Laser safety operational guidelines Office Dermatology Procedures policies and procedures

If you would like to explore NCLE Laser Certification of your facility Laser Safety Program, including policies and procedures, we would direct you to www.LaserCertification.org and check for options under the Facility Laser Safety Program Certification. Your facility would receive the appropriate Certification Certificates.

Our own nonprofit Laser Training Institute offers On-site Laser Safety Compliance inspections, including options to guarantee your acceptance as an NCLE Laser Certified Facility (Laser Safety Program Certification). For details see http://www.lasertraining.org/JCAHO-ANSI%20Safety%20Compliance.htm on our website.

These policies are designed for the safe use of lasers & IPL in dermatology. They incorporate all the applicable guidelines established by A.N.S.I Z136.3 standard “Safe Use of Lasers in Health Care Facilities”.

A. For purposes of documentation it is hereby reasserted that no ionizing radiation hazards exist with the common medical lasers in current use or IPL unit. X-Ray type precautions are NOT required for lasers, even for women in any stage of pregnancy.
B. A laser warning sign will be prominently displayed outside each entrance to the room in which the laser is being used. These signs shall conform to the standard OSHA/ANSI danger signs that will include the type and maximum power of the class IV laser being used.
C. All windows into the laser room (or any other viewing area into the room) must be protected against transmission of the laser light for all lasers/IPL except the CO2 laser. It may be achieved by placement of flame retardant opaque materials over the windows such as taping of towels, blinds, or other opaque cutouts for the windows.
D. Appropriate protective eyewear is required for all persons in the Nominal Hazard Zone (NHZ) during laser use. The Laser Safety Officer has designated the entire room (Laser Treatment Controlled Area) as the NHZ so that protective eyewear is required for all persons in the room. These glasses will be made available at the entrance to the room. The IPL (though not a laser) will also require appropriate safety glasses to be worn by personnel within the room. The LSO may from time to time determine that the NHZ, and the need for laser safety eyewear, is smaller than the entire room and may use their informed judgment to make this determination on a case by case basis as allowed by ANSI 136.3.
1. Safety glasses must be worn by all personnel in the NHZ at all times while the laser is in operation. The safety glasses must be specific to the wavelength of the laser being used. Protective eyewear will be labeled according to the optical density and wavelengths filtered. Safety glasses for the IPL unit will be the generic IPL safety eyewear or the more specific “light-speed” (model name) eyewear.

2. Viewing laser or IPL operation through a video monitor offers no risk to the viewer in any situation.

3. No safety glasses or filters offer eye protection against a direct, close range impact through the safety material into the eyes. Personnel will therefore not point the laser or fiber directly at any person's face. The laser fiber will always be handled as a "loaded gun" and pointed in a safe direction in the event of an accidental firing.

4. 
   Eyewear and filters should be without defect. Frames should not be broken and separated from the lenses. Sideshields - if optionally used - should be in place, and no scratches should be on the front lenses. The laser operators or safety officer will make periodic inspections for these defects.
   
5. 
   The patient shall be provided the same protective eyewear as personnel, or other types of eye coverings. In the event that treatment needs to take place on the face around the eyes, the eyes shall be protected by placing opaque coverings (ie towels) completely around their eyes so that no light shines through - or fitted with eye covers or commercial eye shields that provide similar protection. In the event the laser must be used directly on the eyelid or within the bony orbit of the eye, appropriate laser safety eyeshields will be placed between the lid and the eye to provide protection.
   

E. The laser will be operated only by those who have had training in laser theory, techniques of control, and operation of the laser(s) or IPL.

17. 
    A written record will be kept of laser maintenance, and include documentation of calibration each six months.
    

R. Flammable gases, such as Oxygen or Nitrous Oxide, will be used only if necessary during laser cases, at concentrations less than 40%, and the laser operator will examine the gas delivery system setup to minimize any fire risks. Minimum concentrations of oxygen below the 40%, required to adequately oxygenate the patient, will be used.

The laser manufacturer’s recommendations for operation of the particular unit will be followed by the laser nurse / operator. - Refer to the laser checklist.

The CO2 laser presents the higher risk for ignition of dry and flammable materials and appropriate precautions will be taken when necessary, such as the use of moistened towels or sponges to drape the perimeter of laser treatment areas, and avoiding or protecting hair lines that might have hair spray or flammable prep solutions dried in the hair line. Personnel will be made aware of the location of office fire extinguishers.

Any suspected incidents putting patients or staff at risk of eye injury, or of potentially harmful treatment shall be immediately reported to Dr. Biesman. In the event of suspected eye injury appropriate eye examinations will be performed, and in the event of potential harmful treatment parameters, Dr. Biesman will medically evaluate the patient and appropriately manage any potential complications.

Attached: ASLMS recommendations for office based procedures, training and use of lasers by nonphysicians
END.

(Note that these are currently being updated)

Any physician who delegates a laser procedure to a non-physician must be qualified to do the procedure themselves by virtue of having received appropriate training in laser physics, safety, laser surgical techniques, pre and post operative care, and be able to handle the resultant emergencies or sequelae.

Any non-licensed medical professional employed by a physician to perform a laser procedure must have received appropriate documented training and education in the safe and effective use of each laser system, be a licensed medical professional in their state, and carry adequate malpractice insurance for that procedure.

A properly trained and licensed medical professional may carry out specifically designed laser procedures only under physician supervision and following written procedures and/or policies established by the specific site at which the laser procedure is performed.

Since the ultimate responsibility for performing any procedure lies with the physician, the supervising physician should be immediately available and shall be able to respond within five minutes to any untoward event that may occur. Ultimate responsibility lies with the supervising physician.

The guiding principle for all physicians is to practice ethical medicine with the highest possible standards to ensure the best interest and welfare of each patient is guaranteed. The ASLMS endorses the concept that use of properly trained and licensed medical professionals, under appropriate supervision, allows certain laser procedures to be performed safely and effectively.

Many laser procedures are safe and appropriate to the office setting. High standards of practice, similar to those in the institutional setting, should be maintained to ensure quality of care for the surgical patient who undergoes an outpatient surgical procedure in an office-based surgical facility.(1)

The mere acquisition of a skill is not the only criterion by which to measure qualifications. The office setting should not provide an opportunity for practice of inadequately trained personnel. Office staff must meet accepted standards of training and experience and would generally qualify for and hold privileges in an institutional setting.(2)(3) As new technology is introduced into the clinical setting, it is essential that all medical staff using the technology be appropriately educated and their skills assessed.(4)

Prudent selection of both procedures and patients appropriate for office-based laser procedures is critical. Procedures that have intrinsic risk or require technology not available in the physician's office are more appropriately performed in an institutional setting.

In order to determine and apply proper indications for a procedure and to select the appropriate patients for applications of the technology, comprehensive knowledge of the disease process and experience in management of patients with the disease is essential. Prompt recognition and management of complications can only be achieved when the individual or team member is fully qualified in all aspects of treatment of the disease.(5)

Patient Safety

Patients should receive clear pre-procedure instructions. Confirmation of important compliance issues such as NPO status should be documented.

Conscious sedation used as an adjunct for office-based laser procedures must be conducted safely. There must be appropriate instrumentation and expertise in managing respiratory depression and cardiac arrest. Oximetry and automated blood pressure monitoring should be routinely employed; electronic cardiographic monitoring should be available. Oxygen, drugs and equipment routinely used in cardiopulmonary resuscitation, including adequate suction, must be available.

The availability of emergency transport to an acute care facility willing to accept patients from the office should be guaranteed.

The laser procedure should not be compromised by lack of equipment required to perform the proposed procedure.

All office-based laser patients must be sufficiently recovered from procedures and sedation prior to discharge. Following procedure requiring sedation vital signs should be monitored and respiratory function and mental status assessed in a manner similar to hospitalized patients. If sedation has been used, the patient must be accompanied by a reasonable adult at discharge. Written instructions regarding common complications, directions for returning for emergency evaluation and caution as to continued functional impairment for many hours following conscious sedation are appropriate.

Periodic preventive maintenance and testing of bio-electrical equipment should be done by a qualified professional.

Standard protocols for both personnel and patient protection from infectious disease must be rigorously observed including body fluid isolation, proper specimen handling as well as proper instrument cleaning and disinfection.(6)

Each patient should have at minimum a brief history and physical examination by the physician. Serious cardiopulmonary or other disease should be excluded by appropriate clinical, and if necessary, laboratory evaluation.

The patient chart should contain the clinical examination and evaluation, the justification for the procedure, the description of the treatment and the patient's status on discharge. Informed consent for the procedure should be documented in the chart consistent with local professional standards and applicable state law.

Records should be maintained so that complications and problems can be identified and compliance with recommendations for clinical and laser treatment ensured.(6)

American College of Surgeons monograph Guidelines for Office Endoscopic Services (1991) and Guidelines for Optimal Office-Based Surgery.

Individual should be a licensed medical professional, and carry adequate malpractice insurance.

Individuals should be trained appropriately in laser physics, tissue interaction, laser safety, clinical application, and pre and post operative care of the laser patient.

Prior to the initiation of any patient care activity the individual should have read and signed the facilities policies and procedures regarding the safe use of lasers.

Continuing education of all licensed medical professionals should be mandatory and be made available with reasonable frequency (including outside the office setting) to help insure adequate performance. Specific credit hour requirements will be determined by the state, and/or individual facility.

A minimum of TEN procedures of precepted training should be required for each laser procedure and laser type to assess competency. Participation in all training programs, acquisition of new skills and number of hours spent in maintaining proficiency should be well documented.