Guidelines mean you'll be held to new standard of care for fire prevention
Guidelines mean you'll be held to new standard of care for fire prevention
Do you think surgical fires happen a lot less often than wrong-site surgery or retained instruments? Think again. There are about 550-650 surgical fires in the United States each year, which is generally comparable to the number of wrong-site surgery and retained instruments, according to the ECRI Institute in Plymouth Meeting, PA. For this reason, ECRI has released new surgical fire prevention guidelines that change the standard of practice for delivery of 100% oxygen during surgery of the head, face, neck, and upper chest.1
In just-released research at the annual meeting of the American Academy of Otolarngology — Head and Neck Surgery (AAO-HNW),2 one-fourth (25.2%) of the 349 otolaryngologists studied had witnessed an OR fire during their careers. Several had witnessed multiple fires; some had seen as many as five.
When there is a fire during surgery, patients can be killed, staff can be injured, and critical equipment can be damaged, ECRI warns. This warning carries new weight after the recent death of a 65-year-old Illinois woman days after being burned by a flash fire that occurred during a biopsy on the side of her head. The Tennessee state medical examiner's office said the patient died of complications from thermal burns and classified her death as accidental. According to an investigative report from the Illinois Department of Public Health, the patient used oxygen at home.3 "While being prepared for outpatient surgery, the patient had respiratory difficulty," the report said. "Therefore, she was switched to an O2 mask at 10L and placed in a sitting position."
The medical record doesn't say that, per procedure, the surgical drapes were tented to vent the gas, according to the investigative report. The record says the surgeon noticed a small "bleeder" and used cautery. According to the anesthesia documentation, quoted in the report, "It became apparent that the surgeon was rapidly removing the drapes, face mask and other coverings off the patient and that the patient's hair and gown were burning." The patient received second-degree burns on the face, neck, and upper chest. The state's findings will be submitted to the Centers for Medicare & Medicaid Services. The city fire chief also is investigating.
About 75% of surgical fires are oxygen-enriched fires, including those from oxygen buildup under the drapes, oxygen-enriched fires in the airway, and oxygen-enriched fires during open chest surgery, according to Mark Bruley, CCE, vice president of accident and forensic investigation., ECRI Institute.
Previous lawsuits filed after surgical fires have resulted in up to $4 million awards for patients or their survivors, Bruley tells Same-Day Surgery. Surgical fires are ranked third in ECRI Institute's list of Top 10 Technology Hazards, behind endoscope cross-contamination and alarm hazards. George A. Hettenbach, MS, hospital safety manager at the Hospital of the University of Pennsylvania, Philadelphia, says, "We're starting to load ORs with a lot of technical equipment — electrical support equipment, such as monitors. We get new electrical devices and cameras to record, computers in the OR. It's a lot of equipment."
Lasers and electrosurgical devices are most likely to cause OR fires, according to the research from the AAO-HNW.2 Most of the fires (81%) that were studied occurred when supplemental oxygen was being used, and the most common sources of ignition were electrosurgical units (59%), lasers (32%), and light cords (7%).
Several procedures are considered high risk for fire because an ignition source might be close to or within an oxidizer-enriched atmosphere, according to the American Society of Anesthesiologists. These procedures include tonsillectomy, tracheostomy, and removal of laryngeal papillomas, ECRI says.
Consider taking these steps to avoid a fire:
• Discontinue open delivery of 100% oxygen during surgery of the head, face, neck, and upper chest, except for certain limited exceptions.
Providers don't always realize that oxygen-enriched atmospheres, in which the oxygen concentration exceeds 21% by volume, are a fire risk during surgery in the airway or around the head, face, neck, or upper chest, ECRI says. Forty-four percent of surgical fires occur on the head, face, neck, or upper chest, according to ECRI.
When fire is ignited in an oxygen-enriched atmosphere, it has increased heat, vigor, and intensity, ECRI says. Some materials, such as the polyvinyl chloride (PVC) plastic in tracheal tubes and in other devices, will burn or sustain a flame in oxygen-enriched environments, it says.
If supplemental oxygen is needed during surgery of the head, face, neck, and upper chest, the airway should be secured through intubation or the use of a laryngeal mask airway to prevent oxygen-enriched gases from venting under the surgical drapes, ECRI says. [A free fire prevention poster that summarizes the new ECRI guidelines is available.]
ECRI adds to its warning by saying ambient air can support the combustion of many potential fuels. Also, some materials are flammable in atmospheres of less than 21% oxygen, it says. For example, the red rubber used in medical equipment will ignite and burn in just 17% oxygen, according to ECRI.
Nitrous oxide also can be dangerous, the group warns. "For all intents and purposes, the fire hazards during surgery in N2O-enriched atmospheres should be considered as equal to those of oxygen-enriched atmospheres," ECRI wrote.1
Medical air is not oxygen-enriched at ambient pressure when it is delivered to the patient, the guidelines emphasize. (Editor's note: The ECRI guidelines list options for blending oxygen during exceptional surgical cases in which open oxygen delivery is essential.)
• Make a fire risk assessment part of the timeout.
Increasingly, providers are adopting a fire risk assessment as part of the time out, says Donna S. Watson, RN, MSN, CNOR, ARNP-BC, senior clinical educator at Covidien, a health care products company in Boulder, CO, and former president of the Association of periOperative Registered Nurses (AORN).
The most widely implemented is the fire risk assessment tool developed by Christiana Care Health System in Newark, DE, Watson says. The surgical team assesses fire risk including the use of alcohol-based skin prep solutions and the use of open oxygen sources on the face.
Commenting on the first risk assessment as part of the timeout, Judith Townsley, RN, MSN, CPAN, director of clinical operations for perioperative services, Christiana Care, says, "We were the first in the country to do it." The system was developed after the health system experienced two surgical fires. It was developed by one of their anesthesiologists, and he and Townsley worked together to incorporate the assessment into the timeout, she says.
Watson says, "The system is easy to use and communicates awareness of the fire risk potential by assigning a score of 1 to 3." [A copy of Christiana's fire safety procedure policy, which includes the risk assessment tool, along with the health system's Surgical Safety Team Communication poster, is available.]
• Limit concentration of oxygen under surgical drapes, when medically appropriate.
Ambulatory surgery centers and office-based surgery programs accredited by The Joint Commission are surveyed on a National Patient Safety Goal related to surgical fire prevention. The goal requires establishing "guidelines to minimize oxygen concentrations under drapes" and specify education for all surgical staff on "how to control heat sources and manage fuels."
Although these goals are specifically applied only to ambulatory care programs and office-based settings, hospitals also are encouraged to meet those goals, according to ECRI.
A common misconception is that disposable surgical drapes are more flammable than reusable fabric drapes, Bruley says. In fact, all surgical drapes are flammable, he says.
The Accreditation Association for Ambulatory Health Care (AAAHC) requires each facility to maintain its own emergency plan that includes education, training, and at least four annual drills. Facilities must complete a written evaluation of each drill and include any correction or modification to its emergency plan.
The most important thing you can do to prevent surgical fires? Teach your staff, according to experts interviewed by Same-Day Surgery.
Watson says, "In order to eradicate surgical fires, it is essential to educate and train every member of the perioperative team on contributing factors, etiology, and fire prevention strategies."
References
- ECRI Institute. New Clinical Guide to Surgical Fire Prevention. Health Devices 2009; 38:314-332.
- Smith LP, Roy S. What Causes Operating Room Fires? 2009 American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) Annual Meeting & OTO EXPO. Oct. 6, 2009.
- Department of Health and Human Services. Statement of Deficiencies and Plan of Correction. Marion, IL: Heartland Regional Medical Center; Sept. 17, 2009.
Resources
- The new guidelines on prevention of surgical fires are available in the October 2009 issue of Health Devices. The cost of that issue is $285, including shipping and handling. To order, go to www.ecri.org/Products/Pages/Health_Devices_Journals.aspx.
- ECRI institute has a new surgical fire web site at www.ecri.org/surgical_fires that includes a free poster on extinguishing a surgical fire.
- A web site dedicated to surgical fire education and prevention was developed by the daughter of a seriously burned patient. Web: www.surgicalfire.org.
- The Anesthesia Patient Safety Foundation (APSF) is developing a free educational video on surgical fire prevention and management that, at press time, was due to be released in late 2009 at www.apsf.org/resource_center/educational_tools/video_library.mspx. The accompanying online course will be released soon afterward. Continuing medical education credits will be available. Early next year APSF will provide an e-learning course for CME credit on the web. That e-learning course will be an expanded version of the soon-to-be-released video.
- Covidien offers resources on "Fire Prevention and Safety during Surgical Procedures" including live educational programs and CDs. A study guide is being developed. There usually is no cost for these resources. The reader can access the Valley Lab Institute of Clinical Education at www.valleylab.com/education/index.html. To learn more about the educational services, contact the Clinical Education Department at (800) 255-8522, ext. 6740. E-mail: [email protected].
Skin prep solution must be dry first The accidental ignition of flammable vapors from alcohol cleaning agents that have not fully dried causes about 5% of surgical fires, according to ECRI Institute.1 "If an alcohol-containing skin prep solution is still shiny, it is likely still wet, and draping should not be started," says Mark Bruley, CCE, vice president of accident and forensic investigation, ECRI Institute. The National Fire Protection Association (NFPA) 99 — 2005 edition recommends a time out for flammable prepping solutions to assess that the site is dry prior to application of drapes, to ensure no pooling has occurred or been corrected, and for removal of any materials saturated with the prepping solution, says Donna S. Watson, RN, MSN, CNOR, ARNP-BC, senior clinical educator, Covidien health care products company in Boulder, CO, and former president of the Association of periOperative Registered Nurses (AORN). George A. Hettenbach, MS, hospital safety manager at the Hospital of the University of Pennsylvania, in Philadelphia, warns, "Drying time in one OR might be different from another, based on humidity and temperature." Reference
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