Preventing fires in the OR - Patient Safety First - operating room

Suzanne C. Beyea

The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently released a Sentinel Event Alert related to the prevention of surgical fires. (1) This cautionary alert addressed two reports of OR fires that resulted in serious injury to patients. Facilities reported both of these events under JCAHO's sentinel event policy.

These cases and other fires reported in newspapers and on television provide evidence that significant fire hazards exist in ORs. For example, during surgery to remove blood clots from a patient's brain, the patient received burns from sparks emitted by an electrosurgical device. Another fire occurred when sparks from an electrosurgical unit ignited antiseptic solution that had pooled under a patient's legs. An 84-year-old retired teacher died from pneumonia, which was a complication of burns received during surgical repair of an eyelid. Other cases include a flash fire during surgery that resulted in the death of a premature infant and an oxygen-induced flash fire in an endotracheal tube that led to the death of a 23-year-old man with benign throat tumors. (2,3)

Experts estimate there may be as many as 100 OR fires per year nationwide, with 10 to 20 fires resulting in serious injury and one to two deaths annually. (1,2) Despite the fact that these events are rare, when they occur, they are devastating to victims and their family members. Clinicians strive to make the surgical environment safe, but fire can occur when an ignition source, adequate oxygen, and fuel (ie, something that will burn) are combined. These three elements, which constitute the fire triangle, are prevalent in OR settings and provide many opportunities for unexpected fires to occur. The Joint Commission reports that ECRI found the most common fire locations are the airway, head, and face, and the most common sources of ignition are electrosurgery (68%) and laser equipment (13%). (1,4) Overhead and fiberoptic light sources, drills, and burrs also can be sources of ignition.

Patients undergoing surgery often receive oxygen. This factor alone increases the risk of fire; ECRI found that an oxygen-enriched environment was present during 74% of fires. (1,4) Numerous fuels, including drapes, alcohol-based skin antiseptics, and materials such as endotracheal tubes or oxygen tubing and masks, are present in surgical suites.

Given these factors, every member of the perioperative team must be educated about handling fire emergencies and extinguishing fires. The Joint Commission recommends three steps to help prevent surgical fires. These include

* informing staff members about controlling heat sources;

* developing, implementing, and testing procedures to follow in the event of a fire; and

* reporting fires that do occur to JCAHO, ECRI, state agencies, or the US Food and Drug Administration. (1)

ECRI recommends four OR fire prevention strategies.

* Place electrosurgical electrodes in a holster or another location when they are not in active use, and place lasers on standby mode when they are not in active use.

* Fully dry flammable preps before draping patients.

* Question the use of 100% oxygen during facial surgery, and use air or fraction of inspired oxygen (ie, Fi[O.sub.2]) below 30% for open delivery, if this is consistent with patient needs.

* Soak gauze or sponges used during oropharyngeal surgery so they will resist igniting. (1)

Fire-fighting drills and education also are important; ECRI recommends that clinicians demonstrate competency in the use of fire-fighting equipment, rescuing patients and their colleagues, and escaping from fire. Furthermore, clinicians need to know when, where, and how to shut off medical gases and ventilation and electrical systems. Staff members should know how to initiate a fire alarm in their hospital and how to contact the local fire department. (1)

AVAILABLE RESOURCES

A number of resources exist to assist clinicians in their efforts to reduce the risk of fire in the OR. AORN publishes "Recommended practices for electrosurgery," which outlines practices that reduce risks related to electrosurgical devices. (5) AORN also has produced a videotape titled "Fire Safety in the Perioperative Setting," and a CD-ROM titled "Safety in the Perioperative Setting," which features a segment on fire prevention and safety during surgical and invasive procedures. The videotape is available from Cine-Med at http://www.cine-med.com/cgi-bin/cart/cart-template.pl?CatalogNumber=1883, the CD-ROM is available from Virtual Factory at http://www.virtualfactory.com/aorn/. These resources identify numerous fire hazards in the OR and health care facilities, provide strategies to prevent fires, and address how to respond to a fire should one occur. AORN also has scheduled an audio-conference about fire safety for Nov 12, 2003. More information about this upcoming offering can be obtained on AORN Online at http://www.aorn.org/education/audio/fire.htm

A variety of resources related to surgical fires also are available from ECRI. One of these resources is a free poster titled "Only you can prevent surgical fire," available from ECRI's web site al http://www.mdsr.ecri.org/asp/dynadoc.asp?id=195&nbr=413558. Fire prevention strategies addressed include fire risks during oropharyngeal surgery, electrosurgery, and laser surgery; risks related to oxygen and flammable prep; and other risks inherent in surgical settings. A variety of articles and resources are available on ECRI's web site at http://www.mdsr.ecri.org using the keyword fires. Individuals also can purchase a guidance article about surgical fires published by ECRI by telephoning (610) 825-6000 x 5888.

CONCLUSION

Although fires in the OR rarely occur, their outcomes can be life altering and, in some instances, may result in death. Each day in the OR, clinicians must be alert to fire hazards, strive to prevent fires, and be prepared to extinguish a fire if one should occur. Fire safety is a shared responsibility for every member of the perioperative team. Team members must anticipate the potential reality of an OR fire and prepare for such an event through regular fire drills and ensuring ready accessibility to fire extinguishing equipment in each OR.

Perioperative nurses should take a leadership role in preventing fires by alerting team members to potential fire hazards and methods to minimize related risks. By properly maintaining equipment, nurses provide the first line of defense. They also must ensure that staff members are trained and credentialed and are taking necessary precautions. Remaining vigilant and alert to potential risks will help nurses in their efforts to keep patients safe.

SAFETY COMMISSION

Patient Safety Priorities

Burns and fires are among 11 priority safety topics identified by AORN's Presidential Commission on Patient Safety. Other topics identified as priorities by the commission are

* blood transfusion,

* communication,

* correct site surgery,

* counts,

* equipment failure,

* infection control,

* medication safety,

* patient positioning,

* retained foreign objects, and

* staffing.

The commission is working to develop resources and education for each of these topics. Visit http://www.patientsafetyfirst.org for more information.

NOTES

(1.) "Preventing surgical fires," Sentinel Event Alert 29 (June 24, 2003) http://www.jcaho.org/about+us/news+letters/sentinel+event+alert /print/sea_29.htm (accessed 14 Aug 2003).

(2.) A A Skolnick, "Fires That Break Out During Surgery Are Due to Ignorance, Carelessness, Experts Say. Exact Numbers Aren't Known; Law Doesn't Require Hospitals to Report Them," St Louis Post-Dispatch, 28 May 2000, A13.

(3.) B Bryan, "Woman Dies After She is Set On Fire During Operation. Up to 20 Patients a Year Are Badly Hurt, 2 Killed in Such Accidents. St Louis Victim's Family Sues," St Louis Post-Dispatch, 28 May 2000, A1.

(4.) "A clinician's guide to surgical fires. How they occur, how to prevent them, how to put them out," Health Devices 32 (January 2003) 5-24.

(5.) "Recommended practices for electrosurgery," in Standards, Recommended Practices, and Guidelines (Denver: AORN, Inc, 2003) 237-244.

SUZANNE C. BEYEA

RN, PHD, FAAN

DIRECTOR OF NURSING RESEARCH

DARTMOUTH-HITCHCOCK MEDICAL CENTER

LEBANON, NH

COPYRIGHT 2003 Association of Operating Room Nurses, Inc.
COPYRIGHT 2003 Gale Group