HOT TOPIC Surgical teams at University of Michigan Hospitals discuss the details of specific fire risks during pre-op time outs.

A dry sponge igniting during facial surgery. An alcohol-based prep igniting. A light source singeing a surgical drape. These are all incidents that could occur anywhere and are the types of scenarios we had in mind when we improved our fire safety protocols. Recently, we've revamped our fire assessments that occur during pre-op time outs. Check out how the new system works to see if it would help to better protect patients in your facility.

Most facilities classify cases at high-, medium- or low-risk for fire. Working off that policy, staff assign a rating during the pre-op time out and never think about it again. In our minds, the conventional rating system isn't effective enough. Staff are too quick to classify a procedure and don't address the reasons behind the score. What makes a case high-risk? What elements gave it a high rating? The reasons are rarely discussed and almost never challenged. That way of doing things makes it too easy to check off the fire safety box on the time-out checklist without addressing specific causes for concern.

We've gotten away from using the fire-risk rating system. Instead, the surgical team talks about the specific risks for the case and discusses what preventative measures will help lower those dangers. Anesthesia, surgeons, scrub techs and nurses participate, taking turns leading the conversation, because each discipline is responsible for managing various elements of the fire triangle. Here are 5 factors that will help guide the conversation:

Fuels. A nurse notes if flammable liquids are on the field and alerts the team if an alcohol-based prep was used. If it was, she confirms that enough time passed for it to dry.

Timing of use. A nurse indicates if flammable agents will be introduced later in the case (see "Store Flammable Agents in Red Bins").

Ignition sources. The surgeon identifies ignition sources he plans to use. The scrub person will confirm that a holster for the device is present and simple saline is on the field. They both discuss precautions that will prevent any sort of ignition-source-related incident.

Procedure location. The surgeon and anesthesia provider alert the team if the procedure will be performed above the xiphoid or with any planned breach of the airway or pleural cavity, locations where the elements of the fire triangle could easily combine.

Oxidizing agents. The anesthesia provider discusses the potential for an airway leak, warns the team if open oxygen delivery is planned and discusses the need to tent drapes to prevent oxygen buildup.

Growing awareness
Our revamped protocols alert staff and surgeons to potential issues at the beginning of the case, but also help ensure they follow through on the concerns during the procedure. There are no guarantees, but we believe a richer, fuller discussion brings more attention to the true dangers of surgical fires.

We rolled out the enhanced time-out process last December with educational in-services conducted across the health system. We streamed a how-to video to 6 hospitals where anesthesia providers, surgeons, nurses and scrub techs reviewed the video on the same day.

Once the revamped fire safety protocols went live, staff champions who were involved in the planning of the new protocols swarmed the ORs to observe time outs and coach surgical teams on what we wanted to see happening. We gave the teams a few weeks to get their feet wet before auditing their performances.

A champion reported back that one of the surgeons took the enhanced time out a step further by asking his team if they knew where the nearest fire extinguisher was stored. That was a great question, and something we'll address moving forward as we consider whether to add fire response to the list of safety topics discussed during time outs.

Fire events are rare, but they do occur. And when they do happen, you can trace the causes back to the presence of each element of the fire triangle. It's not that surgical teams don't care about fire safety, but perhaps they're not fully aware of the risks. We hope our improved protocols change their perspectives.

CODE RED
Store Flammable Agents in Red Bins

STOP AND THINK Red bins remind staff about the dangers of flammable agents.

To give staff pause when they bring flammable agents to the sterile field, store the items in red plastic bins and away from all other supplies. The red bins serve as a visual cue for whoever pulls the items for use. Hopefully, they'll remember to alert the surgical team that a flammable agent is entering the sterile field and all ignition sources should be shut off or disconnected — whatever needs to be done to break the fire triangle. Staff should not pick flammable items before cases. The point is to have the circulator retrieve them as needed, especially if it's later in a case, so she stops to think about the dangers involved and warns the surgical team.

— Paula Marentay, RN, CNOR