Best Practices for Fire Prevention in Perioperative Settings
Article Outline
Case Study 1
The facility in this case study uses an electric bariatric surgical table, which accommodates patients up to 500 pounds. During the room setup for the first of two bariatric procedures scheduled, the RN circulator was notified by the emergency room that a trauma patient was on the way to the OR for emergency surgery. Immediately upon the patient's arrival, the nurse brought the patient into the room and, with assistance from the OR team members, moved him onto the electric bariatric table. The team members positioned the patient and, after prepping and draping, the surgeon began an exploratory laparotomy. The emergent nature of the procedure meant that there were a number of clinical staff members coming in and out of the room, adding to the traffic and confusion.
During the procedure, a plastic surgeon arrived to repair a major evulsion to the patient's face and scalp. He, along with the resident, began pouring copious amounts of irrigation solution onto the patient's face using the small basin from the back table. The plastic surgeon asked the OR staff members to place blankets and sheets on the floor to absorb some of the runoff solution. The general surgeon refused to allow this, stating that the patient was too critical to take extra time to clean up the floor. The plastic surgeon and resident continued to pour irrigation solution, which collected on the floor around the surgical bed and spread to the area where the electrical cord to the bed lay. The pooling of solution in contact with the electrical cord caused an explosive short and flames shot out from the bed. The OR team members responded immediately and the fire was quickly extinguished without any injuries to the patient or perioperative team.
After inspecting the bed, biomedical engineering personnel followed up with the manufacturer of the surgical table. The manufacture stated that a “kit” could be purchased separately to shield the electrical plug connection to prevent such an accident. The company also recommended that its electrical tables be charged once a week and that the tables be left unplugged during surgery.
It was also noted, because the perioperative staff members did not report the experience as a fire, that there was a one-day delay in reporting the event to the quality management and risk coordinator, resulting in a reporting delay to the Department of Health and Human Services.
The actions taken to prevent this situation from reoccurring included
Case Study 2
A surgeon packed the wound he had created during an incision and drainage of the patient's perirectal abscess with iodoform gauze. After the packing was in place, he noted a small amount of bleeding at the wound's edge. The surgeon touched the electrosurgical pencil tip to the site and activated it to control the bleeding. The surgical technologist immediately noticed the hair on the patient's buttocks was singeing and pulled the packing out of the abscess cavity and dropped it to the floor. The packing began to blaze after being exposed to room air. The circulating nurse put out the flaming gauze and checked the container the packing came in and discovered that it contained alcohol. The surgeon evaluated the patient's wound and determined that the patient was not injured. None of the perioperative team members were injured, but all were concerned about and frightened by what had happened.
The risk management analysis that followed this situation found the hospital had recently converted to using a new brand of packing material. The previous vendor's packing material did not contain alcohol, and staff members were unaware of the change in the product content. The new brand's contents included alcohol as stated on the label. This product was removed from the department immediately after this incident, and the materials manager was notified to obtain an alternative packing material product that did not contain alcohol.
Case Study 3
A contracted circulating RN was participating in a laparoscopic hemicolectomy for the first time. A seasoned perioperative nurse, she had the additional responsibility of sharing the supervision of a student surgical technologist with the scrub nurse for the procedure. The room was rather noisy with the hum of several items of patient care equipment and the usual OR conversation. Near the end of the procedure, she noticed an alarm sounding, and began looking for its source. After a few minutes, she realized the alarm was coming from the electrosurgical generator. The audible alarm noted the unit was in activation mode, but no one from the scrub team was using the active electrode, nor was the active electrode near the surgical site. The circulator immediately pulled out the monopolar and bipolar leads from the unit, but the sound continued. After carefully examining the scrub area, she discovered that the student had repositioned the Mayo stand. In doing so, the student had placed one of the Mayo stand legs on the electrosurgical unit foot pedal, causing it to activate the alarm. The active electrode lead was not attached to an instrument but was dangling off the sterile field. No injury was reported, and the RN circulator stated that she is more sensitive now to the potential hazards in these situations.
Improving Outcomes
Multiple reporting agencies make an accurate reflection of the total numbers of surgical fires difficult. Without a centralized reporting group, experts estimate between 50 and 100 surgical fires occur annually in the United States. Of the reported number, 70% of these fires are the result of electrosurgical equipment usage and an additional 10 % involve lasers. The remaining 20 % occur from other heat-producing sources found in surgical settings, including fiber-optic light sources, sparking high-speed power equipment, electrocautery (ie, hot-wire) devices, defibrillators, and faulty patient care equipment (eg, an electrical short). These experts also cite an oxygen-enriched environment being present 75 % of the time and alcohol-based prepping agents that contributed to approximately 4 % of surgical fires.1
Although statistical representation of surgical fires does not prevent future events, they do help to illustrate the nature and frequency of where and why fires occur in ORs. Events reported to the former Emergency Care Research Institute (ECRI), and the US Food and Drug Administration's Manufacturer and User Device Experience Network database and the Medical Device Reporting database have identified that
The actual frequency of surgical fires is rare when compared to the more than 50 million combined inpatient and outpatient surgeries.2 The results, however, always devastate the patient, family members, and the clinical staff members involved in the event. The nature of the perioperative environment caters to elements that, when allowed to combine in the right proportions, potentiate disaster. Surgical settings have an abundant supply of burnable items (ie, fuel), oxidizers (eg, oxygen, ambient air, nitrous oxide), and ignition sources (electrosurgical units, lasers, light sources). Clinicians working with these items are aware of the dangers, but also accepting of their inherent risk. Despite efforts to raise awareness regarding perioperative fire prevention by ECRI, the National Fire Protection Association, and medical literature, there continues to be a casual approach to reducing the incidents of surgical fire by health care organizations. A new emphasis on surgical fire prevention, moved forward by the Joint Commission on Healthcare Accreditation (JCAHO) National Patient Safety Goal 11, “Reduce the risk of surgical fires,” is directed toward ambulatory and office-based surgery accreditation programs but also is endorsed for hospital settings.3 Facilities not accredited by the Joint Commission are reviewing fire safety protocols in part to satisfy public concerns raised by the media portrayal of unsafe patient care environments and to accommodate Life Safety Code requirements regulated by the Centers for Medicare and Medicaid Services.4
Changing Practice
Patient safety experts are in agreement that there needs to be improvement in communication between the three disciplines of the perioperative team—surgeon, anesthesia, and nursing. Poor communication styles and inadequate communication have been associated with medical errors and near-miss events. Assertive communication enhances the delivery of information between health care clinicians through clarity of thought, understanding, and the valuing of practice partnerships in the patient care environment.5 An active discussion by the perioperative team members is recommended before each procedure to determine the risk of fire associated with the selected technique and items scheduled for use.6 These discussions should extend throughout the surgical or procedural intervention whenever conditions bring the three elements of the fire triangle into close proximity.
All elements of the fire triangle (ie, an ignition source, fuel source, oxidizer) must be present for a fire to occur. Knowledge of strategies to interrupt the fire triangle is a crucial component of an effective fire safety program. Facilities should identify and disseminate strategies for interrupting each element in the fire triangle and tailor these strategies to the unique characteristics of the source. “Fuel sources must be managed in a way that will prevent fires, ignition sources must be controlled so that they do not come in contact with fuels, and oxidizers must be contained or properly vented so that they do not come in contact with fuels or ignition sources. Keeping the sides of the fire triangle apart is critical.”7
AORN recognizes that these elements that support combustion are present in all ORs and has made detailed recommendations for managing each aspect of the fire triangle in the OR in its “Guidance statement: Fire prevention in the operating room.” AORN's guidance statement on fire prevention also recognizes the arduous task associated with maintaining fluid communications between perioperative care providers in developing a comprehensive fire safety program. AORN believes that all perioperative team members should be familiar with the recommendations to manage the ignition sources, fuel sources, and oxidizers commonly found in the OR as discussed in Tables 1–3 of the guidance statement.7
AORN additionally supports the inclusion of health care industry partners and students in fire safety activities by stating in the document that
Key reinforcements in fire safety education incorporate multiple scenarios for evacuation drills modeled according to local, state, and regulatory guidelines. Fire drills should accommodate different obstacles to prepare clinical staff members for worst-case situations. Multidisciplinary representation during simulation experiences will foster a unified team response during drills. A debriefing period should also occur immediately following the drill to allow staff members an opportunity to evaluate team effectiveness and receive constructive feedback from an objective, noninvolved observer.
Perioperative clinicians should receive instruction regarding the roles they will perform in the event of a fire and be aware of the individualized responses for each member of the team. The clinical team member's response may change according to the location of a fire; therefore, trainees should be aware of any variable responsibilities in relation to the location of the patient care environment (eg, location of fire extinguisher). Education and training also should provide clinical staff members opportunities to practice handling and discharging fire extinguishers. A review of the different types of fire extinguishers and their locations in the practice setting should be included in the training criteria.
Analysis
Case Study Analysis 1
Questions that could be explored to help understand the contributing factors for this near miss include the following.
Emergency situations require an immediate response from the surgical team. Using the available OR and converting the equipment and supplies for the scheduled procedure to accommodate this patient is an appropriate response by an experienced perioperative team. The clinical staff members also anticipated a safety hazard and suggested layering blankets to contain the pooling irrigation fluids on the floor. When the electrical fire began, this perioperative team responded quickly to prevent a potential disaster. Each of these responses demonstrates the perioperative team members’ collaborative efforts to ensure that the patient received the necessary care in an expedited time frame. There are lessons to be learned, however, from this dramatic situation.
In this case, the facility's sentinel root cause analysis group determined that the manufacturer was aware of this potential hazard with this model of surgical table. They concluded that
An emergency situation does not give surgeons or clinical staff members the authority to be careless in the work environment. Active communication between the perioperative team related to the rushed and unsafe practice environment could reinforce the need to exercise caution when implementing surgical interventions. OR staff members should proactively intercede on behalf of the patient and their coworkers. In this instance, pooling fluid posed a risk for slips and falls. Haste added to the surgeons’ inattention to the dangers of pooling fluid as their concentration was dedicated to the task at hand. An assertive action to place the blankets over the pooling fluids and requesting the physicians to raise their feet to facilitate placement would not only protect the scrub team from losing their footing, but may have prevented the accumulation of irrigation solution around the table's electrical cord.
The significance of event reporting should not be ignored. To successfully understand and prevent similar occurrences, an effective evaluation of adverse events and near-miss scenarios should occur.8 Prompt notification of the organizational risk management group helps to initiate an in-depth analysis of contributing factors and raise awareness regarding how and why fires occur. Exposing “root causes” permits health care clinicians to implement changes to prevent or eliminate similar error in the future. During this facility's risk investigation into the causes of this incident and the staff member's responses to extinguishing the fire, they may have uncovered additional concerns for the patient and staff members, such as possible patient exposure to fire extinguisher discharge, the potential for electrical shock to staff members, or hazards related to smoldering electrical components. Without an accurate report of the event, the corrective actions taken by this facility to protect patients and staff may not have occurred, and a future incident may have a different outcome.
Review and education related to the facility's fire prevention policy and applications to departmental response should occur annually at a minimum. All perioperative staff members including nurses, technicians, surgeons, anesthesia care personnel, and ancillary support personnel should participate in department programs that simulate varied scenarios and evacuation protocols. Participants’ responses should be actively evaluated to provide feedback to improve staff member competence and disaster response skills.
Case Study Analysis 2
Questions that could be explored to help understand the contributing factors for this near miss include the following.
Some manufacturers include alcohol in wound packing and dressing products due to its usefulness as a bacteriostatic agent. Surgical fires are frequently associated with alcohol or its vapors coming in contact with ignition sources (eg, heat electrosurgical unit tip). Alcohol is a volatile flammable agent, having a low flash point (ie, the lowest temperature at which a liquid can have an ignitable reaction on exposure to air) and burns with an invisible flame generating intense heat.9, 10 Iodoform, in itself, has a very low flammability rating.11 An alcohol-treated iodoform packing would pose a higher than average risk when placed in a confined wound cavity that potentiates concentration of combustible vapor.
Care should always be exercised in the presence of volatile spirits (eg alcohol, collodium, tinctures). Perioperative clinicians must remain alert to the placement of ignition sources when used near these agents. Active communication between the surgeon and scrub person regarding the distance of the active electrode from the packing could additionally alert the team members to any potential danger. In this instance, the surgical technologist reacted swiftly to remove the outward fuel source when the patient's gluteal hair began to singe. The packing, being exposed to additional oxygen, burst into flames and was extinguished by the circulating nurse. It was only after the incident occurred that the circulating nurse reviewed the label from the packing container.
A multidisciplinary product evaluation team focusing on product safety and quality should evaluate patient care products that act as fuel sources. When new patient care supplies are introduced into the clinical setting, staff members should receive instruction on the applications for and differences between current and new product selection.
Case Study Analysis 3
Questions that could be explored to help understand the contributing factors for this near miss include the following.
Electrosurgical units (ESU) are the second most common element reported in surgical fires.12 When not in use, the ESU active electrode should be placed in a well-insulated holster to protect the tip should an unplanned activation occur. The audible ESU activation tone, a built-in safety feature, does not ensure safe use of the equipment. With accidental activation, an arc of electrical current can penetrate and ignite surgical drapes or concentrated volatile vapors in the immediate area.13
Monitoring of the surgical field by the perioperative nurse helps to ensure that the patient receives delivery of safe care. The perioperative nurse judiciously performs interventions to promote the highest standards of care, which are evident by individual patient outcomes. The circulating RN in this case study demonstrated critical thinking and intuitive response in determining the cause for the unmanned ESU activation. The actions taken to remove the active electrode cords from the generator interrupted the electrical circuit and prevented stray arcing of the current. Her continued perseverance to determine the cause of the continuing alarm resulted in an educational opportunity for the student surgical technologist and a personal reminder of the complexities of the perioperative care environment.
This case study does not provide enough information to determine the significance of the contracted RN acting as a preceptor for a student surgical technologist. Crucial information needed would include the mentoring relationship between the two, the length of time these individuals had been at the facility, and any background educational information about the student's program. AORN believes perioperative nurses should support the education and mentoring of individuals in the perioperative environment to foster career interest in perioperative nursing and facilitate the acquisition of knowledge of interventional patient care.14 The perioperative nurse preceptor should possess characteristics that demonstrate knowledge of
The description in the case study identifies the contracted RN as having extensive experience in perioperative nursing practice and the student projects limited experience. Whether the student has had previous education on electrosurgical safety is unknown. The circulating RN should have had an advanced appreciation for the student's competence and remained attentive to the skill capacity of her charge during the case.
LESSONS LEARNED
Notes
- . Guidance article: Surgical fire safety . Health Devices . February 2006;35:45–66 ECRI
- . Surgical fires: Perioperative communication is essential to prevent this rare but devastating complication . Quality and Safety in Health Care . December 2004;13:467–471
- “FAQs for the 2006 National Patient Safety Goals (Updated 2/06) Goal 11 (Reduce surgical fires)” Joint Commission on Accreditation of Health Care Organizations . http://www.jointcommission.org/NR/rdonlyres/AAB42DE1-3239-4853-9FF9-8601A13A690C/0/06_npsg_faq11.pdf (accessed 15 May 2006)
- “Adoption of new fire safety requirements for religious non-medical health care institutions (RNHCIs), ambulatory surgical centers (ASCs), hospice, programs of all-inclusive care for the elderly (PACE), hospitals, long term care (LTC), intermediate care facilities for the mentally retarded (ICFs/MR), and critical access hospitals (CAHs)” (May 8, 2003) Centers for Medicare and Medicaid Services . http://www.cms.hhs.gov/SurveyCertificationGenInfo/downloads/SCLetter03-21.pdf (accessed 23 April 2006)
- . Improving verbal communication in clinical care . AORN Journal . May 2004;79:1053–1057
- . Fire expert suggests OR teams need pre-op exchange on fire awareness . AORN Management Connections . April 2005;8–9
- In: “AORN guidance statement: Fire prevention in the operating room” in Standards, Recommended Practices, and Guidelines . Denver: AORN, Inc; 2006;p. 251–259
- “White paper: Strategies and tips for maximizing failure mode and effect analysis in your organization” American Society for Health Risk Management . http://www.hospitalconnect.com/ashrm/resources/files/FMEAwhitepaper.pdf (accessed 15 May 2006)
- “Flash point” definition in The MSDS Hyper Glossary . http://www.ilpi.com/MSDS/ref/flashpoint.html (accessed 15 May 2006)
- . Talk to the specialist: Surgical fire hazards of alcohol . Health Devices . July 1999;28:286
- . Iodoform” Mallinckrodt Baker, Inc . http://www.jtbaker.com/msds/englishhtml/i3480.htm (accessed 15 May 2006)
- . Surgical fire safety . Health Devices . February 2006;35:45–46
- . Burns and fires from electrosurgical active electrodes . Health Devices . August-September 1993;22:421–422
- In: “AORN resolution on responsibility for mentoring” in Standards, Recommended Practices, and Guidelines . Denver: AORN, Inc; 2006;p. 363
- In: AORN Perioperative Orientation Resources: A Guide to Orientation, Recruitment and Retention . Denver: AORN, Inc; 2006;p. 33
PII: S0001-2092(06)60084-7
doi:10.1016/S0001-2092(06)60084-7
