Semester

Summer

Date of Graduation

2026

Document Type

Problem/Project Report

Degree Type

DNP

College

School of Nursing

Department

Anesthesiology

Committee Chair

Kendra Barker

Committee Co-Chair

Aaron Ostrowski

Committee Member

Dawn Yost

Abstract

Background: Surgical smoke produced during procedures poses serious health risks to operating

room (OR) staff and patients, yet many hospitals, including an academic medical center in

northern West Virginia, have underutilized smoke evacuation systems. The imminent

enforcement of West Virginia House Bill 4376, mandating smoke evacuation use, provided both

urgency and opportunity for an intervention.

Purpose: The purpose of this Doctor of Nursing Practice (DNP) quality improvement project

was to increase timely compliance with the use of smoke evacuation systems during all smoke-

producing procedures, ensuring alignment with safety standards and legislative requirements.

Methods: A systematic evidence review of academic databases was conducted to find support

for this evidence-based quality improvement project. The project used the Institute of Healthcare

Improvement Plan-Do-Study-Act (PDSA) framework to guide the implementation and

evaluation.

Intervention: Project implementation included smoke evacuator use policy development and

execution, staff education with pre and post implementation staff surveys for knowledge and

attitudes, and electronic medical record (EMR) charting modifications. Chart audits and vendor

supply tracking were used to measure compliance. Compliance data were collected from

September 2024 through February 2025.

Results: Compliance with Smoke evacuator utilization improved from 63.5% in September 2024

to 99.7% by January 2025, slightly declining to 93% in February. Pre- and post- survey findings

demonstrated that education reduced the knowledge gap by more than half, with participants’

understanding the importance, and function of smoke evacuators more than doubling.

Discussion: Key facilitators included leadership engagement, vendor collaboration, and

integration into EMR systems. Barriers included inconsistent staff buy-ins, equipment

backorders, and workflow disruptions.

Conclusions: The project significantly increased compliance with smoke evacuator use and

demonstrated how policy, education, and health IT integration can affect sustainable practice

change. The results highlight the importance of stakeholder engagement and continuous

monitoring in improving workplace safety in surgical settings.

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