It seems simple enough. You see flames, pull the fire alarm, call 911 and evacuate the area. Easy, right? Wrong. Never assume your staff understands all they need to know about fire safety. Here's advice on running a tabletop fire drill and then following that up with a mock fire drill.

Reacting when a crisis hits
During tabletop drills, divide staff according to their primary roles in the OR (see "R-A-C-E-E Against Time" on page 57). Provide each group with cards that outline their position's responsibilities in the event of a surgical fire. Encourage them to work together to develop a sense of teamwork and to refer to their role cards to build confidence in your fire drill policies. Tabletop discussions are largely effective for getting staff to think about fire safety, but minimizing reaction times during a fire event won't be as simple as working through code red scenarios in a conference room. You need to test staff on the floor, where they'll be reacting when a crisis hits.

Set aside about an hour of in-service time for a mock fire drill and advertise the event to staff, letting them prepare for their first on-the-floor test. Divide your surgical teams and assign them to individual suites, where safety team members and OR leadership will facilitate the action. Give the facilitators identical worksheets listing code red scenarios to ensure the entire surgical staff is evaluated under standardized testing conditions. Have OR teams complete anonymous surveys after the drill, giving them a non-punitive forum for providing the feedback that you'll use to measure their education progress and identify areas of needed improvement. Our surveys revealed a growing confidence across clinical teams. They demonstrated the knowledge and ability to act appropriately during fire emergencies. Their toughest test, however, was still to come.

Raise the stakes
Plan a real fire drill for a date and time known only to high-level management. Ask your local fire department to assist in the planning and evaluation of the drill. They should be more than happy to promote fire safety, and their participation will improve the drill's effectiveness and give it added credibility.

Write down a specific scenario and deliver it to the OR supervisor to start the drill's chain of action. We gave our OR supervisor a note that read: "This is the real fire drill. Do not let anyone else know this is a drill. Assign a circulator and scrub team member to go directly to OR No. 4 and begin preparing for an emergency case that has just been added. Supplies for the case have already been pulled and are in the room. The doctor wants to begin as soon as possible. Send one other person (RN, scrub tech or clinical assistant) to assist them in their preparations."

Your fire committee and a staff volunteer playing the role of the patient should greet the unsuspecting clinical team when they arrive at the designated OR. Set up the back table with the equipment and supplies the staff would use during an actual case. Place paper flames where you want the mock fire to "burn." Announce the case details, relay the fire scenario and ask the surgical team to respond.

Let's say a fiber optic light cable ignites a sponge on the patient. The surgeon should immediately try to smother the fire with a wet towel. The anesthesia provider must stop the flow of oxygen and convert to room air until the fire is under control. The scrub tech needs to grab a saline-water mix from the back table and pour it onto the fire, smother it with wet towels and push the back table away from the sterile field. The circulator should activate (or delegate activation of) the fire alarm, page other staff members and extinguish burning materials. And the OR supervisor needs to pull the fire alarm if it hasn't already sounded, help the anesthesia provider turn off the oxygen, direct personnel to close all OR doors, unplug electrical devices, grab a fire extinguisher if it's needed and inform the nurse manager and surgical department director of the fire event.

What if the fire rages out of control, smoke fills the OR and the patient needs to be evacuated? The anesthesia provider should tell the circulator to close the oxygen shut-off valve, announce the need for evacuation, disconnect the breathing circuit from the patient, turn off the oxygen flow and convert to room or medical air, and release the surgical drapes. The surgeon must cover the open wound with a sterile barrier drape or sterile towels, and help move the patient from the surgical table to a predetermined evacuation area (an empty OR or PACU bay, for example). The scrub tech is charged with helping the surgeon cover the open wound and the staff with moving the patient. The circulator should disconnect the patient from all equipment, activate the fire alarm, send a page for help, notify the OR supervisor and file an incident report. And the OR supervisor must notify the surgical manager and other personnel, assess possible evacuation destinations, decide on a location and alert staff in that area of the impending arrival of the evacuated patient.

Debrief
After the drill, meet with the fire committee and participants to identify and learn from missed opportunities. Here are the issues we needed to reinforce during follow-up staff education sessions.

• Dial the appropriate number. Make sure staff know whom they need to call to set your facility's code red wheels in motion. Sounds like a basic task, but it's not. Our staff must dial "66666" to reach the hospital's operator, who knows that calls to that extension necessitate an immediate overhead code red page. We discovered that OR teams had dialed outside to 911 or 0 to reach the switchboard operator. Both actions delayed our hospital's emergency response when seconds mattered most.
• Delegation increases efficiency. Circu-lators are charged with pulling the fire alarm in our code red protocols. They can delegate the task, but not the responsibility. If they pass the buck, they must follow up to ensure the fire alarm has been activated.
• Know how equipment operates. Make sure every member of your surgical staff knows how to unlock and move OR tables at a moment's notice. Also review and understand how tables and other equipment work during power failures.
• Post room evacuation signs. Hang laminated, double-sided (one side white, the other neon orange) cards outside each OR, white side up. When a room is empty staff should flip the cards, displaying the neon-orange side. This simple system eliminates repeatedly checking the same room to ensure the area has been evacuated.
• Open communication with other ORs. Surgical supervisors are invaluable assets during fire emergencies. They're in position to coordinate evacuations and assist where and when they're needed most. They also manage the influx of support personnel arriving in response to code red overhead pages. But supervisors can help only if they're notified of a fire event. We noticed that our staff failed to alert floor supervisors during fire drills, eliminating the possibility of receiving help from key surgical leaders.
• Create a mechanism for accounting. Review the surgical schedule before evacuating so you can ensure all patients and staff are accounted for at a predetermined outside rendezvous. For example, our staff meets for roll call at the hospital's heliport.
• Check fire alarm pull stations. Fire drills offer the opportunity to check the functioning of alarm pull stations. They also give staff the chance to pull fire alarms, a task that requires more force than you might think.

Constant state of readiness
The basic elements of the fire triangle — ignition source, fuel source and oxidizer — are present in every OR, every day. But the triangle's danger potential is easy to overlook in the hustle and bustle of a busy surgical schedule. Avoid the complacency that can hamper your preparedness for a fire event and slow reactions during code red emergencies. Follow this advice to ensure your surgical teams rely on learned responses and focus on specific roles and practiced responsibilities when adrenaline rushes blur the line between rational and irrational decision making.