Prevention and Management of an OR Fire

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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 sdill1@columbus.rr.com

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

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

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

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

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

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

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

Oxidizers

Anesthesia usually bring the oxidizers

Oxygen-enriched atmospheres

Nitrous oxide

Medical compressed air

Ambient air

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

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.

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

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

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/

SEA 17 Fires in the Home Care Setting

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www.jointcommission.org/sentinel_event_alert_issue_17_lessons_learned_fires

_in_the_home_care_setting/

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/

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

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

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http://www.cms.hhs.gov/SurveyCertificationGenInfo/

downloads/SCletter04-23.pdf

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

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

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

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

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

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

Minimizing Fires During Laser Surgery

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https://members2.ecri.org/Components/HRC/Pages/

SurgAn17.aspx

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

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

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

So What’s In Your Policy?

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Magnitude of the Problem

Known fires

•Unreported•Near misses

ECRI Institute

One of the richest sources

Provide posters “Only You Can Prevent Surgical Fires” (info@ecri.org)

Fighting Fires on the Surgical Patient

Extinguishing Airway Fires

Many materials have an associated cost unless subscriber to Healthcare Risk Control (HRC)

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=

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

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

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

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

AORN Perioperative Evaluation Tool

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AORN Fire Safety Toolkit

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http://www.aorn.org/PracticeResources/

ToolKits/

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

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

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)

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

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 sdill1@columbus.rr.com

Resources

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American College of Surgeon

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http://www.facs.org/about/committees/cpc/oper0897.html

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”

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

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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