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Prevention and Management of an OR Fire
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2
Speaker
Sue Dill Calloway RN, EsqAD, BA, BSN, MSN, JD CPHRM President
Patient Safety and Health Care Consulting 5447 Fawnbrook Lane
Dublin, Ohio 43017 614 791-1468 [email protected]
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Headlines You Don’t Want to See
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A Patient Seriously Burned from an OR Fire
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Another Patient Seriously Burned
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4 Year Old in OR Fire Case
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Surgeon Accused of Covering Up OR Fire
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New Clinical Guide to Surgical Fires
ECRI and the Anesthesia Patient Safety Foundation have issued new clinical guidelines to surgical fire prevention
Recommendations include two important things
Eliminate the traditional practice of open delivery of 100% oxygen during sedation
Securing the airway is recommended if the patient requires an increased oxygen concentration
The surgery team should talk about the risk of a surgical fire before each surgery
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New Clinical Guide to Surgical Fires Surgical fires is one of the three never events along with
wrong site surgery and leaving an instrument in the patient
65% of fires occur with high concentrations of oxygen around the face, neck, and upper chest
Fires in oxygen rich atmospheres ignite more easily, burn hotter, and spread quicker
The goal is to stop open oxygen delivery around the head and upper chest
If oxygen is needed use the minimum and follow the new guidelines
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New Clinical Guide to Surgical Fires
Carefully arrange surgical drapes to minimize oxygen build up underneath
Always make sure the surgical prep is dry before draping
Use only air for open delivery to the face
Provided that a spontaneously breathing sedated patient can maintain his or her blood oxygen saturation without extra oxygen
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New Clinical Guide to Surgical Fires If the patient cannot maintain safe blood oxygen
saturation without supplemental oxygen, secure the airway by using a laryngeal mask airway or tracheal tube, so that oxygen-enriched gases do not vent under the surgical drapes
Discontinue the traditional practice of open delivery of 100% oxygen with limited exceptions
Suggest may want to require that all staff watch the video on surgical fire prevention and management It includes the new recommendations for controlling oxygen
delivery by minimizing the presence of oxygen rich environment of the head, face, neck and upper chest
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Fire Safety Video
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http://www.apsf.org/resources_video.php
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Fire Safety Video
APSF or Anesthesia Patient Safety Foundation, with the assistance of ECRI, has a 18 minute video
On Prevention and Management of an OR Fire
Anyone can watch the video on their computer
Can also request a complimentary DVD copy Available at http://www.apsf.org/resources_video.php
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ECRI’s Surgical Fire Prevention Website
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www.ecri.org/surgical_fires
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ECRI Has 2 Posters for Your OR Only You Can Prevent Surgical Fires
–Oxygen and nitrous oxide increase the flammability of drapes, plastics, and hair
–Do not apply drapes until all flammable preps have dried as oxygen can be trapped under the drapes
–Moisten sponges to make them ignition resistant in oropharyngeal and pulmonary surgery
–Fiberoptic light sources can start a fire. Complete all cable connections before activating the source. Place the source in the standby mode when disconnecting cables
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ECRI Has 2 Posters for Your OR Only You Can Prevent Surgical Fires (continued)
Has important recommendations for surgery during head, neck, face, and upper chest surgery since 65% of the burns occur here
Begin with a 30% delivered O2 and increase if necessary
For unavoidable open O2 delivery above O2, deliver 5 to 10 L/min of air under the drapes to wash out the excess O2
Poster includes recommendations during oropharyngeal surgery, tracheostomy, bronchoscopic surgery and when using electrosurgery, lasers, or electrocautery
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Posters for the OR
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Emergency Procedure Extinguishing a Surgical Fire
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AORN Poster
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Could You Catch Fire During Surgery?
Fires in operating rooms happen at least 600 times a year
ECRI has 1 to 2 fires reported to them per week
Pa Patient Safety Authority cited the chances of a surgical fire in Pa at 1 in 87,646 operations
For Pa this averages 28 surgical fires per year
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Could You Catch Fire During Surgery?
Only 5% of the fires cause harm to patients
10-20 patients are seriously burned every year
1 to 2% are fatal
Mostly involving airway fires
70% of fires involve electrosurgery equipment
10% involve lasers
20% are electrocautery equipment and fiberoptic light sources
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What Are the Highest Surgical Fire Risks?
The following examples of high-risk procedures provided by ASA are ranked in descending order based on fire incidence:
Removal of lesions on the head, neck, or face
Tonsillectomy
Tracheostomy
Burr hole surgery
Removal of laryngeal papillomas Source: American Society of Anesthesiologists (ASA) Task Force on Operating Room Fires.
Practice advisory for the prevention and management of operating room fires. Anesthesiology 2008 May;108(5):786-801.
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Pa Patient Safety Authority
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http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2010/Jun7(2)/Pages/60.aspx
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Airway Fires During Surgery
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Did You Know? 75% involve oxygen enriched
atmospheres under surgical drapes
Oxygen enriched atmosphere are created when oxygen at concentrations above 21% in ambient air provided by face mask, ET tubes or nasal cannula
4% involve alcohol-based skin prepping agents
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Location of Surgical Fires
44% face, head, neck and chest
Another source (APSF) says 65%
21% airway
26% elsewhere on the body
8% elsewhere in the body Source: ECRI Surgical Fires July 2010
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Fire Triangle
Preventing OR fires is a team approach
Each member of the surgical team is involved with one or more sides of the triangle
• Ignition sources
• Oxidizers
• Fuels
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Ignition Sources
Surgeons usually have the ignition source
Electrosurgical or Electrocautery devices
Lasers, heated probes
Drills and burrs, argon bean coagulators
Fiberoptic light cable sources
Defibrillators paddles or pads
Ignitions sources are 70% electrosurgery, 10% laser, and 20% are cautery, light sources, bur sparks, or defibrillators
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Oxidizers
Anesthesia usually bring the oxidizers
Oxygen-enriched atmospheres
Nitrous oxide
Medical compressed air
Ambient air
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Fuels Nurses usually bring the fuel Make sure the surgical prep is dry!!!
Surgical drapes, mattresses, sheets, gowns, towels, etc
Volatile organic chemicals, packing material
Body hair, gloves, smoke evacuator hoses, flexible endoscopes
Intestinal gases and tracheal tubes
Body tissue, adhesive tape, ointments
Aerosol adhesives, Alcohol, Degreasers (ether, acetone)
Tinctures and surgical skin prep (Hibitane, DuraPrep, Chloraprep, etc.)– The list is seemingly endless
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Do You Know the Following? Is the hallway free of clutter?
Where is the oxygen or medical gas shut-off valve? What is the coverage area of this zone?
Where is the fire alarm pull stations and exits?
Where is the hallway fire extinguisher, and what type is it?
Who is the spread of smoke prevented? By closing the doors or using smoke doors and air-duct
dampers
Source:. Steelman VM. Where there's smoke, there's ... AORN Journal 2009; 89:825-827.
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Do You Know the Following
Where is the fire extinguisher in the OR, and what type is it?
Does top management create a culture that is supportive of fire prevention?
How would you evacuate from this OR?
Stretcher or OR table in corridors
When and how do you communicate with the OR, within the suite, with the rest of the facility and with the local fire department?
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Do You Know the Following?
How do you operate the fire extinguisher?
Is the path to the extinguisher accessible?
Is there saline on the sterile field?
Where is the self-inflating ambu bag?
Where is the flashlight?
Can also use these during practice drill
Perioperative briefing to identify high risk procedures before every case
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www.mdsr.ecri.org/static/surgical_fire_poster.pdf
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ASA Practice Advisory
ASA or the American Society of Anesthesiologists has a free 16 page practice advisory on the prevention and management of operating room fires
Published in 2008
Defines the following;
Operating room fires are defined as fires that occur on or near patients who are under anesthesia care, including surgical fires, airway fires, and fires within the airway circuit
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ASA Practice Advisory
A surgical fire is defined as a fire that occurs on or in a patient
An airway fire is a specific type of surgical fire that occurs in a patient’s airway.
Airway fires may or may not include fire in the attached breathing circuit
OR fires can cause burns, inhalation injuries, infection, disfigurement, and death
ASA recommends that every anesthesiologist should have knowledge of OR fire safety protocols
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ASA Practice Advisory
ASA recommends that every anesthesiologist participate in OR fire safety education
Education should emphasize the risk created by an oxidizer enriched atmosphere
ASA recommends that anesthesiologist participate in OR fire drills and simulation training with the entire OR team
Team should determine if high risk situation exists
If yes then a discussion of the strategy to prevent an OR fire
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ASA Practice Advisory
The protocol to prevent and manage fires should be posted in each location where a procedure is performed
Each team member should be assigned a specific fire management task to perform in the event of a fire
Remove the ET tube, stop the flow of airway gases, douse with saline, etc.
Study showed that the configuration of surgical drapes can result in oxygen build up increasing the risk of fire
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ASA Practice Advisory
Studies show that replacing oxygen with compressed air or discontinuing supplemental oxygen for a period of time will reduce the oxygen build up without reducing oxygen saturation levels
Studies found that lasers, electrosurgical or electrocautery devices are a common source of ignition for many OR fires
Cases found the alcohol based skin prep agents generate volatile vapors that ignite easily
Insufficient drying time is cause of many fires
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ASA Practice Advisory
Studies show that conventional tracheal tubes are more likely to ignite or melt that laser resistant tracheal tubes when exposed to a laser
Dry sponges and gauzes are common sources of fuel
Flammability of sponges, cottonoids, or packing material is reduced when wet
ASA has an operating room fire algorithm
Is it a high risk procedure, are there early warning signs of a fire, airway or non-airway fire
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ASA Practice Advisory
Surgeon should be notified when an ignition source is in proximity to an oxidizer enriched atmosphere or when the concentration of oxidizer has increased
Oxygen delivered to the patient should be as low as clinically feasible when ignition source is in proximity to an oxygen enriched atmosphere
Reduction of oxygen (fraction of inspired oxygen or FIO2) is guided by monitoring the pulse ox
This should include measuring inspired, expired, and or delivered oxygen
Use of nitrous oxide should be avoided in settings that are considered high risk for fire
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ASA Practice Advisory
For laser surgery, the cuff of the ET tube should be filled with saline instead of air
The saline should be tinted with methylene blue to act as a marker for cuff puncture by a laser
For cases involving surgery inside the airway, a cuffed tracheal tube should be used when medically appropriate
Surgeons should be advised not to enter the trachea with an ignition source such as an electrosurgical device
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ASA Practice Advisory
If surgery around the face, head, or neck and sealed gas delivery device is needed then use a cuffed tracheal tube or laryngeal mask
Sealed gas should be considered if exhibits oxygen dependency during moderate or deep sedation
If open gas system is using, such as a facemask or nasal cannula is used, and surgery around face, neck or head, surgeon needs to give notice before ignition source is activated
Anesthesiologist need to stop the O2 or reduce delivery and wait a few minutes before activation of the ignition source
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ASA Practice Advisory
Management of OR fires
Early signs of a fire may be a flame or flash, unusual sounds, odors, smoke, or heat
Halt the surgery
Remove the tracheal tube for an airway fire or fire in the breathing circuit and stop the oxygen
Pour saline into the tracheal tube
If fire in the patient or elsewhere remove all drapes and burning material and extinguish (saline, water, smothering)
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ASA Practice Advisory
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https://ecommerce.asahq.org/p-303-practice-advisory-for-the-prevention-and-management-of-operating-room-
fires.aspx
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ASA Practice Advisory
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https://ecommerce.asahq.org/p-303-practice-advisory-for-the-prevention-and-management-of-operating-room-fires.aspx
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TJC – Sentinel Alert #29
TJC issues Sentinel Event Alert (SEA) 29 on June 24, 2003 on Preventing Surgical Fires
Also issued SEA 17 on Fires in the Home Care Setting
SEA 39 focused on understanding & mitigating fire risks rather than prohibiting patient care products
Discusses how you need all three things of the fire triangle to start a fire
Heat fuel, and oxygen
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www.jointcommission.org/sentinel_event_alert_issue_29_preventing
_surgical_fires/
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SEA 17 Fires in the Home Care Setting
53
www.jointcommission.org/sentinel_event_alert_issue_17_lessons_learned_fires
_in_the_home_care_setting/
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TJC 3 Recommendations Everyone should be aware of the importance of controlling
heat sources by following laser and electrosurgical units (ESU)
Manage fuel by making sure all preps (chloraprep, etc.) have had enough time to dry
Establish guidelines for minimizing oxygen concentration under the drapes
Develop, implement, and test procedures to ensure appropriate response to all surgical team members in the event of an OR fire
Report any surgical fires to TJC, ECRI, FDA, state agency
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TJC Data on Sentinel Events
TJC reported 7391sentinel events from January of 1995 through December 31, 2010
There were 68 fires
TJC evaluated these fires to determine their root causes
The most common root cause was communication which resulted in 33 fires
If a hospital experiences a surgical fire TJC has a matrix which includes which issues should be evaluated
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Root Cause of Fires by TJC
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TJC Sentinel Event Alert 29 Preventing Fires
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www.jointcommission.org/sentinel_event_alert_issue_29_preventing_surg
ical_fires/
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CMS Hospital CoP
Hospitals that accept Medicare or Medicaid reimbursement must follow the hospital conditions of participation
The CoPs requires hospitals to have a safe environment
Tag 702 requires hospital to comply with the LSC National Fire Protection Amendment or NFPA 101
Tag 709 states must ensure life safety from fire
Tag 714 requires the hospital to have written fire control plans that contain provisions for prompt reporting of fires
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www.cms.hhs.gov/manuals/downloads/som107_Appendicestoc.pdf
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CMS Hospital CoP
Must report all fires to the state fire marshal
This would include having procedures to prevent and respond to a surgical fire
CMS has the following on page 327 Tag 951
Use of Alcohol-based Skin Preparations in Anesthetizing Locations. Alcohol-based skin preparations are considered the most effective and rapid-acting skin antiseptic, but they are also flammable and contribute to the risk of fire
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CMS Hospital CoP
CMS also note the following under tag 951
There is concern that an alcohol-based skin preparation, combined with the oxygen-rich environment of an anesthetizing location could ignite when exposed to a heat-producing device in an operating room. Specifically, if the alcohol-based skin preparation is improperly applied, the solution may wick into the patient’s hair and linens or pool on the patient’s skin, resulting in prolonged drying time. Then, if the patient is draped before the solution is completely dry, the alcohol vapors can become trapped under the surgical drapes and channeled to the surgical site.
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CMS Prep Must Be Dry
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CMS Hospital CoP This would include having procedures to prevent and
respond to a surgical fire
CMS issued a memo in 2004 on the procedure to follow in the event of a fire
Fires are to be considered a priority assignment of immediate jeopardy
CMS will consider all fires with serious injury or death to be entered into their computer system as a complaint or self reported incident
State agency will compile information about the fire and perform a life safety code investigation
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CMS Memo
66
http://www.cms.hhs.gov/SurveyCertificationGenInfo/
downloads/SCletter04-23.pdf
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Many Resources to Consider
ECRI Institute
ASA or American Society of Anesthesiologist
APSF or Anesthesia Patient Safety Foundation
AORN Fire Safety Toolkit or Association of periOperative Nurses
TJC Sentinel Event Alert
National Guideline Clearinghouse
MDSR – Medical Device Safety Reports
ASHE
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OR Fires Introduction
Develop a fire safety plan
Make sure OR has appropriate firefighting equipment See later section on use of extinguishers
Focus on education Fires are less likely to occur if they act as a team
And if surgical team understands their causes and how to respond should one occur
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OR Fires Introduction Develop an effective fire drill program
Drills enable the staff to learn the plan and test the effectiveness of he plan
Helps to identify areas of improvement
Schedule drills so surgeon and anesthesiologist can participate
Evaluate performance during surgical fire drill
Have a competency tool for staff
Do an annual literature review and update the policy as needed
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OR Fires Introduction
Have one person assigned to be the OR fire safety officer
Require mandatory education in orientation and during annual skills lab
Do a self assessment on risk of fires
Report all fires and document
Have policies in procedures in effect
Watch the video on preventing fires by A
Whatever you do don’t think this can’t happen to you!
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Fire Risk Assessment
AORN Fire Safety toolkit has a fire risk assessment tool
Circulating nurse completes the risk assessment to determine the risk level
Risk levels include A, B, C, D, or E
Circulating nurse reports this during the time out
The interventions are taken from the policy and procedure for Fire Safety in the Perioperative Setting
It contains actions for each of the risks71
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AORN Fire Risk Assessment Tool
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Fire Risk Assessment
A. Is there an alcohol based prep or other volatile chemical being used?
If yes then prevent pooling of skin prep, removed soaked linen, allow skin prep to dry, conduct skin prep time out, etc
B. Is the surgery being performed above the xiphoid process?
If yes then coat head and facial hair near the surgical site with water soluble lubricant, use adhesive incise drape etc.
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Fire Risk Assessment
C. Is open oxygen being used?
If yes, then configure surgical drapes to allow sufficient venting of oxygen delivered by mask or cannula, deliver 5 to 10 L/min of air under the drapes to flush out excess oxygen, titrate O2 to lowest %, use cuffed ET tube when possible, stop supplement O2 for one minute before electrosurgery, electrocautery or laser for head, neck, or upper chest procedure etc.
D. Is an ESU, laser, or fiber-optic light cord being used?
E. Are there other possible contributors like a defibrillator, drills, saws, burrs etc.
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Prevent OR Fires During Prep
Be aware alcohol based preps are flammable
Avoid pooling or wicking of flammable liquid preps
Allow flammable liquid preps to dry fully before draping
Spilled or pooled agent should be soaked up and removed from the patient
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Prevent OR Fires During Prep Proper application of an incise drape ensures that there are
no gas communication channels from the under- drape space to the surgical site
Remove towels used to catch dripped flammable prep before draping
Keep fenestration towel edges as far from incision as possible
About 4% of all fires are due to alcohol bases surgical preps
These fires are devastating because they are often undetectable
The blue-yellow flame of an alcohol fire can be invisible under the bright surgical lights
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Preventing OR Fires During Electrosurgery Place electrosurgical pencil in holster when not in
use
Place unit in standby mode when not in active use
Allow the electrosurgical active electrode to be activated only by the person wielding it
Activate active electrode only when tip is under surgeon’s direct vision
Deactivate the unit before the active electrode tip leaves the surgical site
Instrument can momentarily retain sufficient heat for fuel ignition
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Preventing OR Fires During Electrosurgery
If open O2 source is use, use bipolar electrosurgery when possible and clinically appropriate since bipolar creates little or no sparking or arcing
Never use electrosurgery to enter the trachea
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Preventing OR Fires During Electrosurgery
Never use electrosurgery in close proximity to fuels in oxidizer enriched atmosphere
Never forget may need to turn off valve for medical gases such as oxygen
Consider the use of non-thermal surgical therapies for cutting and coagulation
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Reducing Likelihood of Airway Fires
Have policy when electrosurgery will be removed from the surgical field because of risk of fire
Some hospitals remove the unit when the trach tube is put on the surgical field
Do not use electrosurgical units to cut tracheal rings and enter the airway
A hot electrode tip or ember could contact the tube or tube cuff inside the trachea and ignite a fire
Instead, use a “cold” scalpel or scissors to avoid the risk of fire
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Reducing Likelihood of Airway Fires
If long, insulated electrosurgical electrode probes are needed to prevent mouth burns during procedures such as tonsillectomies, use only commercially available insulated probes
Do not use red rubber catheters or other materials to sheathe probes
The heat from the active electrode will ignite the rubber even in air
When operating in the oropharynx, scavenge around the surgical site with separate suction to catch leaking O2 and nitrous oxide
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OR Fires in General Coat facial hair (including eyebrows,
beard, and mustache) near the surgical site with water-soluble surgical lubricating jelly to make the hair nonflammable
Be aware of the flammability of tinctures, solutions, and dressings (such as benzoin, phenol, and collodion) used during surgery, and take steps to avoid igniting their vapors
Moisten sponges to make them ignition resistant in oropharyngeal and pulmonary surgery
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Minimizing Fires During Laser Surgery
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https://members2.ecri.org/Components/HRC/Pages/
SurgAn17.aspx
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Prevention of Fires During Laser Use
Lasers are used to cut, vaporize, or remove tissues
Despite their many benefits, lasers can pose some risks such as burns
Patients have been severely burned by laser-ignited fires
Class 4 lasers are considered a fire hazard and produce laser-generated air contaminants
About 10% of all the fires are caused by lasers
Source: ECRI Laser Use and Safety March 2011
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Prevention of Fires During Laser Use
Goal of the surgical fire prevention protocol includes
Minimize or avoid oxidizer (such as oxygen) enriched atmosphere near the surgical site as 75% of the fires occur in oxygen enriched environments
Safely manage the ignition source
Safe manage the fuels
Caution when performing laser surgery in the area of the perineal area such as hair removal surgery
Physicians will pack the rectum with saline saturated gauze to prevent the unintentional expulsion of gases (methane gas is highly flammable)
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Prevention of Fires During Laser SurgeryLimit the laser output to the lowest clinically
acceptable power density and pulse duration
Test-fire the laser onto a safe surface (such as laser firebrick) before starting the surgical procedure to ensure that the aiming and therapeutic beams are properly aligned
Place the laser in standby mode whenever it is not in active use
Activate the laser only when the tip is under the surgeon’s direct vision
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Prevention of Fires During Laser Surgery
Allow only the person using the laser to activate it
Deactivate the laser and place it in standby mode before removing it from the surgical site
Use surgical devices designed to minimize laser reflectance
Never clamp laser fibers to drapes; clamping can break the fibers
Use a laser backstop to reduce the likelihood of tissue injury distal to the surgical site
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Prevention of Fires During Laser Surgery Place wetted gauze or sponges adjacent to the
tracheal tube cuff to protect the tube from laser damage, and keep them wet
Wet any gauze or sponges used with uncuffed tracheal tubes to minimize leakage of gases into the oropharynx, and keep them wet
Keep all moistening sponges, gauze, pledgets, and their strings moist throughout the procedure to render them ignition resistant
Consider the use of towels soaked in saline or sterile water around the operative site to minimize the risk of igniting the towels
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So What’s In Your Policy?
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Magnitude of the Problem
Known fires
•Unreported•Near misses
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ECRI Institute
One of the richest sources
Provide posters “Only You Can Prevent Surgical Fires” ([email protected])
Fighting Fires on the Surgical Patient
Extinguishing Airway Fires
Many materials have an associated cost unless subscriber to Healthcare Risk Control (HRC)
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MDSR (Medical Devise Safety Reports) Excellent tool to be aware of specific equipment-
both the risk and recommendations
Free poster
Offers an “Electrosurgery Checklist”
Examples
– Wrong gas in laparoscopic insufflator
– Excessive illumination during surgical microscopy
– Ignition of debris on active electrosurgical electrodes
www.mdsr.ecri.org/summary/detail.aspx?doc_id=8271&q=
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Medical Devise Safety Report Website
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http://www.mdsr.ecri.org/
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Electrosurgery Checklist
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Can Search OR Fires
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Fire Response Staff should know what to do in response to a fire
If unexpected flash, unusual odors or unexpected smoke
Surgery team needs to halt the procedure
If a fire is confirmed then stop the flow of gases Rapidly remove the burning material
Water or saline fore quenching the fire should be immediately available
Use fire extinguisher if extensive, usually CO2 extinguisher
Take care of the patient98
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Do Fire Drills Previously discussed the importance of doing fire drills
Previous questions were provided that could be asked during the fire drill
AORN fire safety tool kit also has a tool on hospital fire drill scenarios
The scenarios have a corresponding set of roles and checklist
Alert team of a fire, smoother or extinguish, push back table from field, remove burning material, assess for secondary fire, assess patient for injuries, complete incident report, assign person to family members, etc
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Sample Scenarios to Use for Fire Drill
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Surgical Fire
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Fire Extinguishers If airway fire, remove the ET tube and have another
member extinguish it and stop flow of gases
Pour water or saline into the airway and care for the patient
Review poster on fighting surgical fires before each surgical procedure
Fire extinguisher is one of those things that OR staff seldom think about until it is needed
OR fires occur in 3 possible locations In the airway
Fires in or around the patient
Fires elsewhere in the OR102
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https://www.ecri.org/surgical_fires
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Fire Extinguishers
Pull the pin and use sweeping motion at base of fire
Be sure to select the right fire extinguisher
This is decided by National Fire Protecting Agency (NFPA) code and state law
Fires are categorized by NFPA as: A Fires involving ordinary materials like burning paper, lumber,
cardboard, plastics, etc.
B Fires involving flammable or combustible liquids such as gasoline, kerosene, and organic solvents
C Fires involving energized electrical equipment such as appliances, electrical equipment, panel boxes, and power tools.
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Fire Extinguishers
Fires are categorized by NFPA as (continued):
D Fires involving combustible metals such as magnesium, titanium, potassium, and sodium
K Fires that occur in the kitchen
The corresponding labeled fire extinguisher should be used
For airway fires the oxidizer is usually the sole cause so turn the oxygen or nitrous oxide off
Most ET tubes will not continue to burn without the oxygen or other oxizider
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Fire Extinguishers
PVC tubes melt and undergo a depolymerization but does sustain the burning process
Silicone tubes disintegrate into an ash powder
The tube should be removed and the oxygen or other oxidizer discontinued as previously mentioned
Fires not extinguished by the removal of oxidizers can usually be smothered or doused with water
Persistent fires can be eliminated with a carbon dioxide (CO2) extinguisher
Make sure easy to use and readily available106
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Types of Fire Extinguishers
APSF Winter 2011 Newsletter includes information on the types and also how they can cause medical problems
A: Plain water which delivers a stream of water to cool the fire. These are prone to re-ignition and generally not safe to use in the OR because of all of the electrical equipment
AC: Water mist which delivers a fine mist to cool the fire. This is safe for electrical fires because the mist does not allow an arc to be formed which could result in electrocution. Need adequate volume to put out the fire
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Types of Fire Extinguishers
BC: Dry chemical such as sodium or potassium bicarbonate or Co2 which smoothers the fire. Fires extinguished with CO2 are prone to re-ignition and can cause frostbite of the skin.
The dry chemical dust of BC and ABC can cause respiratory irritation. The dust is difficult to remove from moist tissue
ABC: Dry chemical and has ammonium phosphate
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Types of Fire Extinguishers
Halon and halotron: extinguishes the fire by replacing oxygen and cooling and safe for electronic devices
Sensitizes myocardium to catecholamines and can cause lethal arrhythmias
Halon is being phased out because of ozone issues
FE-36 (HFC-23fa): is a clean agent, non-toxic, ozone safe and has no residue but is more expensive
D and K: are only kept in locations where appropriated and highly specific and would be used in places like the kitchen
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Placement of Extinguisher
Should be consistent with the local fire code and NFPA guidelines
NFPA recommends there should be one within 75 feet of any working area
Should be mounted in a consistent location such as near main door and on the left
One hospital has a CO2 extinguisher in every OR room and with the laser cart
A rated extinguisher in the hall cabinets
AC rated water mist for the MRI suite and halon and CO2 in the fire hose cabinet
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Fire Extinguishers
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ECRI Institute Surgical Fires
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Competency Hospital should make sure staff are evaluated on their
competency for fire safety
AORN has a perioperative RN Performance Evaluation Tool for fire safety
AORN members have free access to their fire safety toolkit
Circulating nurse
Reports and documents fire risk assessment
Manages fuel source by preventing pooling of prep solutions, removes prep soaked linen, provides anesthesia a laser resistant coated ET tube
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Competency
Circulating nurse manages ignition sources Keeps active electrode cords free of coils off of sterile field
Places the electrosurgical unit (ESU) dispersive pad on a large muscle close to the surgical site
Inspects ESU or laser electrical cords and plugs for integrity
Uses only connectors or adapters to connect to the ESU which fit securely
Sets the power setting as low as possible to achieve the result
Places light source in standby mode or turns it off when cable is not in active use etc.
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AORN Competency Tool
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Competency Circulating nurse manages oxidizers
Use a pulse ox to determine oxygen level
Titrates oxygen to lowest % to support patient’s needs
Configures drapes to help prevent oxygen accumulation if mask or nasal cannula is used, beneath the drapes
Stops oxygen for 1 minute before using laser or electrosurgery for head, neck, or upper chest when requested
Scrub nurse competencies follow117
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AORN Perioperative Evaluation Tool
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AORN Fire Safety Toolkit
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http://www.aorn.org/PracticeResources/
ToolKits/
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AORN Fire Safety Resources
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Remember the Major Guideline Changes
Remember the major changes in clinical practice for face, neck, head, or upper chest surgery;
Use only air for open delivery to the face, provided that a spontaneously breathing sedated patient can maintain his or her blood oxygen saturation without extra oxygen
Secure the airway by using a laryngeal mask airway or tracheal tube if the patient cannot maintain safe blood oxygen saturation without supplemental oxygen, so that oxygen-enriched gases do not vent under the surgical drapes
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Remember the Major Guideline Changes
Discontinue the traditional practice of open delivery of 100% oxygen with limited exceptions
–Exceptions might include when the patient needs to speak during procedure when oxygen is delivered by a cannula or mask to maintain adequate oxygen saturation
–Might include carotid artery surgery, neurosurgery, and some pacemaker implantations
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In Summary Surgical fires are a preventable hazard
Success requires understanding risks & promoting perioperative communication among all members of the team
Educate staff about OR fire safety
Have a plan to extinguish fire and protect patient and staff
Provide review of fire safety at least annually
Conduct regular drills
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In Summary Ensure staff are competent in fire safety
Surgical Team Communication is vital and include summary in time out
Enriched O2 & N20 vastly increase flammability of drapes, plastics & hair be aware of trapping under drapes
Delay draping until preps are completely dry
Fiber optics can start fires complete cable connections before activating source
Moisten sponges to make ignition resistant in oropharyngeal & pulmonary cases
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In Summary If O2 & N20 are administered during oral or ophthalmic
surgery make hair near operative site nonflammable by thoroughly coating with water-soluble surgical lubricating jelly
Position safety holsters for electrocautery or active electrode in a convenient location and mandate use
During oropharyngeal surgery scavenge deep within oropharynx with separate suction to catch leaking O2 & N20
Soak gauze or sponges used with uncuffed tracheal tubes to minimize gas leakage into oropharynx (keep moistened)
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In Summary
Keep tip of any electrosurgical equipment in plain view
Eliminate the traditional practice of open delivery of 100% oxygen during sedation
Securing the airway is recommended if the patient requires an increased oxygen concentration
Inspect every cable and electrical supply cord before
Update P&P on an annual basis and make sure staff is aware of policy
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In Summary Keep abreast of current literature to be aware of
newly discovered sources for fuel/ignition
Thoroughly analyze any incidents including near misses
Report all fires to the fire marshal
Be aware of the position statements of organizations like AORN and ASA
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The End Questions
Sue Dill Calloway RN, EsqAD, BA, BSN, MSN, JD CPHRM President
Patient Safety and Health Care Consulting 5447 Fawnbrook Lane
Dublin, Ohio 43017 614 791-1468 [email protected]
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Resources
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American College of Surgeon
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http://www.facs.org/about/committees/cpc/oper0897.html
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ASHE Organization associated with AHA
Material covered by other resources
Minimizing Fuel
Risks during skin prep
Be aware and alert to the flammability of alcohol-based preps
Avoid pooling or wicking of liquid preps
Allow liquid to fully dry before draping
Use a properly applied drape (no gas communication channels
Analyzes NFPA and provides Guidance articles
e.g. “Use of Alcohol-based Surgical Prep Solutions”
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Other Factors Increasing Risk
Only metal ones are nonflammable
Endotracheal tubes most made of flammable materials like silicone, rubber, and plastic
Most made of flammable materials like silicone, rubber, and plastic
Only metal ones are nonflammable
Increased use of disposable drapes
Less expensive & more water resistant but burn more readily
– Once ignited burn with alarming speed
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ASHE Website
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http://www.ashe.org/
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SurgicalFire.org
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Resources Petersen C, ed. Perioperative Nursing Data Set. 3rd ed.
Denver, CO: AORN, Inc; 2010.
Recommended practices for electrosurgery. In: Perioperative Standards and Recommended Practices. Denver, CO: AORN, Inc; 2010:105-125.
“Recommended practices for endoscopic minimally invasive surgery.” In Standards, Recommended Practices, and Guidelines. Denver, Co: AORN, Inc; 2010:139-174.
“Recommended practices for laser safety in practice settings.” In Standards, Recommended Practices, and Guidelines. Denver, Co: AORN, Inc; 2010:133-138.
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Resources
Caplan RA, et al. Practice advisory for the prevention and management of operating room fires. American Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology. 2008;108:786-801
National Fire Protection Association. NFPA 10, Standard for portable fire extinguishers. 2011. Chapter 5.2
American National Standards Institute. American national standard for safe use of lasers in health care facilities. ANSI Z136.3 – 2005 C.9.35. Appendix: 52. 2005.
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Resources
ECRI. New clinical guide to surgical fire prevention. Health Devices. 2009;38(10):314-332.
Allen, G. “Evidence for Practice. Laser ignition of surgical drape materials.” AORN J. 2004;80:577-578.
Andersen, K. “Safe use of lasers in the operating room: what perioperative nurses should know.” AORN J. 2004;79;171-178.
Ball, Kay. Lasers: The Perioperative Challenge. Denver, Co: AORN, Inc; 2004.
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Resources
Ossoff RH, Duncavage JA, Eisenman TS, Karlan MS. Comparison of tracheal damage from laser-ignited endotracheal tube fires. Ann Otol Rhinol Laryngol 1983;92:333-336.
DuPont. DuPont fire extinguishants: DuPont FE-36 use as a fire suppressant in surgical operating rooms. White Paper. Jan 2005. Available at: http://www2.dupont.com/FE/en_US/products/fe36.html. Accessed January 6, 2011.
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Resources
Amerex Corporation. ABC dry chemical fire extinguishant. Trussville, AL, June 2010. Available at: http://www. amerex-fire.com/msds/msd/2. Accessed January 6, 2011.
H3R Aviation. Halon 1211. Larkspur, CA, August 18, 2009. Available at: http://www.h3rcleanagents.com/downloads/Halon-1211-Clean-Agents-MSDS.pdf. Accessed January 6, 2011.
National Fire Protection Association. NFPA 10, Standard for portable fire extinguishers. 2010. Table 6.2.1.1.
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Resources
Beyea, S.C. “Preventing fires in the OR. AORN J. 2003;78:664-666.
Flowers, J. “Code red in the OR—implementing an OR fire drill.” AORN J. 2004;79:797-805.
Hogan, C. “Responding to a Fire at a Pediatric Hospital.” AORN J. 2002;75:793-800
Salmon, L. “Fire in the OR—prevention and preparedness.” AORN J. 2004;80:41-52.
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Resources
McCarthy, PM, Gaucher, KA. “Fire in the OR—developing a fire safety plan.” AORN J. 2004;79:587-594.
Smith, C. “Surgical fires—learn not to burn.” AORN J. 2004;80:23-34.
Stewart, D. “Fire and life safety for surgical services: What’s new and what to review.” Surgical Services Management. April 2003; 26-31.
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