The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) recently called on hospitals and ambulatory surgery centers to reduce the risk of serious and deadly fires in operating rooms with its set of "7 Absolutes" to help you educate operating room (OR) staff.
The JCAHO bulletin advises that such fires are significantly underreported and are preventable. Of the more than 23 million inpatient surgeries and 27 million outpatient surgeries performed each year, fires break out in surgical suites an estimated 100 times a year, resulting in up to 20 serious injuries and one or two patient deaths, based on data from the Food and Drug Administration and other sources. Despite these figures, JCAHO’s patient safety reporting database includes only two such cases since 1996.
Heat, fuel, and oxygen, known as the fire triangle, are in abundance in operating rooms across America, says Mark Bruley, vice president for Accident and Forensic Investigation with ECRI, the nonprofit medical safety organization in Plymouth Meeting, MA. "The basic elements of a fire are always present during surgery and a misstep in procedure or a momentary lapse of caution can quickly result in a catastrophe," Bruley says.
These dangers mean that each member of the surgical team — the surgeon, the anesthesiologist and the nurses — must work to manage their specific side of the fire triangle to avoid danger. JCAHO’s alert recommends that health care risk managers help prevent surgical fires by educating staff members about the importance of controlling heat sources by following laser and electrosurgical unit safety practices. JCAHO also suggests managing potential fire fuels by allowing sufficient time for patient prep and establishing guidelines for minimizing oxygen concentration under the drapes.
Surgical fires getting more attention
The warning about surgical fires is the latest in a series of patient safety alerts issued by JCAHO. Previous alerts have focused on hospital-acquired infections, wrong-site surgery, deadly medication mix-ups, patient suicides, infant abductions, and fatal falls among the elderly.
Surgical fires have not increased, but they are getting more attention now as part of the medical community’s overall emphasis on adverse events and reporting, says Remar Thorsness, RN, BSN, MB, director of nursing leadership, at VHA in Minneapolis. She teaches a fire safety course to VHA members. Many more near misses are coming to light, she says. "The worst fires are publicized in the media, but those are only a minor indicator," Thorsness says. "There are so many more that we never hear about, including plenty of close calls in which a small fire was extinguished immediately."
When educating OR staff about fire safety, Thorsness says you should teach them about ignition sources, combustible materials, and methods for fighting fires. Cautery devices start most surgical fires, she says. Other ignition sources include lasers, high-intensity fiber optic light sources, defibrillators, and drills. Flammable materials include alcohol prepping agents, surgical gowns, drapes, hoods, and masks.
The most typical surgical fire involves electrosurgery (ESU) tool igniting drapes when it is inadvertently fired. That initial fire can spread quickly and be fed by other fuel sources such as sponges, gauze, gowns, adhesive tapes, huck towels, prep solutions, alcohols, hair, and ointments.
Another danger comes from the oxidant-enriched atmosphere created when anesthesia compounds become entrapped in airways, catheters, tracheostomy tubes, anesthesia circuits, breathing tubes, masks, drapes, gastrointestinal tracts, and bowels. Combustible gases don’t pose as much of a risk as you might think, Thorsness says, because people think of them as inherently flammable, unlike much of the material in the OR. Many of the hazards associated with combustible gases also are addressed with engineering precautions.
"Two preventive measures that are very important are color-coded fire extinguishers and fire blankets available in the OR," Thorsness says. "Those are things that were not routinely there before. That can be your opportunity for big improvement in this area."
7 steps that sharply reduce risk of OR fires
Thorsness urges risk managers to teach VHA’s 7 Absolutes for fire prevention. If these measures are followed day in and day out, you can avoid most OR fires and respond well to any that do happen, she says:
- Apply the dispersing electrode (ESU plate, grounding plate) to a dry, clean, muscular, hair-free area as close to the surgical site as possible.
- Ensure proper application of and appropriate drying of all potentially flammable prep solutions or aerosols.
- Clear the prepped area of any pooled prep solutions and any prep-soiled products.
- For procedures involving the airway, inflate the endotracheal tube with methylene blue-tinted water or saline regardless of whether the heat source used is the ESU or laser. (When working near tube, the dye helps clinicians see the tube better so they don’t get too close.)
- Place drapes in manner that allows for venting of gas to prevent oxidant (O2, N2O) accumulation, leading to an oxidant-enriched environment for an errant arc or spark.
- Ensure that a basin of sterile water/saline is readily available and in near proximity to the surgical site for emergency quenching.
- Ensure that a fire blanket is available and confirm that an appropriate fire extinguisher is readily available in each operating room (or in close proximity to each operating room).
The Joint Commission on Accreditation of Healthcare Organizations recently called on hospitals and ambulatory surgery centers to reduce the risk of serious and deadly fires in operating rooms with its set of 7 Absolutes to help you educate operating room staff.
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