Preoperative Smoke Check and Surgical Smoke Evacuation Compliance

Background/Rationale: Surgical smoke is a mixture of particulate matter and gases generated by the use of energy-based devices (e.g., monopolar electrocautery, lasers) on tissue. Appropriate evacuation of surgical smoke at its source is an important safety practice to reduce unnecessary occupational and patient exposure. The AORN Guideline for Surgical Smoke Safety recommends that surgical smoke be captured as close as possible to its source and that an appropriate evacuation/filtration system be actively and continuously used whenever a smoke-generating energy device is activated, and that the evacuation system be ready for use before the procedure begins. In real clinical practice, however, smoke evacuation is not routinely or correctly used in every smoke-generating procedure. Reported barriers include failure to anticipate smoke generation in advance, unready equipment, delayed activation of the evacuation system, and lack of clearly assigned responsibility among perioperative staff for this task.

Aim: The aim of this study is to evaluate whether a brief, low-cost preoperative Smoke Check practice, consisting of two short safety questions asked by the circulating nurse before a procedure begins, increases the proportion of smoke-generating procedures in which surgical smoke evacuation is used appropriately.

Research Question: Does implementing a short, standardized preoperative Smoke Check increase appropriate use of surgical smoke evacuation in smoke-generating procedures, compared with current (baseline) practice?

Design: This is a single-center, prospective, quasi-experimental before-after (pre-post) study. In the first (Baseline) period, current smoke-evacuation practice will be observed in eligible procedures without any change to existing workflow. In the second (Post-Smoke Check) period, the Smoke Check will be added to the circulating nurses' existing preoperative workflow, consisting of two questions: (1) "Is surgical smoke expected to be generated during this procedure?" and (2) "If yes, is an appropriate smoke evacuation system ready for use?" The same observation protocol will be used to assess smoke evacuation practice in both periods, and outcomes will be compared between periods.

Setting and Population: The study will be conducted at a single center, Ağrı Training and Research Hospital, between October 2026 and December 2026. The unit of analysis/observation is the surgical procedure (not the patient or staff member); eligible procedures are those in which surgical smoke generation is anticipated or observed due to the use of an energy-based device (e.g., monopolar electrocautery, bipolar, ultrasonic, or laser devices) in an open, laparoscopic/endoscopic, or other surgical approach. No patient- or staff-identifying information will be recorded; only a procedure research code will be used for data linkage.

Instruments/Data Collection: Two structured, non-validated, study-specific observation forms developed by the investigators will be used: (1) a Surgical Smoke Compliance Observation Form, used in both periods, to record the surgical branch, surgical approach, energy device used, whether visible surgical smoke occurred, whether the evacuation system was ready before the procedure began, whether it was used during energy device activation, whether the capture device was appropriately positioned near the smoke source, whether evacuation was sustained throughout the smoke-generating portion of the procedure, and an overall appropriate-use judgment; and (2) a Smoke Check Application Form, used only in the post-intervention period, to record whether the Smoke Check was completed, at what stage, and whether it caused any delay or required additional equipment. No licensed, validated, or psychometric scale or patient survey is used in this study; all measures are investigator-developed, guideline-based observational checklists.

Outcomes: The primary outcome is the proportion of smoke-generating procedures in which surgical smoke evacuation is used appropriately (defined as: the evacuation system was ready before the procedure, was actively used during energy device activation, the capture device was appropriately positioned near the smoke source, and evacuation was sustained for as long as clinically necessary). Secondary outcomes include: readiness of the smoke evacuation system before the procedure begins, appropriate positioning of the capture device relative to the smoke source, and continuity/duration of evacuation use throughout the smoke-generating portion of the procedure.

Statistical Analysis: Descriptive statistics will be used to summarize procedure and observation characteristics. The primary and secondary outcome proportions will be compared between the Baseline and Post-Smoke Check periods using chi-square or Fisher's exact test as appropriate, with a two-sided significance level of .05.

Difficulties and Limitations: As a single-center, non-randomized before-after design, the study is subject to potential confounding by time-related changes in staff, case mix, or other concurrent quality initiatives, and causal inference is limited compared with a randomized design. The use of non-validated, investigator-developed observation forms, rather than a licensed audit tool, is acknowledged as a limitation, although this reflects the pragmatic, guideline-based nature of the intervention. Because the unit of observation is the procedure, potential clustering of multiple observations from the same operating room or energy-device combination will be considered in the interpretation of results.

This research does not involve the administration of any investigational drug or device. It is registered as an observational study because procedures are not randomly assigned to an intervention as in a controlled interventional design; the Smoke Check practice-change is applied uniformly to workflow in the second period rather than randomized at the individual procedure level.

Note: The unit of observation and analysis in this study is the surgical procedure, not the individual patient. The eligibility criteria below describe which surgical procedures were eligible for inclusion in observation and data collection.

Inclusion criteria

• Surgical procedures performed at Agri Training and Research Hospital during the designated Baseline Period or Post-Smoke Check Period data collection windows
• Procedures utilizing an energy-based device (electrosurgery, laser, or ultrasonic device) capable of generating surgical smoke
• Procedures for which smoke evacuation practices could be directly and continuously observed by the study's trained observer for the full duration of the procedure

Exclusion criteria

• Procedures not utilizing an energy-based device or not expected to generate surgical smoke
• Emergency procedures in which direct, continuous observation of smoke evacuation practices was not feasible
• Procedures with incomplete or missing observation data on the Surgical Smoke Compliance Observation Form