education frameworks provide a good template. In the present paper we propose a Planetary Health Healthcare Framework that we hope will stimulate systems thinking about healthcare issues.

How could our proposed framework guide the management of surgical smoke? One insight gained from the present study was the need not to simply pursue a “policy”. A smoke-free policy, while widely supported by theatre workers in our institution, will be only one piece of the answer.

Environmental concerns of waste and emissions would come to the forefront in the framework. How can we reduce, reuse and recycle the devices? Can we find a supplier that complies with an environmental reporting standard?

Social issues take high priority. Is it fair that staff who do not have control over the use of smoke evacuation devices have to be exposed to smoke? Social justice must be addressed in order to tack-le planetary health crisis, but if we cannot address social justice in our own healthcare workplaces, how can we address it globally?

The framework acknowledges technology and the tools we use. Do we need open a diathermy device for every operation? What are the alternatives? Following this piece of work, our paediatric operating rooms removed diathermy handpieces from the standard setup, only opening diathermy when required.

The framework also acknowledges economics. Changing the ways that we do things could bring efficiencies (although focusing on efficiency can paradoxically increase consumption).[[29]] Do our economists use environmental accounting practices?

This framework could be applied to other aspects of healthcare, targeting issues of justice and management of resources. It is a tool to get one thinking about the wider effects of our decision making within the healthcare setting with the hope of establishing a comprehensive, integrated, and environmentally sound response to health challenges.

Limitations

The present study was limited by an overall response rate of just over one third. This may have been influenced by our wide invitation list that included some healthcare professionals who no longer worked in the operating theatre, which would be supported by the lower response rate from nurses and surgical trainees compared to anaesthetist and surgeons. Response might also have been influenced by people’s level of concern about the issue, their engagement with the hospital system, or simply time constraints. Almost one half of consultant surgeons responded. It would be interesting to survey a sample of those who did not respond to determine any differences in demographics or attitudes. Although support for a smoke-free policy was impressive, the results of the survey cannot be considered a mandate given the limited response rate and voluntary response bias.

The qualitative component of the study was based on written responses in optional text field in the survey. Greater depth of understanding might be gained from interview studies. We took a constructionist paradigm in which the researchers themselves are seen as integral to the study, not impartial observers. This could be construed as bias by some or as a strength by others.[[24]]

The framework did not arise solely from our data but also from our thinking and reading. The framework takes earth and its ecosystems as an overarching consideration, but few data extracts went into the environmental theme. The proposed framework represents a hypothesis which needs to be tested in future studies. Whether or not it would be useful for other healthcare issues remains to be determined.

Conclusions

Although smoke-free policies form part of the solution to surgical smoke, they are not the whole solution. Qualitative analysis allowed a more nuanced plan than simply mandating smoke evacuation devices. Further research could help clarify whether mixed methods analysis of survey data within a planetary health healthcare framework could lead to more ecologically and socially sound approaches to healthcare.

View Appendices.

Summary

Abstract

Aim

The smoke generated from electrocautery machines may be harmful to health. Healthcare in general, and surgery in particular, has a large environmental footprint. The aims of this study were to discover what healthcare workers thought about the problem of electrocautery smoke, the idea of a surgical smoke-free policy, and to formulate ideas on how the matter could be approached in an environmentally and socially responsible way.

Method

Operating room personnel in a tertiary referral hospital were invited to complete a survey about electrocautery smoke: perceived risks, current exposure, and measures to minimise exposure. Quantitative data were analysed in a generalised linear model, and qualitative data by reflexive thematic analysis within a constructivist theoretical framework.

Results

The survey response rate was 463/1234 (38%). Most supported a smoke-free policy (89%). Support for a policy was positively correlated with the perceived risk of electrocautery smoke (p<0.001. Sup-port was lower amongst males (p<0.05). Themes from the qualitative analysis developed around nature, society and technology. A framework was developed consisting of earth and its ecosystems, human health, governance, economics, society, and the interconnected of these systems.

Conclusion

Although smoke-free policies form part of the solution to electrocautery smoke, they are not the whole solution. Healthcare issues, in this case the issue of electrocautery smoke, could be tackled within a planetary health healthcare framework, promoting a systems approach. Applicability of the framework requires confirmation by further research.

Author Information

Lucy Barber: Surgical Registrar, Starship Children’s Health, Auckland, New Zealand. Rosemary Lane: Surgical Registrar, Starship Children’s Health, Auckland, New Zealand. Linda Holmes: Theatre Staff Nurse, Starship Children’s Health, Auckland, New Zealand. Ngaire Murray: Theatre Nurse Manager, Starship Children’s Health, Auckland, New Zealand. James K Hamill: Paediatric Surgeon, The University of Auckland, Auckland, New Zealand.

Acknowledgements

Correspondence

James Hamill: Department of Paediatric Surgery, Starship Children’s Health, Park Road, Private Bag 92024, Auckland 1042, Aotearoa New Zealand. Ph.: +6421753081

Correspondence Email

jamesh@adhb.govt.nz

Competing Interests

Nil.

1) Limchantra IV, Fong Y, Melstrom KA. Surgical smoke exposure in operating room personnel: a review. JAMA Surg. 2019;154(10):960-967.

2) Georgesen C, Lipner SR. Surgical smoke: risk assessment and mitigation strategies. J Am Acad Dermatol. 2018;79(4):746-755.

3) Yeganeh A, Hajializade M, Sabagh AP, Athari B, Jamshidi M, Moghtadaei M. Analysis of electrocautery smoke re-leased from the tissues frequently cut in orthopedic surgeries. World J Orthop. 2020;11(3):177.

4) Moot AR, Ledingham KM, Wilson PF, et al. Composition of volatile organic compounds in diathermy plume as de-tected by selected ion flow tube mass spectrometry. ANZ J Surg. 2007;77(1‐2):20-23.

5) Bree K, Barnhill S, Rundell W. The dangers of electrosurgical smoke to operating room personnel: a review. Work-place Health Saf. 2017;65(11):517-526.

6) Fox-Lewis A, Allum C, Vokes D, Roberts S. Human papillomavirus and surgical smoke: a systematic review. Occup Environ Med. 2020;77(12):809-817.

7) Hill D, O’Neill J, Powell R, Oliver D. Surgical smoke–a health hazard in the operating theatre: a study to quantify ex-posure and a survey of the use of smoke extractor systems in UK plastic surgery units. J Plast Reconstr Aesthet Surg. 2012;65(7):911-916.

8) Lindsey C, Hutchinson M, Mellor G. The nature and hazards of diathermy plumes: a review. AORN J. 2015;101(4):428-442.

9) Steege AL, Boiano JM, Sweeney MH. Secondhand smoke in the operating room? Precautionary practices lacking for surgical smoke. Am J Ind Med. 2016;59(11):1020-1031.

10) Okoshi K, Kobayashi K, Kinoshita K, Tomizawa Y, Hasegawa S, Sakai Y. Health risks associated with exposure to surgi-cal smoke for surgeons and operation room personnel. Surg Today. 2015;45(8):957-965.

11) Beswick A, Evans G. Evidence for exposure and harmful effects of diathermy plumes (surgical smoke). Buxton Health Saf Exec. Published online 2012.

12) Zhu, Wei L. What is surgical smoke and what can be done about it? Published online 2021.

13) New Zealand. Health and Safety Act 2015.; :Part 2 s 30. file:///Users/seamas/Downloads/Health%20and%20Safety%20at%20Work%20Act%202015.pdf

14) Matthews S. Preventing harm from surgical plume. Kai Tiaki Nurs N Z. 2016;22(6):26.

15) Atwoli L, Baqui AH, Benfield T. Call for emergency action to limit global temperature increases, restore biodiversity and protect health. BMJ Paediatr Open. 2021:e056565.

16) Karliner J, Slotterback S, Boyd R, Ashby B, Steele K, Wang J. Health care’s climate footprint: the health sector contri-bution and opportunities for action. Eur J Public Health. 2020;30(Supplement_5):ckaa165-843.

17) Horton R, Beaglehole R, Bonita R, Raeburn J, McKee M, Wall S. From public to planetary health: a manifesto. The Lancet. 2014;383(9920):847. doi:10.1016/S0140-6736(14)60409-8.

18) Harris PA, Taylor R, Minor BL, et al. The REDCap consortium: Building an international community of software platform partners. J Biomed Inform. 2019;95:103208.

19) McQuail P, McCartney B, Baker J, Kenny P. Diathermy awareness among surgeons-An analysis in Ireland. Ann Med Surg. 2016;12:54-59.

20) Michaelis M, Hofmann FM, Nienhaus A, Eickmann U. Surgical smoke—hazard perceptions and protective measures in german operating rooms. Int J Env Res Public Health. 2020;17(2):515.

21) Team RC. R Core Team R: a language and environment for statistical computing. Found Stat Comput. Published online 2021. https://www.R-project.org/.

22) Braun V, Clarke V. Using thematic analysis in psychology. Qual Res Psychol. 2006;3(2):77-101.

23) Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qual Res Sport Exerc Health. 2019;11(4):589-597.

24) Braun V, Clarke V. Thematic Analysis. A Practical Guide. SAGE publications.; 2022.

25) Rampin R, Rampin V. Taguette: open-source qualitative data analysis. J Open Source Softw. 2021;6(68):3522.

26) Guzmán CAF, Aguirre AA, Astle B, et al. A framework to guide planetary health education. Lancet Planet Health. 2021;5(5):e253-e255.

27) MacNeill AJ, McGain F, Sherman JD. Planetary health care: a framework for sustainable health systems. Lancet Planet Health. 2021;5(2):e66-e68.

28) Brundiers K, Barth M, Cebrián G, et al. Key competencies in sustainability in higher education—toward an agreed-upon reference framework. Sustain Sci. 2021;16(1):13-29.

29) Shove E. What is wrong with energy efficiency? Build Res Inf. 2018;46(7):779-789.

For the PDF of this article,
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Electrocautery smoke consists of volatile compounds and organic material.[[1]] The nature of the smoke depends on the type of surgery performed, the type of tissue cauterised, and the instrument used.[[1,2]] Smoke from muscle contains ethylbenzene and styrene which are carcinogenic, and toluene, which is mutagenic.[[3]] Other carcinogens found in surgical smoke include hydrogen cyanide, butadiene and benzene.[[1,2,4,5]] Human papilloma virus has been detected in surgical smoke.[[6]] One study found that the amount of smoke produced in a plastic surgery operating room in a day was equivalent to 27 to 30 cigarettes.[[7]] For these reasons, surgical smoke may be considered an occupational health hazard.[[8]]

Exposure to surgical smoke has been linked to acute adverse health effects in healthcare workers including headaches, nausea, cough, and irritation of the eye, nose and throat.[[9,10]] Data on the long-term effects of surgical smoke are lacking;[[1]] however, almost 10 years ago, a UK research report concluded that “taking into account the published studies included in this review, there is sufficient published evidence to consider the use of surgical smoke evacuation devices and their effectiveness in reducing the levels of smoke exposure”.[[11]]

How to manage surgical smoke remains controversial. One survey of 4533 operating theatre personnel found that only 14% always used a mobile smoke evacuation system in their theatre.[[9]] Some states in the USA have taken a legislative approach by enacting surgical “smoke-free” legislation.[[12]] In Aotearoa New Zealand, the Health and Safety at Work Act 2015 imposes a duty on a person who “has, or would reasonably be expected to have, the ability to influence and control the matter to which the risks relate: (a) to eliminate risks to health and safety, so far as is reasonably practicable; and (b) if it is not reasonably practicable to eliminate risks to health and safety, to minimise those risks so far as is reasonably practicable”.[[13]] Currently, there is no specific requirement for the control of surgical smoke in New Zealand.[[14]]

In the lead up to the 2021 United Nations General Assembly, a group of medical journals released a joint statement in which they said that “the greatest threat to global public health is the continued failure of world leaders to keep the global temperature rise below 1.5°C and to restore nature”.[[15]] The healthcare system is one of the world’s largest polluters, contributing 4.4% of global carbon emissions.[[16]] This means that in any healthcare issue, such as surgical smoke, environmental (planetary health[[17]]) as well as the human (occupational health) perspectives must be taken. Therefore, given the concerns in the literature, the variation in practice, and the larger environmental problems in healthcare, we were interested to learn how theatre workers view surgical smoke and the purported “solution” of a smoke-free policy.

The aims of this study were to discover what healthcare workers thought about the problem of surgical smoke and the idea of a smoke-free policy, and to formulate ideas on how the matter could be approached in an environmentally and socially responsible way. We hypothesised that the people who were exposed to surgical smoke in their jobs would have valuable insights into how to address the problem.

Methods

This study received approval from the Auckland DHB Research Office. The settings were the operating theatre suites of a children’s hospital and an adjoining adult hospital. Smoke evacuation devices are available in the operating rooms, but their use is not mandatory. The survey was developed using the REDCap electronic data capture tools hosted by the Faculty of Medical and Health Sciences at The University of Auckland. REDCap (Research Electronic Data Capture) is a secure, web-based software platform designed to support data capture for research studies.[[18]]

Survey design

The survey consisted of 23 questions asking for demographic details, perceived risk of surgical smoke, current measures used to minimise surgical smoke within the operating theatre, estimated exposure to surgical smoke when not using a smoke evacuation device, barriers to using a smoke evacuator, and support or not for a surgical smoke-free policy. Free text fields gave respondents the opportunity to provide more information if desired. Questions were devised in a meeting held with all authors and adapted from similar questionnaires and published data on the negative effects of surgical smoke.[[19,20]] Please refer to Appendix 1 for a copy of the survey questions, including a broad definition of a smoke-free policy.

Participants

This was a cohort survey aiming to reach as many healthcare workers who might be exposed to surgical smoke as possible. Email lists of perioperative nurses, anaesthetic technicians, anaesthetists, and surgeons were obtained from the hospital administration. The exclusion criterion was anyone who did not work in the operating theatre. A sample size calculation was not performed.

Distribution

The survey was distributed by email to 1,234 recipients. We sent the first email invitation on 17 April 2021. Periodic reminder emails were sent to non-responders, and the final invitation was sent on 28 May 2021. Invitation emails contained the link to the REDCap survey. Using only official hospital email addresses and the REDCap system made multiple participation by participants unlikely. While the survey was not anonymous, confidentiality was maintained through the secure REDCap platform and the University based password protected file storage.

Quantitative analysis

For statistical analysis we used the statistical program, R.[[21]] Exposure to surgical smoke was analysed by converting estimated exposure (<20%, 20–40%, 40–60%, 60–80%, >80%) to an ordinal factor, then performing a cumulative link model in which rage, gender, professional role, and work-place were explanatory variables. Perceived risk of smoke was analysed in a linear model in which age, gender, role, and workplace were explanatory variables. Support for smoke-free policy was analysed using a generalised linear model in which age, gender, perceived risk of smoke, role, and workplace were explanatory variables. Log odds were exponentiated to odds ratios (OR) and reported with their 95% confidence intervals (CI). Missing data were handled by omission.

Qualitative analysis

Qualitative data from text responses in the survey were analysed using reflexive thematic analysis.[[22–24]] Braun and Clarke[[24]] have clearly described how to do reflexive thematic analysis making it accessible to those of us with less experience in qualitative research and aiding reproducibility for those performing similar studies in the future. The theoretical flexibility of reflexive thematic analysis allowed us to choose our epistemological approach and to interpret data both inductively (data driven) and deductively (theory driven).

Theoretical framework

We chose a constructionist theoretical approach in order to view the issues surrounding surgical smoke as social constructs. We felt this was the best framework in which to achieve our aim of developing concepts on how to approach the surgical smoke problem. The constructivist epistemology takes a critical, as opposed to experiential, orientation to what participants had written in the survey. In coding and theme formation, we started inductively, forming codes from what the data “said”, then deductively, formulating our final themes by using a pre-existing theoretical framework.

Researcher’s reflexivity

The researchers are healthcare workers within Starship Children’s Hospital (two nurses, two paediatric surgical registrars and one paediatric surgeon). As such, the researchers are located within the research setting, i.e., we work within the health system we are studying. We try to take an overtly environmental perspective on healthcare, and on life in general.

Data processing

The online version of Taguette[[25]] was used for coding. Researchers read and re-read the texts, tagged comments, and coded the tagged comments. These tagged and coded data extracts formed the data units of the study.

Data analysis

Coding and theme review were a recursive process involving review of the data, review of relevant literature, and deep reflection, in an iterative process. We first read the data set, reflected on the ideas, and presented these at a theatre management meeting. In Taguette, we highlighted data extracts and made codes for each. Next, we grouped codes together into initial themes then, after further reflection and review, refined and renamed themes. We then reflected on the social constructs that the themes evoked, looking to the literature and our own understandings and experiences. We finished by merging the themes we developed from the data with a previously reported Planetary Health Education Framework,[[26]] thus drawing on the wider literature as well as our data set.

Results

Response rate and demographics

From 1,234 invitations, we received 463 responses (38%) of which one was excluded because no fields were completed, leaving 462 for analysis.

The highest response rate was from anaesthetists (62%). Almost half of the surgical consultants responded (49%). Response rates by professional group are shown in Appendix 2, Table S1. Demographics of responders and their specialty areas are shown in Table 1.

The median perceived risk of surgical smoke on a 0–100 scale was 71. Surgeons and anaesthetists perceived less risk than nurses (estimate -23, 95%CI -29 to -17; p<0.001; and -16, 95%CI -23 to -10; p<0.001, respectively). Those identifying as male gender perceived less risk than females (estimate -5, 95%CI -10 to -0.4; p<0.05) as shown in Figure 1.

Estimated exposure and risk of surgical smoke

Almost half (48%) of the nurses reported exposure to surgical smoke in >60% or more cases in which diathermy was used without a smoke evacuation device; almost one quarter (23%) reported exposure in >80% of cases. Estimated exposure was lower amongst surgeons (OR 0.55; 95%CI 0.31 to 0.98; p<0.05) and anaesthetists (OR 0.16; 95%CI 0.08 to 0.32; p<0.001) compared to nurses (Table 2).

Support for a smoke-free policy

All professional groups supported the implementation of a smoke-free policy. Support was strongest amongst nurses (171/180; 95%), anaesthetic technicians (45/47; 96%), and anaesthetists (81/88; 92%). Most surgeons supported a smoke-free policy (108/139; 78%). In the generalised linear mod-el, the most powerful predictor of support for a smoke-free policy was the perceived risk of surgical smoke (estimate 1.07, 95%CI 1.05 to 1.10; p<0.001). Support was lower amongst males compared to females (estimate 0.2, 95%CI 0.05 to 0.84; p<0.05). Although fewer surgeons supported a smoke-free policy than other professions, this was not statistically significant when the perceived risk of smoke was included in the model. Age, nursing level, and surgical specialty were not significant predictors of support for a smoke-free policy.

Perceived risks and management of smoke

Most participants found surgical smoke unpleasant (82%). Over three quarters thought it was potentially carcinogenic (76.7%). One third thought it was potentially teratogenic (35.1%). Commonly cited disadvantages included cough, eye irritation, headache and nausea (Table 3). Participants saw better staff health as the main advantage of a surgical-smoke-free policy (92.9%) (Table 4).

Answers to the following questions are shown in Appendix 2, Tables S2–S6: “In what percentage of cases do you think you are exposed to diathermy smoke without the use of a smoke evacuation device?”; “When using diathermy, what smoke evacuation method/s do you usually use?”; “How should diathermy smoke be best managed?”; and “What reasons are there against the use of smoke evacuation diathermy?”

Thematic analysis

One hundred and sixty participants (35%) wrote comments in free-text fields of the survey. From these, we tagged 200 comments from which we developed 18 codes. In the first round of coding, we developed eight initial themes along with 14 sub-themes. After reviewing the initial themes, refinement and renaming, we developed three broad themes, nature, society (including the economics theme), and technology, with a total of ten sub-themes, as shown in Figure 2. Finally, we reflected on the themes through a constructionist lens, bringing published literature and our own under-standing to bear on the study question of how the problem of surgical smoke could be approached in an environmentally and socially responsible way. The nature theme was not as strongly supported in terms of number of comments from our dataset but was a strong overarching concept in planetary health literature.[[26,27]] Many of our participants commented on aspects of human health as reflected in the sub-themes, including health and feeling valued. This also fitted into a planetary health concept, in which earth and its ecosystems, including human health, takes a higher order than the constructs that society functions within (see Figure 3).

For a detailed explanation of the themes and sub-themes, along with exemplar data extracts, please see Appendix 3, Supplementary Results.

View Tables & Figures.

We propose that all three sub-themes need addressing to bring about change. The healthcare system is situated within the constructs. Steps to address an issue in healthcare are as follows:

1. What are the implications for the planet?

2. What are the implications for society’s constructs?

• Technology—scientific evidence, engineering, devices, machines, information

• Economics—financial cost, efficiencies, opportunity cost

• Governance—movement-building and systems change, equity and justice

3. Consider the interconnection within nature—employ systems-thinking, integrated problem-solving and a collaborative approach.

Discussion

This study analysed an issue of concern in medicine, surgical smoke, through the opinions of front-line workers. Using mixed methods, we have been able to show the many facets of the issue. There was majority support for a surgical smoke-free policy across all professions. Thematic analysis revealed nuances that were not apparent at first, which allowed the issue to be viewed from social, economic, and technical perspectives within a planetary health framework.

To construct an environmentally sustainable health system, MacNeill et al.[[27]] outlined three principles: reduce demand for healthcare, match supply of health services to demand, and optimise the environmental performance of healthcare delivery. The third principle suggests healthcare workers should look at health through a different lens, one of planetary health. Guzmán et al.[[26]] proposed a Planetary Health Education Framework consisting of five domains: interconnection within nature, the anthropocene and health, systems thinking and complexity, equity and justice, and movement building and systems change. Brundiers et al.[[28]] defined the competencies for sustainability in education as values-thinking, systems-thinking, future-thinking, interpersonal, strategic-thinking, integrated problem solving, and implementation. Our concern was for the health system, not the education system; however, the education frameworks provide a good template. In the present paper we propose a Planetary Health Healthcare Framework that we hope will stimulate systems thinking about healthcare issues.

How could our proposed framework guide the management of surgical smoke? One insight gained from the present study was the need not to simply pursue a “policy”. A smoke-free policy, while widely supported by theatre workers in our institution, will be only one piece of the answer.

Environmental concerns of waste and emissions would come to the forefront in the framework. How can we reduce, reuse and recycle the devices? Can we find a supplier that complies with an environmental reporting standard?

Social issues take high priority. Is it fair that staff who do not have control over the use of smoke evacuation devices have to be exposed to smoke? Social justice must be addressed in order to tack-le planetary health crisis, but if we cannot address social justice in our own healthcare workplaces, how can we address it globally?

The framework acknowledges technology and the tools we use. Do we need open a diathermy device for every operation? What are the alternatives? Following this piece of work, our paediatric operating rooms removed diathermy handpieces from the standard setup, only opening diathermy when required.

The framework also acknowledges economics. Changing the ways that we do things could bring efficiencies (although focusing on efficiency can paradoxically increase consumption).[[29]] Do our economists use environmental accounting practices?

This framework could be applied to other aspects of healthcare, targeting issues of justice and management of resources. It is a tool to get one thinking about the wider effects of our decision making within the healthcare setting with the hope of establishing a comprehensive, integrated, and environmentally sound response to health challenges.

Limitations

The present study was limited by an overall response rate of just over one third. This may have been influenced by our wide invitation list that included some healthcare professionals who no longer worked in the operating theatre, which would be supported by the lower response rate from nurses and surgical trainees compared to anaesthetist and surgeons. Response might also have been influenced by people’s level of concern about the issue, their engagement with the hospital system, or simply time constraints. Almost one half of consultant surgeons responded. It would be interesting to survey a sample of those who did not respond to determine any differences in demographics or attitudes. Although support for a smoke-free policy was impressive, the results of the survey cannot be considered a mandate given the limited response rate and voluntary response bias.

The qualitative component of the study was based on written responses in optional text field in the survey. Greater depth of understanding might be gained from interview studies. We took a constructionist paradigm in which the researchers themselves are seen as integral to the study, not impartial observers. This could be construed as bias by some or as a strength by others.[[24]]

The framework did not arise solely from our data but also from our thinking and reading. The framework takes earth and its ecosystems as an overarching consideration, but few data extracts went into the environmental theme. The proposed framework represents a hypothesis which needs to be tested in future studies. Whether or not it would be useful for other healthcare issues remains to be determined.

Conclusions

Although smoke-free policies form part of the solution to surgical smoke, they are not the whole solution. Qualitative analysis allowed a more nuanced plan than simply mandating smoke evacuation devices. Further research could help clarify whether mixed methods analysis of survey data within a planetary health healthcare framework could lead to more ecologically and socially sound approaches to healthcare.

View Appendices.

Summary

Abstract

Aim

The smoke generated from electrocautery machines may be harmful to health. Healthcare in general, and surgery in particular, has a large environmental footprint. The aims of this study were to discover what healthcare workers thought about the problem of electrocautery smoke, the idea of a surgical smoke-free policy, and to formulate ideas on how the matter could be approached in an environmentally and socially responsible way.

Method

Operating room personnel in a tertiary referral hospital were invited to complete a survey about electrocautery smoke: perceived risks, current exposure, and measures to minimise exposure. Quantitative data were analysed in a generalised linear model, and qualitative data by reflexive thematic analysis within a constructivist theoretical framework.

Results

The survey response rate was 463/1234 (38%). Most supported a smoke-free policy (89%). Support for a policy was positively correlated with the perceived risk of electrocautery smoke (p<0.001. Sup-port was lower amongst males (p<0.05). Themes from the qualitative analysis developed around nature, society and technology. A framework was developed consisting of earth and its ecosystems, human health, governance, economics, society, and the interconnected of these systems.

Conclusion

Although smoke-free policies form part of the solution to electrocautery smoke, they are not the whole solution. Healthcare issues, in this case the issue of electrocautery smoke, could be tackled within a planetary health healthcare framework, promoting a systems approach. Applicability of the framework requires confirmation by further research.

Author Information

Lucy Barber: Surgical Registrar, Starship Children’s Health, Auckland, New Zealand. Rosemary Lane: Surgical Registrar, Starship Children’s Health, Auckland, New Zealand. Linda Holmes: Theatre Staff Nurse, Starship Children’s Health, Auckland, New Zealand. Ngaire Murray: Theatre Nurse Manager, Starship Children’s Health, Auckland, New Zealand. James K Hamill: Paediatric Surgeon, The University of Auckland, Auckland, New Zealand.

Acknowledgements

Correspondence

James Hamill: Department of Paediatric Surgery, Starship Children’s Health, Park Road, Private Bag 92024, Auckland 1042, Aotearoa New Zealand. Ph.: +6421753081

Correspondence Email

jamesh@adhb.govt.nz

Competing Interests

Nil.

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