Fighting fire with preparation
Preventing fires in the operating room and being ready in the event that one occurs are equally important aspects of a good fire safety program
By Kimberly Retzlaff
Associate Editor, AORN Journal
Fire safety is of the utmost importance in the surgical environment, in the interest of protecting patients and healthcare workers alike. The truth is that no surgical environment—including long-term, acute care and outpatient facilities—is invulnerable to fire risk. By arming healthcare personnel with knowledge and preparing them for the possibility of fire in the operating or procedural room, healthcare facilities can help prevent fires and reduce the risk of harm if one breaks out.
Fire is an ever-present risk in the surgical arena. Knowing how to respond in the event of a fire can be the difference between a minor flare-up and a serious adverse event. Photo courtesy of the ECRI Institute. Used with permission.
By the numbers
About 550 surgical fires occur in the United States each year, according to the most recent data from the ECRI Institute. This number was extrapolated from three years’ worth of data from the Pennsylvania Patient Safety Reporting System (PA-PSRS).
These numbers represent the first ever hard data of surgical fire occurrence, according to Mark Bruley, a biomedical engineer and vice president for accident and forensic investigation at the ECRI Institute, who has been investigating surgical fires, teaching and publishing about them for more than 30 years.
About 95% of surgical fires are minor, Bruley added, but about 30 or so result in serious injury or disfigurement and one or two are also fatalities.
The new data from the PA-PSRS and the ECRI Institute prove what Bruley believed all along and reported to Claire Everson (member of AORN board of directors) in 2005 when AORN released its Fire Safety Guidance Statement and Fire Safety Tool Kit: that surgical fires are underreported, and the previous estimates of 50 to 100 surgical fires per year were much lower than the actuality.
Changing oxygen use practices
Because of the increased risk of fire in oxygen-enriched environments, the ECRI Institute and the Anesthesia Patient Safety Foundation (APSF), supported by funding from the American Society of Anesthesiologists (ASA), have joined forces to promote significant changes to practices in the surgical environment this year.
“Open delivery of 100% oxygen is no longer recommended for surgery of the head, neck, face and upper chest with only a few limited exceptions,” Bruley explained. “This is a major change in clinical practice that is being advised because oxygen enrichment is one of the greatest causes of medical fires historically.”
The APSF is expected to officially roll out the new recommendations in a video produced by the ECRI Institute at the ASA’s October meeting. The ECRI Institute also is updating its educational poster, Only You Can Prevent Surgical Fires, which is scheduled for release this October.
An oxygen-enriched environment is when the oxygen level in the air goes above 21%, which can be created when a patient is given oxygen through a nasal cannula or disposable mask. The flowing oxygen can build beneath the drapes, increasing the oxygen in the air and, therefore, the fuel for fire.
“The fundamental issue is that as long as a spontaneously breathing, sedated patent can maintain their blood oxygen saturation without extra oxygen, then giving them medical grade air is what is indicated—not 100% oxygen,” Bruley added.
Awareness is key
Being aware of situations when oxygen levels are high enough to increase the risk of fire is imperative, particularly when other factors converge to increase that risk even more. Recognizing what’s known as the fire triangle is key to fire prevention in the operating room, said Joan Blanchard, RN, MSS, CNOR, CIC, a perioperative nursing specialist in the AORN Center for Nursing Practice.
The fire triangle comprises the three elements that support combustion: an ignition source, an oxidizer and a fuel source. All of these things are present in the OR. Ignition sources include electrosurgical units and lasers, and the main oxidizers in the OR are oxygen and nitrous oxide. Fuel can be almost anything, including drapes, linens and alcohol-based prep agents.
“If a hospital or ambulatory surgery facility is using [alcohol-based skin preps], a really important part of the fire safety plan has to be on making sure those preps have been evaporated before the drapes are put on,” said Victoria Steelman, PhD, RN, CNOR, FAAN, an advanced practice nurse at the University of Iowa Hospitals and Clinics, Iowa City, Iowa. Steelman also said that any drapes or sheets that have prep solution on them be removed before the case starts, and that everyone discuss the fact that a flammable agent is being used.
“One of the best things the perioperative nursing staff can do is help encourage preoperative communication—essentially, a surgical fire ‘Time Out’,” Bruley said.
A fire safety Time Out can be as simple as asking if there are any special considerations for surgical fire for the patient, Bruley added. If the answer is yes, then the team can talk about how to minimize risk, such as the anesthesia professional and the surgeon discussing the temporary cessation of supplemental oxygen while the electrosurgical unit is being used.
Practice makes perfect
Participating in fire drills at their facility has helped increase staff member confidence in what to do during a fire, Steelman said. The practice also has resulted in improvements to the fire safety measures in their facility.
As many as 120 staff members from nursing, surgery, anesthesia, housekeeping and sterile supply participate in quarterly drills, said Rachel A. Hottel, RN, MSN, CNOR, an advanced practice nurse at the University of Iowa Hospitals and Clinics. They practice everything they would have to do in an actual fire during these drills: shutting off the oxygen in the operating room, locating saline or water on the field to douse a small fire, dialing the hospital operator and pulling the fire alarm. They also practice full-scale evacuations.
By holding regular fire drills and having staff members actively participating, “It becomes almost second nature to the staff,” Hottel explained.
Staff members at the Iowa facility also practice using fire extinguishers and are taught about the difference between carbon dioxide and water fire extinguishers. Water fire extinguishers cannot be used on electrical fires, for example.
Promoting fire safety
Nurses can promote fire drill participation at their facilities, and it helps to have a physician champion, Blanchard noted. Blanchard also recommends the AORN Fire Safety Tool Kit to help raise fire safety awareness within health care facilities. The kit contains tools to help meet everyday practice needs, help with annual competencies for evacuation planning and fire drills, and raise awareness for communication and collaborative planning.
Other ways to promote fire safety knowledge is to have quizzes or host tours of the department, asking personnel to observe for fire safety issues such as doorways or hallways that are blocked with equipment, Blanchard added.
Ultimately, being aware of fire risk is the most important step to take in planning for and preventing fires. “Feeling vulnerable is very important,” Steelman said. “It can happen to you, it can happen in your OR or your OR suite. If you feel vulnerable, you’re more willing to learn and be prepared.”
Be sure to look at the Patient Safety First column in the October issue of AORN Journal for more on fire safety.
Additional Resources
AORN Fire Safety Tool Kit
Pennsylvania Patient Safety Authority
Practice Advisory for the Prevention and Management of Operating Room Fires
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