Hospital Laser Safety Manual

Transcription

1 Louisiana State University Health Sciences Center Shreveport Hospital Laser Safety Manual 1

2 Contents Hospital Safety Manual Introduction Definitions Procedural and Administrative Controls Device Management Laser Usage Physician Laser Privileges Training Laser Safety Training Program for Health Care Support Staff Laser Safety Officer Training Signs Laser Repair Accident / Incident Reporting Environmental Safety during Laser Procedures General Procedures Outer Door Warning System Window Covering Eye Protection Electrical/Water Safety Instrumentation Smoke Evacuation Fire Extinguisher and Fire Safety Laser Key Designated Laser Room (Stationary Lasers) Foot Pedal Safety Checklist Specific Procedures Patient Eye Protection during Laser Application Personnel Eye Protection during Laser Procedures Smoke Evacuation during Laser Application Emergency Laser Shutdown for Fire Appendix A Appendix B Appendix C Appendix D

3 Introduction Hospital Safety Manual Purpose: To provide patient, employee, and environmental safety during laser usage for clinical applications. 1. Definitions Controlled Area An area where the activity and occupancy of those within the area are controlled and supervised to provide protection from radiation hazards. Health Care Support Staff This includes the laser scrub nurse, the laser nurse/technician, the circulating nurse and anesthesia staff who assist during a laser procedure. The laser nurse will have no other responsibilities other than the laser during laser procedures. Laser Acronym for Light Amplification by Stimulated Emission of Radiation Laser Safety Officer (LSO) Professional who provides consultative services on laser hazard evaluation and control and oversees laser use. This includes training, documentation, purchasing, monitoring and other safety concerns. LSO also has the authority to suspend, restrict or terminate the operation of a laser system if he/she deems that laser hazard controls are inadequate. Laser Nurse Specialist An R.N. who has been in-serviced on all available types of lasers in the Operating Room and is fully knowledgeable of the operation, handling, maintenance and minor troubleshooting of the laser. He/she works closely with the LSO to ensure environmental safety during laser procedures and reports incidents/accidents and problems promptly to LSO. Laser Nurse/Technician Nurse or technician who sets up laser procedure prior to physician use and completes laser log and ensures safety checklist is followed during an OR procedure. Physician Laser user credentialed in the usage of lasers for clinical applications and surgical procedures. In all cases, the physician must use the laser for its intended purpose within the scope of his/her practice, training, and experience and be familiar with safe laser practices to ensure the safety of patients, employees, and the environment. 3

4 2. Procedural and Administrative Controls Hospital Safety Manual 2.1 Device Management A department which requests and/or uses a laser will comply with the Hospital Medical Equipment Management Plan and the Approval Process for Acquisition and Implementation of Patient Related Equipment policy (Hospital Policy 2.18) regardless of laser ownership. All necessary safety equipment and considerations should be included in equipment description and information packet requests. This information would include training, service contract, maintenance information, smoke evacuators, eyewear, and other safety apparel. Biomedical Engineering will include the Laser Safety Officer in laser equipment evaluations. Additional purchases of safety equipment and laser accessories, i.e., eyewear, protective equipment, smoke evacuators, must be submitted to the Laser Safety Officer for review before purchase. Before initial laser usage, a standard operating procedure (SOP) must be established for the laser. Additionally, the user department will contact Biomedical Engineering and the Laser Safety Officer to schedule an inspection before the laser is placed in service. A representative of the laser service provider should also be present during the inspection. The inspection will include a thorough review of the equipment, applicable ANSI standards, regulatory requirements, safety issues, and established procedures. Only lasers approved by Biomedical Engineering and the Laser Safety Officer will be placed in service. 2.2 Laser Usage Usage of the laser will comply with the Hospital Medical Equipment Management Plan and the Approval Process for Acquisition and Implementation of Patient Related Equipment policy (Hospital Policy 2.18). This includes development of departmental standard operating procedures for each laser. A laser log will be maintained for each laser procedure to document and ensure environmental, employee and patient safety (See Laser Safety Manual Appendix D for laser log example). Any problems, incidents or accidents involving patients, employees or staff and laser use should be entered into the laser log and reported as required by Section 2.7 of the Laser Safety Manual. Laser use is subject to review by the Laser Safety Officer at all times. The Laser Safety Officer will work closely with departmental staff to monitor environmental, employee, and patient safety during laser procedures. It is 4

5 the responsibility of all personnel (nurse, technicians, physicians, anesthesiologists, etc.) to maintain safety during laser procedures. 2.3 Physician Laser Privileges Only those physicians who have been granted laser privileges recommended by the Credentials Committee and approved by the Clinical Board shall have laser privileges. This includes, but is not limited to, the credentialing of House Staff and Fellows. Criteria for laser privileges may be established using ASLMS Policy on Standards of Training for Physicians for the Use of Lasers in Medicine and Surgery, ANSI Z as a guideline (see Laser Safety Manual Appendix B). Criteria will be submitted annually to the Laser Safety Officer to ensure all credentialing and safety issues are addressed. Along with the criteria, a current list of credentialed physicians should be submitted annually. An applicant requesting or appealing laser privileges must follow the procedures specified in the LSUHSC-S Medical Staff Bylaws. The applicant must present documentation of laser training and obtain a signature from his Medical Department Head. The request and evidence of attendance or training at a qualified class/seminar/workshop with documented records shall be submitted to the Credential s Committee for review. The Credential s Committee may use the expertise of the department chairperson, or any member of the department, or an outside consultant, if additional information is needed regarding the applicant s qualifications. The applicant, along with the appropriate use areas and supervisors, shall be notified of the committee s approval. The recipient shall be notified in writing and the staff shall have access to EPRIV to document approved privileges of all staff/housestaff. 2.4 Training Laser Safety Training Program for Health Care Support Staff Health care support staff may be trained by the Laser Safety Officer. The Laser Nurse Specialist may train operating room staff. Training will include but not be limited to the laser beam, safety measures in laser surgery, and methods / procedures to assure safety as suggested in ANSI Z (See Laser Safety Manual Appendix C). The training will be documented and maintained by the department. 5

6 Extended training for other lasers and procedures should include basic laser physics, laser tissue interaction, discussions of clinical specialty field and hands-on experience with lasers. Training will be conducted on an as needed basis at the request of the department. The need for training will be reviewed at least annually through departmental competency assessments on laser usage. Each department will maintain records of these assessments Laser Safety Officer Training 2.5 Signs To ensure that all training needs are met, the Laser Safety Officer will take refresher courses which will update skills and obtain current safety information for use in training others in the facility. Alternate years for training would be optimum. Signs will be posted as recommended by applicable ANSI standards and regulatory requirements. Before repair, alteration, or service of a laser system, appropriate notices and signs will be posted on the entrance to the controlled area. The LSO may be contacted to provide these signs. Other signs appropriate for laser operations may be obtained from the LSO. 2.6 Laser Repair Repair requests and repair work will be conducted as required by the Biomedical Engineering Repair Service policy (Hospital Safety Manual Policy 6.1). All repair work and service will be documented on the laser log. Repairs, alterations, or service of a laser system which result in changes to the laser control measures will be reported to the Laser Safety Officer. 2.7 Accident / Incident Reporting All patient accidents or incidents involving laser operations will be reported as required by the Variance and Sentinel Event policy (Hospital Policy 2.22). Additionally, a copy of the report will also be sent directly to the Laser Safety Officer for review to ensure safety and corrective actions are followed. 6

7 Any laser equipment failure which occurs during patient care will be reported as required by the Medical Equipment Management Plan, Biomedical Engineering Repair Service policy (Hospital Safety Manual Policy 6.1) and the Medical Device Reporting Program (Hospital Safety Manual Policy 6.2). All employee accidents or incidents involving laser operations will be reported as required by the On-the-Job Injury policy (Hospital Safety Manual Policy 8.3) and by the Variance and Sentinel Event policy (Hospital Policy 2.22). Additionally, a copy of the reports will also be sent directly to the Laser Safety Officer for review to ensure safety and corrective actions are followed. 7

8 3. Environmental Safety during Laser Procedures Purpose Lasers possess physical properties which make them very desirable as alternative surgical modalities. When used they also present special dangers to individuals (patents and staff) who are present in the controlled area. Throughout this policy, controlled area refers to the actual treatment area where laser instrumentation is in use. Various precautions greatly reduce the primary risks of fire, electrical injury, and ophthalmic injury. Policy During the time a laser is in a controlled area and in use, the following procedures will be carried out without exception. It is the responsibility of all personnel (nurses, technicians, physicians, anesthesiologists) to continually monitor these safety procedures. 3.1 General Procedures Outer Door Warning System A controlled area will be identified by a series of indicators placed on the outside door of all entrances into the room. A. A warning sign will be posted which states type of laser and wattage. B. Appropriate goggles for the specific wavelength laser in use will be located outside the door for any personnel who may enter the controlled area during a procedure Window Covering A. No additional window protection is necessary for stray CO2 energy because it is absorbed by glass. B. Argon and Nd:YAG energy is easily transmitted through glass. When these lasers ware in use, all windows will be covered using window inserts. Note: A diffuse laser beam is not sufficient to cause fire to the window shade, but a very minimal amount of laser energy is easily refocused by the lens of the eye and directed onto the retina. 8

9 3.1.3 Eye Protection Hospital Safety Manual Eye protection is mandatory for all personnel (staff and patient). See section (Personnel Eye Protection During Laser Application) and / or (Patient Eye Protection During Laser Application) Electrical/Water Safety Personnel will check integrity of electrical plugs and outlets prior to plugging tin instrumentation. Any problems with electrical outlets and leaks in plumbing will be immediately reported to Physical Plant A. The laser will not be used when: 1. Electrical cords are loose or frayed 2. The isolated transformer alarms 3. There is significant leak in water hoses 4. There is any water leakage from the laser console B. Power outlet requirements Nd:YAG 208 volts, 3 phase Argon 208 volts, single phase CO2 110 volts, grounded These are general guidelines. Requirements do vary among some lasers. C. General Water Safety Quick disconnects decrease water leakage. Water requirements are generally cool water at 8 liters/min. Personnel will stand on dry floor when plugging in the laser. The laser foot pedal will remain on dry floor while in use Instrumentation It is recommended that instruments which are to be used in close proximity to a laser beam have a dull, rough surface to diffuse any stray energy or be constructed of material that will absorb energy. 9

10 Choice of instrumentation is left to the discretion of the physician performing the laser procedure. Type of Instrumentation: Ebonizing Black Nickel Plating Black Chroming Smoke Evacuation Some laser procedures generate little, if any, smoke. If a procedure is to be performed in which tissue vaporization will occur with concurrent generation of smoke, a means of smoke evacuation will be employed. See Smoke Evacuation During Laser Application Fire Extinguisher and Fire Safety A. A fire extinguisher must be readily available and always present within the area utilizing the laser. B. Container of sterile water available at all times. C. Do not use flammable tapes, skin degreasers, prep solution, lubricants, and drying agents during laser surgery. D. PVC endotracheal tubes are not suitable for use during laser surgery involving the airway or head and neck region. E. Cover rectal area with moist sponge when operating in close proximity to rectum. Methane gas is flammable. F. Use non-explosive anesthetics and localized ventilation in laser surgery of digestive tracts. Avoid flammable gases near laser energy. See Section of the Laser Safety Manual for Emergency Laser Shutdown for Fire Laser Key When the laser is not in use the laser key will be removed and placed in secure location to ensure no unauthorized use of the instrument. 10

11 3.1.9 Designated Laser Room (Stationary Lasers) Hospital Safety Manual Stationary laser units will be kept in one designated area and only moved when needed after approval and notification of Laser Safety Officer Foot Pedal Only one foot pedal will be used by the physician during laser operation Safety Checklist A. The safety checklist will be followed for each laser procedure. Any items or conditions which are not met will be documented on the laser log which is maintained for each procedure. B. See Laser Safety Manual Appendix A 3.2 Specific Procedures Patient Eye Protection during Laser Application Purpose To outline specific procedures which must be followed during various types of laser applications. To ensure maximum eye protection for patients who are undergoing laser surgery. Policy The following measures will be instituted for all patients who are having procedures involving the use of lasers. Procedures 1. Laser surgery in the head and neck area A. CO2 laser If patient is asleep, saline-soaked sponges should be taped securely over the patient s eyes. Protective goggles will be provided for patients who are awake. 11

12 B. Nd:YAG or Argon laser Hospital Safety Manual 1. Treatment of areas on the face and neck which are outside the immediate eye area. Eyes should be covered with oval gauze pads and overlying filtering lenses that correspond to the specific laser wavelength. Both should be taped securely in place and there should be no exposed area through which light can radiate. Protective goggles will be provided for patients who are awake. 2. Treatment of the periorbital area that would ordinarily be covered by gauze pads (excluding eyelids). The eye can be protected by holding a covered or dull metal tablespoon over the eye itself, and thus expose more skin surface for treatment. 2. Surgery below the head and neck area A. Patients who will be awake during the laser procedure. 1. Patients may wear goggle, provided there is no open area between the goggle and skin surface where laser light may enter. 2. Patients may wear a sleep mask with gauze pads placed between the mask and face. B. Patients who will be having general anesthesia. The eyes must be cared for in the usual manner (i.e. lubricated and taped closed). Gauze pads may then be taped securely over the eyes or properly fitting goggle may be placed over the eyes Personnel Eye Protection during Laser Procedures Purpose To outline specific requirements for personnel eye protection during all laser procedures. These requirements are in accordance with the recommendations of the American National Standards Institute (ANSI). Policy All personnel are to wear appropriate eyewear when in a controlled area. A controlled area is a room where a laser is present and turned on. The 12

13 controlled area will be clearly identified by warning signs on all outside doors. See Environmental Safety During Laser Procedures. Procedure 1. Eyewear Selection Appropriate eyewear is specific to laser wavelength. The wavelength and optical density (OD) for which the eyewear will provide protection must be printed on the eyewear. New eyewear purchases must be reviewed by the LSO or Laser Nurse Specialist. The following is a list of acceptable eyewear. B. For CO2 Laser Procedures Clear goggles to cover prescription glasses Clear glasses with side shields Contact lenses are not acceptable C. For Argon Laser Procedures Special eyewear states that it is for the argon laser and states optical densities (OD>5<0.52 um) Amber filtered goggles Amber filtered glasses with side shields D. For Nd:YAG Laser Procedures Special eyewear states that it is for the Nd:YAG laser and states optical densities (OD 4.5 at 1.06 um) Green filtered goggles Green filtered glasses with side shields E. For Diode Laser Procedures Special eyewear states that it is for optical densities (OD 4 at um) 2. Care of Special Laser Eyewear This eyewear is very expensive and the lenses are porous. It should be carefully handled and stored. Avoid scratching this would lead to less protection form laser light. A. Clean by using a soft cloth and warm sudsy water (mild soap). Blot dry with a towel. B. Check eyewear for scratches and cracks after use. 13

14 C. Protective eyewear will be kept under lock and key and may be obtained from the Laser Nurse Specialist. 3. Use of Laser Through Microscope or Endoscope When using the laser through a microscope or endoscope all personnel in the laser treatment room must use appropriate eye protection. Endoscopic lens covers with appropriate filtering lenses must be used during microscopic and endoscopic procedures during direct vision through scopes to protect physician s eyes Smoke Evacuation during Laser Application Purpose Thermal interaction with tissue produces the plume of smoke in laser procedures. The laser plume or laser smoke may contain chemicals and some intact DNA, bacteria, and viruses. These biological and chemical hazards of the laser plume may cause lacrimation, nausea, abdominal cramping and vomiting. Policy During any laser procedure in which smoke will be generated, wall suction will not be used for smoke evacuation. In all procedures where there is laser smoke, smoke evacuators will be used to remove chemical and biological hazards. Procedure If patients expel smoke during procedures, smoke evacuators must be used and personnel must wear surgical masks. Masks must be designed to filter 0.1 micron particulate matter. To work effectively, the smoke must be captured as close as possible to the point of evolution. The charcoal and/or HEPA filters must also be monitored to maintain efficient removal of laser smoke. Change filters following the manufacturer s recommendations. The replaceable filters should be considered as a possible biohazard and disposed of accordingly. 14

15 3.2.4 Emergency Laser Shutdown for Fire Hospital Safety Manual Purpose To outline emergency steps to be followed in the event of a fire during laser operation in the Operating Room. Policy During any laser procedure in which a fire erupts, turn off any combustible gases in use and the laser immediately. Procedure 1. Management of Fire In or Out of Operative Field A. Turn combustible gases and laser off. B. Remove burning materials from operative site. C. Attempt to extinguish fire in operative field by dousing area with water or saline. Activate fire extinguisher to extinguish burning materials away from operative area. D. If fire occurs away from patient, turn laser off and follow standard fire protocols. 2. Management of Airway Fire Primary Emergency Care A. Stop ventilation, disconnect oxygen and turn off laser. B. Attempt to extinguish airway fire with water or saline. C. Remove burning tube. D. The anesthetist or anesthesiologist should remove any segments of tube or packing from the patient s trachea. Failure to remove these items allows the trachea to continue to burn. E. Place oral airway and ventilate with anesthesia mask. (All materials and devices are to be saved for later investigation.) 15

16 Secondary Emergency Care Hospital Safety Manual A. An airway must be established whether by reintubation or by a trachesostomy. Know the location of the bronshoscopes and trach trays. B. Reintubate with small, cuffed or uncuffed tube or ventilating bronoscope. C. By flexible fiberoptic bronchoscopy, visualize small airways, remove small distal foreign bodies and lavage distal airways. D. Repeat rigid bronschoscopy with rod telescope to evaluate tracheobronchial tree. E. Use direct laryngoscopy and phyaryngoscopy to evaluate airway and to remove fragmented mucosa or papilloma. F. If necessary, perform tracheostomy, preferably below third tracheal ring; use low-pressure cuff. G. Administer antibiotics and steroids short-term only. 3. Fire Prevention in the Operative Field Techniques A. Prep solution should dry before start-up procedure to allow any vapors to dissipate. B. Saline soaked sponges also protect tissues. C. Moist RTX sponge in rectum prevents emission of methane gas. D. Fire retardant drapes, tubes, and accessories. No such thing as fire resistant E. Instrumentation designed to absorb or scatter energy. F. Careful aim of the laser beam; never place two foot pedals side by side. A physician could accidentally activate the laser when he thinks he is using the electrocautery unit. G. Place laser in stand-by mode when not in use. 16

17 H. One Operating Room surgeon will exclusively operate foot pedal and will not be given any other foot pedal. 4. Other Indication for Emergency Laser Shutdown Indicators A. Shutter failure B. Water leakage form laser console C. Water leakage from water hoses (significant) D. Electrical hazard alarm on isolated transformer E. Faulty or damaged electrical cord F. Unexplained, abnormal operation of instrument G. Inappropriate or unsafe use of the laser 17

18 Appendix A Safety Checklist 18

19 Safety Checklist Hospital Safety Manual Preoperative 1. Eye Protection Personnel Patient 2. Doors Proper warning sign Extra goggles appropriate for wavelength being used Flashing light on 3. Smoke Evacuation Clean filter 4. Fire Extinguisher Room free of flammables Patient free of flammables hairspray, clothing in operative area 5. Water Laser hoses connected to outlets and turned ON Excessive water not leaking from hoses 6. Electricity Electrical cords are in good repair Cords are plugged into the appropriate outlet Circuit breaker switch in correct position 7. Traffic Laser console, water hoses, and electrical cords are out of the traffic mainstream 8. Gases Coaxial proper kind and amount for procedure Assist for CO2 laser CO2 for CO2 laser enough for the procedure 9. Recirculation System Recirculation system OFF or ON as appropriate High and low flows regulated Suction regulated Endoscope T-Piece ready for use Pleurovac assembled and ready for use 10. Delivery System Inspection/Placement Fiber 19

20 Handpiece Micromanipulator Hospital Safety Manual 11. Modified Instrumentation Retractors Suction Special finish on instruments Modified endotracheal tubes Modified cottonoids 12. Reintubation Equipment Second prepared ET Tube ready to go Laryngoscope and stylette checked and ready for use 13. Obtain Key to Laser 14. Basin of Sterile Water Available 15. Test Fire Laser 16. Check Laser for Proper Functioning Check standby /OFF Check HIGH/LOW laser power Check all mode and malfunction panels Intraoperative 1. When physician requests laser, turn machine to standby and position foot pedal for physician. 2. Select mode and power requested by physician. 3. Do not leave laser while in use. 4. Place laser on standby when not in use. 5. Turn off the laser before changing gas tanks. 6. Maintain communication with surgeon while operating the laser. Postoperative 1. Turn off laser and remove key. 2. Return laser key to proper storage. 20

21 Appendix B ASLMS Policy on Standards of Training for Physicians for the use of Lasers in Medicine and Surgery 21

22 ASLMS Policy on Standards of Training for Physicians for the Use of Lasers in Medicine and Surgery 15 D1. Training An applicant for hospital or other institutional privileges should be familiar with the pertinent literature and should have completed a basic training program devoted to the principles of lasers, their instrumentation and physiological effects and safety requirements. The initial program should include clinical applications of various wavelengths in the particular specialty field and hands-on practical sessions with lasers and their appropriate surgical or therapeutic delivery systems. A minimum of 8-10 hours is suggested by the ANSI standards. A further 40% of the time should be allocated to the practical sessions. However, more time may be required to complete the basic course contents. Usually, basic training is concentrated on one or more wavelengths. Subsequent programs covering different wavelengths or substantially different applications or delivery instruments may require more hours of training of which 50% of the time is allocated to hands-on sessions. A small faculty-student ratio in the range of 1 to 3-5 is optimal. See the ASLMS Course Content Guidelines. It is recommended that an applicant for privileges spend time after the basic training course in a clinical setting with an experienced operator (such programs are often called preceptorship training programs or observation ) when appropriate and practical. Several brief visits or a more prolonged period suffices provided that a variety of cases is observed. It is valuable for the novice to perform the laser procedures with supervision by the expert, however, for a variety of reasons, such as hospital privileges, status of patients and insurance coverage of physicians, this is not always possible. In lieu of extramural course work and observation, an application should be considered for privileges after completing a residency program which has included significant training and practice with one or more wavelengths. Individuals in training are urged to obtain laser experience as part of their residency wherever possible, especially if they believe they will 15 Approved by the Board of Directors, American Society for Laser Medicine and Surgery, Inc., April 15, 1999 ultimately apply for privileges. Hospital The program Safety for Manual training would be similar as outlined Policy in Num paragraph ber: D2. Credentialing Hospital privileges are and must remain the responsibility of the hospital or other institutional governing board. Physicians requiring privileges to use lasers should first of all meet all the standards of that institution with respect to board certification, board eligibility, specialty training, ethical character, good standing, judgment, etc., and should have interventional privileges in the specialty before requesting laser privileges. For example, a cardiologist should have coronary artery angioplasty privileges before requesting privileges for use of lasers in angioplasty procedures and, likewise, gynecologists requesting privileges for use of lasers in laparoscopic delivery for surgery should already have privileges and experience in operative laparoscopy. It is recommended that methods for quality assurance be in effect as per the guidelines of the particular institution involved. D3. Suggested Outline for Specific Laser Courses Proprietary disclosure should be made part of the written course materials and the oral presentation and must be completed and signed by course directors and faculty. Proprietary disclosure should be required of any presenters who may have received financial interest by any commercial company in the material being presented. This includes financial grants, research grants, equipment, discounts, travel aid, consulting fees, paid travel expenses, salaries or stock benefits, royalties, honoraria for educational services, equity position, etc. The course directors and faculty must indicate the FDA status of the devices used for the material being presented. D3.1 Category A Review Basic Science I. Introduction and welcome A. Self-graded pre-test II. Fundamentals of lasers A. Electromagnetic spectrum B. Methods of production of laser light C. Special qualities of laser light 1. Spatial beam characteristics 2. Temporal beam characteristics III. Summary of laser effects on tissue 22

23 IV. Brief review of types of lasers, special characteristics, and clinical applications A. Argon laser B. CO2 laser C. Nd:YAG laser D. Tunable dye lasers pulsed and continuous-wave E. Others V. Discussion of laser safety A. OSHA requirements B. Eye protection C. Thermal damage hazard prevention D. Special considerations for endotracheal anesthesia E. Limited access and posting of laser rooms F. OR laser safety principles and protocol 1. Laser safety committee 2. Proper training 3. Limited access 4. Warning sensors, emergency positive action cut-off switch 5. Hazard reporting 6. Laser journal documentation 7. Malpractice considerations VI. Installation and maintenance of laser systems A. Special requirements electrical power, cooling (water/air) B. Routine maintenance C. Emergency maintenance D3.2 Category B Review Advanced Didactics I. Introduction and welcome A. Self-graded pre-test II. Fundamentals of lasers A. Electromagnetic spectrum B. Methods of production of laser light C. Special qualities of laser light 1. Spatial beam characteristics 2. Temporal beam characteristics III. Summary of laser effects on tissue IV. Brief review of types of lasers, special characteristics, and clinical applications A. Argon laser B. CO2 laser C. Nd:YAG laser D. Tunable dye lasers pulsed and continuous-wave E. Others V. Discussion of laser safety A. OSHA requirements Hospital Safety Manual B. Eye protection C. Thermal damage hazard prevention D. Special considerations for endotracheal anesthesia E. Limited access and posting of laser rooms F. OR laser safety principles and protocol 1. Laser safety committee 2. Proper training 3. Limited access 4. Warning sensors, emergency positive action cut-off switch 5. Hazard reporting 6. Laser journal documentation 7. Malpractice considerations VI. Installation and maintenance of laser systems A. Special requirements electrical power, cooling (water/air) B. Routine maintenance C. Emergency maintenance VII. Clinical summary of laser usage A. Discussion of basic pathology in the specialty B. Brief discussion of alternate methods of treatment and results C. Specific discussion of laser treatment and results 1. Method of treatment 2. Specific equipment and/or space requirements 3. Long term results 4. Pathological slides 5. Indications, contraindications 6. Follow-up care 7. Results of treatment 8. Side effects and complications 9. Practice organization and management 10. Financial and insurance considerations 11. Malpractice considerations 12. Record keeping including hazard documentation 13. Forms, correspondence, office administration VIII. Complete bibliography A. General bibliography for lasers in medicine and surgery B. Specific subject bibliography for the specialty IX. Research concepts X. Future developments 23

24 XI. Conclusion A. Self-graded post-test B. Course evaluation C. Certificate of attendance D3.3 Category C Review Advanced Didactics and Hands-On I. Introduction and welcome A. Self-graded pre-test II. Fundamentals of lasers A. Electromagnetic spectrum B. Methods of production of laser light C. Special qualities of laser light 1. Spatial beam characteristics 2. Temporal beam characteristics III. Summary of laser effects on tissue IV. Brief review of types of lasers, special characteristics, and clinical applications A. Argon laser B. CO2 laser C. Nd:YAG laser D. Tunable dye lasers pulsed and continuous-wave E. Others V. Discussion of laser safety A. OSHA requirements B. Eye protection C. Thermal damage hazard prevention D. Special considerations for endotracheal anesthesia E. Limited access and posting of laser rooms F. OR laser safety principles and protocol 1. Laser safety committee 2. Proper training 3. Limited access 4. Warning sensors, emergency positive action cut-off switch 5. Hazard reporting 6. Laser journal documentation 7. Malpractice considerations VI. Installation and maintenance of laser systems A. Special requirements electrical power, cooling (water/air) B. Routine maintenance C. Emergency maintenance VII. Clinical summary of laser usage A. Discussion of basic pathology in the specialty B. Brief discussion of alternate methods of treatment and results Hospital Safety Manual C. Specific discussion of laser treatment and results 1. Method of treatment 2. Specific equipment and/or space requirements 3. Long term results 4. Pathological slides 5. Indications, contraindications 6. Follow-up care 7. Results of treatment 8. Side effects and complications 9. Practice organization and management 10. Financial and insurance considerations 11. Malpractice considerations 12. Record keeping including hazard documentation 13. Forms, correspondence, office administration VIII. Complete bibliography A. General bibliography for lasers in medicine and surgery B. Specific subject bibliography for the specialty IX. Research concepts X. Future developments XI. Conclusion A. Self-graded post-test B. Course evaluation C. Certificate of attendance XII. Hands-on laser experience with one expert monitor/3-4 attendees A. Minimum 25% of time devoted to lab B. Inanimate objects (fruit, meat) C. Observe all safety precautions D. Live animals D3.4 Category D Review Courses in this category are specifically designed for individuals with basic laser training who have already had experience in laser applications, but now wish to become versed in a new laser wavelength or procedure. Such courses usually are one day in length. I. Introduction and welcome A. Self-graded pre-test where appropriate II. Basic science fundamentals and fundamentals of laser physics III. Physiology and procedures appropriate to the wavelength IV. Application of the laser wavelength to the clinical situations (specialty specific) 24

25 A. Discussion of basic pathology in the specialty B. Brief discussion of alternate methods of treatment and results C. Specific discussion of laser treatment and results 1. Method of treatment 2. Specific equipment and/or space requirements 3. Long term results 4. Pathological slides 5. Indications, contraindications 6. Follow-up care 7. Results of treatment 8. Side effects and complications 9. Practice organization and management 10. Financial and insurance considerations 11. Malpractice considerations 12. Record keeping including hazard documentation 13. Forms, correspondence, office administration V. Laser safety specific to wavelength and procedure A. OSHA requirements B. Eye protection C. Thermal damage hazard protection D. Personnel laser safety principles and protocol VI. Complete bibliography specific to the wavelength and specialty VII. Research concepts VIII. Future developments IX. Conclusion A. Self-graded post-test B. Course evaluation C. Certificate of attendance X. Hands-on laser experience with one expert per three to four attendees A. Minimal of 25% of time devoted to lab B. Appropriate inanimate or live objects C. Observe all safety precautions D. Observation of clinical procedures where appropriate or viewing of videotapes Hospital Safety Manual * This revised outline represents the knowledge that is available to the Board of Directors of the American Society for Laser Medicine and Surgery, Inc. as of April 15,

26 Appendix C Laser Safety Education Program 26

27 Table F1 Laser Safety Education Program (1) The Laser (a) Physics and biological effects (b) Components of the laser system, delivery devices, and instrumentation (c) Overview of clinical applications (2) Administrative Controls (a) Laser committee (b) Role of the LSO (c) Development of policies / procedures (d) Documentation methods (e) Regulations, standards and recommended professional practices (f) Certification criteria and skills validation (g) Medical surveillance (3) Perioperative Safety (a) Controlled access (b) Eye protection (c) Refection hazards (d) Flammability hazards and draping (e) Electrical safety (f) Management of plume (g) Management of anesthesia in airway surgery (h) Equipment testing, aligning, and troubleshooting Table F2 Laser Safety Training Program MD RN Tech Service LSO 1) Laser Physics / Biological Effects X X X X X 2) System Components / Delivery X X X X X Devices / Instrumentation 3) Federal, State, Local Regulations X X X X X 4) ANSI Z136.1, Z136.3 Standards X X X X X 5) Institutional Policy / Procedures X X X X X 6) Hazard Classification X X 7) Access to Laser Key X X 8) Medical Surveillance X X X 9) Documentation / Incident Reporting X X X X 10) Anesthesia Hazards / Controls X X X X 11) Personal Protective Equipment X X X X X 12) Patient Protection X X X X 13) Operational Skills Workshops X X X X X 14) Procedure for Safety Audits X 27

28 Appendix D Laser Log 28

29 29