If asked how often fires occur during surgery, most healthcare professionals would probably be of the opinion that these situations are extremely rare. However, the truth is that surgical fires occur fairly often. In fact, it is estimated that between 550 and 650 surgical fires occur in the United States every year.
There are a number of common causes of surgical fires. Seventy percent of them are ignited by electrocautery devices. Twenty percent start because of light sources, wires and defibrillators. And 10% are started by lasers.
While surgical fires mainly occur in hospitals, they can happen anywhere – including ambulatory surgery centers and physician offices. Furthermore, these fires most commonly occur in the head, neck and chest area during those types of surgeries.
So what can we do to help prevent surgical fires from happening? According to Caroline Stegeman – who serves as a senior patient safety consultant at LHA Trust Funds – we begin by focusing on three factors. First, identify the locations and types of procedures where surgical fires commonly occur. Second, identify the three components of the “fire triangle.” And third, institute best practices for surgical fire interventions.
“Surgical fires occur in, on or around a patient who is undergoing a medical or surgical procedure,” Caroline says. “Unfortunately, they are underreported. However, since we know the root causes of these fires, we can take steps to help prevent them.”
Some surgeries pose a higher risk of surgical fires than others. These surgeries include procedures that are performed above the xiphoid process and in the oropharynx that carry the greatest risk: T&As, traches, removal of a laryngeal papilloma, burr hole surgeries, and any lesions removed on the head, face and neck. The reason why these are at high risk for surgical fires is that anesthesiologists or CRNAs can have a tendency to give patients more oxygen than necessary.
So exactly how do surgical fires happen? We can help to explain this by discussing the “fire triangle,” which consists of three elements: the ignition source, fuel source and oxidizer. These elements exist in almost every surgical situation. When you visualize this triangle, imagine the patient being right in the middle of these three elements. Now let’s take a closer look at each element.
This includes anything in the O.R. that can spark a fire (which can occur wherever oxygen and a fuel source are present). Ignition sources include overhead surgical lights, defibrillators, electrosurgical or electrocautery units, heated probes, power tools, drills or burs, fiber-optic light sources and cables, lasers, magnets and MRI machines. Other sources include overheated IV solutions or blankets that are warmed in heating cabinets.
This includes anything that is flammable. Remember that almost everything that comes in contact with a patient in the O.R. is a potential fuel source – and the patient is also considered a fuel source. Examples of fuel sources include prep solutions, sponges, drapes, towels, hoods, masks, anesthesia circuits, dressings and ointments. Even the patient’s hair (both on the head and body) is a fuel source – along with the patient’s tissue and GI content.
Oxidizers are supplied by the anesthesiologist or the CRNA. They monitor the amount of oxygen given to the patient. It is important to minimize the amount of oxygen used to reduce the risk of fire. Also, the standard procedure is that if more oxygen is needed, it’s vital to secure the airway and mask placed over the airway and prevent oxygen from venting under the drapes.
Now that we’ve covered the fire triangle and the risks involved, let’s focus on some best practices. First it must be understood that fire prevention is a team effort. It includes all surgical team members, from the physician to the anesthesiologist delivering the medical gases, the surgeon controlling the ignition source, the O.R. staff applying the skin prep agents and drapes, and any additional staff that may be in the room.
The first step is to conduct a surgical fire risk assessment prior to surgery on all patients – whether they’re having surgery on their face or on their foot. You need to be aware of high-risk procedures, any possible ignition sources, the delivery of supplemental oxygen – you really need to be aware of any use of an ignition source near the oxygen. If it turns out that your fire risk assessment score is three or greater, you need to implement high-risk prevention measures. If it’s under two, implement routine measures.
“The team then needs to discuss how a fire will be prevented – and what to do if a fire occurs,” Caroline says. “All of this discussion needs to occur in the Time Out process for every patient and you need to ensure that you document this in your EMR.”
The following are several more specific best practices:
Safe Use of Oxidizers – You should titrate to the minimum concentration and use the closed oxygen delivery system if possible. If using an open system, exclude oxygen and flammable/combustible gases from the O.R. field. Tent the drapes to allow for free airflow and also evacuate any surgical smoke from small or enclosed spaces. Most importantly, turn off the O2 at the end of each procedure.
Safe Use of Ignition Sources – Consider alternatives to using an ignition source for high-risk surgeries if you’re delivering high concentrations of supplemental oxygen. If using an ignition source, allow time for the oxygen concentration to decrease in the O.R. area. Do not allow an ignition source to enter the bowel when it is distended with gas. And you also want to inspect all instruments for evidence of insulation failure.
Other best practices quick tips include:
• Do not activate electrosurgical units when near or in contact with other instruments.
• Keep tips of cautery instruments clean and free of char and tissue.
• When not in use, keep instruments in a designated area away from patients.
• Use water-based ointments on patients’ hair (head or body).
• Prevent pooling of skin prep solutions.
• Beware of ANY items in the O.R. that may be fuel sources (drapes, towels, sponges, gauze, ET tubes, laryngeal mask, suction catheters, etc.).
Other ways to promote surgical fire prevention include conducting education and drills at least annually – as well as for new employees. You also should make sure that surgical suites and procedure areas have appropriate firefighting equipment and that staff members know where to find it and how to use it properly.
“In order to increase surgical fire safety it’s also important to promote a culture that allows all surgical team members to speak up,” Caroline says. “Everyone must feel comfortable in pointing out potential problems without fear of retaliation or punishment.”
While surgical fires are not the most common type of risk in the healthcare environment, they can be devastating to both the patient and medical staff members when they do occur. That’s why it’s vital to take the steps necessary to prevent these fires from ever happening at your facility.
Hi, and welcome to LHA Trust Funds webinar series. My name is Caroline Stegeman and I’m a senior patient safety consultant with LHA Trust Funds. Today we’ll be presenting a webinar on surgical fire prevention, reducing the risk.
Just your review of our disclosure, we don’t have any conflicts of interests, commercial support or sponsorship in this presentation and no product endorsements are being made.
Our objectives today will be to identify the locations where a surgical fire may occur, identify the three components of the fire triangle and best practices for surgical fire interventions.
Here are some surgical fire facts. It is estimated that 550 to 650 surgical fires occur in the United States each year. Most of them occur in the head, neck and chest area in those types of surgeries. They may involve the airway. Seventy percent are ignited by electrocautery devices. Twenty percent started because of light sources, wires and defibrillators; and 10% are sparked by lasers.
Surgical fires can occur anywhere, mainly in hospitals, but they can also occur in ambulatory surgery centers and physician offices. They occur in, on or around a patient who is undergoing a medical or surgical procedure. They occur within the “Fire Triangle.” Unfortunately, they are underreported. They’re also considered a Healthcare-acquired Condition and a Never Event. And unfortunately, we know the root cause, which is well known.
When a surgical fire happens, the patient can experience injury to their head, neck and chest area, burns, pain, severe disfigurement, and even death. Surgical fires are preventable, yet they still occur.
Here’s some surgical fires reported by procedure: cervical conization, C-sections, any type of facial surgeries, infant surgeries where they’re having repair on the PDA, any type of oral surgery, pneumonectomy, tonsillectomy and a trache.
Here are some high risk surgeries that are at high risk for surgical fire. These are procedures that are performed above xiphoid process and in the oropharynx that carry the greatest risk: your T&As; traches; removal of a laryngeal papilloma; burr hole surgeries; any lesions removed on the head, face and neck. And why are these high risk for surgical fires? It’s because the anesthesiologist or the CRNA have a tendency to give patients more oxygen than necessary.
How do surgical fires happen? There are three elements of the fire triangle which we’re going to discuss today: the ignition source, fuel source and oxidizer. They exist in almost every surgical situation. When you look at this triangle, you have all three, ignition source, fuel source and oxidizer. Think of the patient being smack dab in the middle of it.
Ignition sources. This includes anything in the O.R. that can spark a fire. When oxygen and a fuel source are present, the sparks are given off by the sources which produce temperatures that can go up from several hundred to a few thousand degrees. Who controls the heat source? The surgeon.
Some ignition source examples are overhead surgical lights; your defibrillators; electrosurgical or electrocautery units; heated probes; any power tools, drills or burs; fiber-optic light sources and cables; any lasers; magnets; your MRI machine. Also a source can be overheated IV solutions or blankets that are warmed in our heating cabinets.
Fuel sources. This is anything that is flammable. Almost everything that comes in contact with the patients in the O.R. can be a fuel source. A patient is also considered a fuel source. In an oxygen risk environment, even things that are not considered to be flammable can ignite and burn. Who controls the fuel sources? Nurses, circulators and scrub techs.
Some examples of fuel sources: your prep solutions; sponges; drapes; towels; your hoods; masks; anesthesia circuits; dressings; ointments, oil-based ointments; even the patient’s hair, not only the hair on our head but facial hair and body hair; patient’s tissue and patient’s GI content can be a fuel source.
Some examples of how a fuel source can ignite: surgical drapes placed in a way that allows oxygen to pool under them; liquid alcohol from a wet dripping prep pools under the patient and generates vapors that can ignite; your alcohol-based sterilizers can ignite if not given sufficient time to dry.
Oxidizers. These are supplied by the anesthesiologist or the CRNA. They monitor the amount of oxygen given to the patient. They need to minimize the amount of oxygen used; and standard procedure is if more oxygen is needed, they need to secure the airway and mask placed over the airway and prevent oxygen from venting under the drapes.
When you have a high concentration of oxygen that is greater than the room air in the O.R., that can equal the potential for a surgical fire to ignite.
Some misleading beliefs. When a surgical fire occurs, normally the healthcare provider will suggest that equipment failure was the cause. ECRI Institute has research that proves that the cause is misuse of the equipment. When you put human complacency, fuel, oxygen and heat altogether, it equals a disaster.
Now we’re going to discuss some best practices.
Fire prevention is a team effort. It includes all surgical team members from the physicians, anesthesia delivering the medical gases, the surgeon controlling the ignition source, your O.R. staff applying the skin prep agents and drapes, any additional O.R. staff that may be in the room and the EVS staff.
You want to conduct a surgical fire risk assessment. It should be conducted prior to surgery on all patients, whether they’re having surgery on their face or they’re having surgery on their foot. You really need to conduct a surgical fire risk assessment on all patients. You need to be aware of high risk procedures, any possible ignition sources, the delivery of supplemental oxygen – you really need to be aware of any use of an ignition source near the oxygen.
Here’s an example of a surgical fire risk assessment tool, again, conducted on every patient. Some questions that need to be answered: Is an alcohol-based prep agent or other volatile chemical being used preoperatively, yes or no? Is this surgical procedure being performed above the xiphoid process, yes or no? Is open oxygen or nitrous oxide being administered? Is an ESU, laser or fiber-optic light code being used? And you really need to look around the O.R. or the procedure room to look for any other possible contributors.
Once you’ve done that assessment, then you’re moving on to your universal protocol and you want to include the surgical fire risk assessment in your “Time Out” process. When you’re doing your Time Out, validating that you have the right patient, you’re doing the right surgery on the right area, you want to include the surgical fire risk. You want to look at your fire risk assessment score and discuss it. Is it three or greater? You want to implement high risk prevention measures. If it’s under two, implement routine measures. The team needs to discuss how fire will be prevented; and if one is to break out, how [inaudible 00:09:02]. All of this discussion needs to occur in the Time Out process for every patient and you need to ensure that you document this in your EMR.
Safe use and administration of oxidizers. You want to evaluate the need for supplemental oxygen. When we have an increase in oxygen, we have an increase in fire risk. You want to titrate to the minimum concentration, use the closed oxygen delivery system if possible. If using an open system, take precautions. You want to exclude oxygen and flammable/combustible gases from the O.R. field. You want to tent the drapes to allow for free air flow. Use an adhesive incise drape. Evacuate any surgical smoke from small or enclosed spaces. And most importantly, you want to turn off the O2 at the end of each procedure.
For safe use of possible ignition source devices, you want to consider alternatives to using ignition source for high risk surgeries if you’re delivering high concentrations of supplemental oxygen. If using ignition source, allow time for the oxygen concentration to decrease in the O.R. area. Do not allow an ignition source to enter the bowel when it is distended with gas. This is very important. And you also want to inspect all instruments for evidence of insulation failure.
If you’re using electrosurgical units, do not activate when near or in contact with other instruments. Use a return electrode monitoring system. Only the person controlling the active electrode activates the ESU. Tips of cautery instruments should be kept clean and free of char and tissue. And when not in use, please, please, please place ignition source in a designated area away from the patient.
Controlling fuel sources. Use moist towels around the surgical site when using a laser. When you’re doing a throat surgery, you want to use moist sponges as packing in the throat. And importantly, you want to use a water-based ointment, not an oil-based ointment in the facial hair and other hair near the surgical site.
You want to prevent pooling of skin prep solutions. Remove pre-soaked linen and disposable prepping drapes. You really want to allow the skin prep agents to dry and fumes to dissipate before draping. You also want to allow any other chemicals you may be using to dry. This would be a good time to conduct a skin prep “time out,” which is where you allow the chemicals or the skin prep agents that you’ve used to dry according to the manufacturer’s guidelines.
You want to be aware of other surgical suite items that may be a fuel source. Products that trap oxygen such as your drapes, your towels, sponges and gauze; any products made of plastic, your ET tubes, laryngeal mask and suction catheters; and patient-related sources, which can be hair, again, not only hair on the head but facial hair and body hair, and GI gases.
What happens if a surgical fire was to ignite? Your staff really needs to know what to do. Immediately, stop the surgery. Stop the flow of all airway gases. You want to disconnect a breathing circuit. You want to remove all burning and burn materials from the patient. You want to extinguish the fire and care for the patient. The staff needs to know how to do this day in and day out.
Now we’re going to discuss some ways to have surgical fire prevention in your organization. You want to conduct education and drills during orientation when you have a new employee and at least annually. Now, these drills are not just a basic fire drill. This is a drill where you pretend a patient is on fire. We do fire drills randomly and as per regulatory requirements. However, how often do you do a drill where you pretend the patient is on fire so that the staff can walk through the process of how to handle it and how to try to prevent it? You want to involve all O.R. and surgical staff in surgical fire drills. This is including the physician. You want to evaluate each drill, which helps us identify opportunities for improvement. You want to ensure the surgical suites and procedure areas have appropriate firefighting equipment, and that the staff know where to find it and how to utilize it.
You also want to promote a safety culture that allows all surgical team members to speak up. You want them to be able to speak up without any fear of punishment or retaliation. Our staff is our eyes and our ears out there. When they see something important, they need to be able to speak up and bring it to light. You want to support reporting of near misses. Near misses really go under reported. We can learn a lot from near misses. It’s when a mistake almost happens, but it doesn’t reach the patient. Staffing, they don’t need to report it.
Usually near misses go under reported, and then something big happens and we realize while we’re doing the root cause analysis that we’ve been having a lot of near misses that no one reported. Encourage your staff to report near misses and you can do RCAs on your misses and drill down to see what’s going on and identify opportunities before something big happens. Ensure that all fires, whether they’re big or small, are reported. You want to conduct debriefings after any near miss or surgical fire. You want to make sure the staff is okay because that’s going to really shake the staff up. And you need to secure any materials or devices that were involved in a surgical fire in case any PCF claim or lawsuit comes.
That brings us to the end of our webinar today. Here are some resources. AORN has great resources on their website. Also, ECRI has great resources.
And just a little note for you. We have a website LHAtrustfunds.com, which has a wealth of information on the website. We have a toolkit library. We have training opportunities, webinars, trending now articles and opioid management initiatives, plus a wealth of other opportunities there for you to look at. Please go to our website LHAtrustfunds.com.
If you have any questions about today’s webinar, please contact one of us that are listed on the screen now, and we thank you so much for your time in attending our webinar. Have a great day.