HALLWAY HUDDLE Chief of Anesthesia Brad Williams, MD, Assistant Nurse Manager Jessica Haury, RN, BSN, and Chief of Surgery Mark Homra, MD, discuss fire risks before patients are brought back to the OR.

The estimated 550 to 650 surgical fires that occur each year are entirely preventable, but there's no national standard that requires surgical teams to discuss fire risks before every patient is taken to the operating room. Until there is, take the lead by having your pre-op nurses assess patients' fire risks using the following 5-point questionnaire, with 1 point assigned to each "yes" answer:

Scores of 0 or 1 indicate a low fire risk, a score of 2 indicates a medium risk and scores of 3 to 5 indicate high risks. But ticking off the risk assessment is not enough. What do the answers to the yes-or-no questions really mean? Before high-risk patients are brought back to the OR, the operating surgeon, anesthesia provider and circulating nurse should huddle to discuss what must be done to minimize the specific dangers.

Bring the high-risk alert up again during the pre-op time out in the OR, where you should discuss the specific reasons for the warning. That will put each member of the surgical team on notice. Instead of assuming proper safety protocols are followed, the surgical team confirms it will happen (see "Managing the Fire Triangle").

ROLES IN THE ROOM
Managing the Fire Triangle

Scrub tech >> Ignition sources

• defibrillators
• electrosurgical units
• fiber-optic lights
• high-speed burrs
• lasers

Anesthesia >> Oxidizers

• gases
• open oxygen sources (masks, nasal cannulas)
• closed oxygen sources (endotracheal tubes, anesthesia circuits)

Circulating RN >> Fuels

• body hair
• alcohol-based preps
• drapes
• dry sponges
• intestinal gases

Simply having the discussion before surgery heightens the awareness among all disciplines of the surgical team. Members of the team who are fully engaged in the procedure and aware of the fire potential will observe the surgeon's actions and intervene if necessary. They must also confirm that a saline-water mix is on the back table, identify locations of nearby fire extinguishers and ensure each member knows just what to do if a fire starts. For example: The anesthesia provider immediately stops the flow of oxygen and removes the endotracheal tube; the surgeon shuts off the surgical energy device and pulls the drapes off the patient; and the scrub tech grabs the saline-water mix from the back table to douse the flames and pushes the table away from the sterile field.

Engaged and aware
Fire risk assessments are needed most, but often overlooked, when the surgical procedure is above the xiphoid or in the oropharynx. These cases demand open communication between the surgeon and anesthesia provider; the surgeon must indicate when he's going to activate an energy device so the provider can stop the flow of oxygen. Nurses who are aware of fire risks are more alert and focused on each step of the case to ensure that open communication exists.

In the midst of a procedure, surgeons understandably zero in on the task at hand and may not be fully aware of actions that increase fire risk as the procedure progresses. It's up to the other members of the surgical team to ensure the components of the fire triangle remain separate and inert. Challenge beliefs that a fire can't happen in your ORs, educate every staff member about fire safety, and adapt and respond to constant change in the OR that creates different fire risk scenarios. Patient safety is your top priority.