Perioperative Fire Safety Prevention

							        Fire Prevention
        in the Perioperative Practice Setting




2010 AORN Fire Safety Tool Kit
Introduction


              Speaker
         (Name & Credentials)
Objectives

1. Identify the three components of the
   fire triangle.
2. Identify fire prevention
   interventions.
3. Identify the steps in extinguishing a
   fire.
4. Identify evacuation routes.
Objectives

5. Describe the Fire Risk Assessment.
6. Describe the types of fire
   extinguishers.
7. Describe the PASS technique.
8. Describe the RACE technique.
Estimated Frequency
• 550-650 per year in the U.S.
  – 44% on head, neck or upper chest,
  – 26% elsewhere on the patient,
  – 21% in the airway,
  – 8% elsewhere in the patient.

• Locations: ANYWHERE
  – Ambulatory, Dr’s offices, Hospitals.
Patient Injuries
• Of the 550-650 fires per year in the U.S.
  – 20 to 30 are serious and result in disfiguring
    or disabling injuries,
  – 1 to 2 are fatal.
Procedures With Surgical Fires Reported
•   Facial surgery,
•   Tracheotomy,
•   Oral surgery,
•   Tonsillectomy,
•   Infant surgeries,
•   Pneumonectomy,
•   Cervical conization,
•   Cesarean section,
High Risk Procedures
• Surgical procedures of the head, neck,
  face, or upper chest carry the greatest risk
  – Lesions removal on the head, neck, or face;
  – Tonsillectomy;
  – Tracheostomy;
  – Burr hole surgery;
  – Removal of laryngeal papillomas.
Contributing Factors
Ignition Sources                 Oxidizers
• 70% Electrosurgical units,     • 75% Oxygen-enriched
• 20% Other heat sources           atmospheres.
   – Electrocautery equipment
     (battery operated),
     fiberoptic light sources,
     high-speed burrs,           Fuel
     defibrillators              • 4% Alcohol-based
• 10% Lasers,                      surgical prepping agents.
   Testimonial

                     I won’t ever have a fire




                        Testimony from Paula Graling, AORN Past President




* Double-click on video to watch.
Fire Triangle
Ignition Sources

• Electrosurgical unit       • Fiber optic light
  (ESU),                       source,
• Argon beam                 • Fiber optic light cable,
  coagulator,                • Defibrillator paddle,
• Power tools/drills/burr,   • Electrical equipment,
• Laser,
Ignition Control Interventions
• Place the patient return electrode on a large
  muscle mass close to the surgical site.
• Keep active electrode cords from coiling,
• Store the ESU pencil in a safety holster when
  not in use.
• Keep surgical drapes or linens away from
  activated ESU.
• Moisten drapes if absorbent, towels, and
  sponges that will be in close proximity to the
  ESU active electrode.
Ignition Control Interventions
• Do not use ignition source to enter the bowel when
  distended with gas.
• Keep ESU active electrode away from oxygen or
  nitrous oxide.
• Keep the active electrode tip clean.
• Use active electrodes or return electrodes that are
  manufacturer approved for the ESU being used.
• Use approved protective covers as insulators on
  the active electrode tip. NOT red rubber catheter
  or packing material.
• Activate active electrode only in close proximity to
  target tissue and away from other metal objects.
Ignition Control Interventions
• Inspect minimally invasive electrosurgical
  electrodes for impaired insulation; remove
  electrode from service if not intact.
• Use cut or blend settings instead of
  coagulation.
• Use lowest power setting for the ESU.
• Only the person controlling the active
  electrode activates the ESU.
• Remove active electrode from electrosurgical
  or electrocautery unit before discarding.
Ignition Control Interventions
• Use a laser-resistant endotracheal tube when
  using laser during upper airway procedures.
• Place wet sponges around the tube cuff if
  operating in close proximity to the
  endotracheal tube.
• Use wet sponges or towels around the
  surgical site.
• Only the person controlling the laser beam
  activates the laser.
• Have water and the appropriate type fire
  extinguisher available.
Ignition Control Interventions
• Place the light source in standby mode or turn off .
• Inspect light cables before use and remove from
  service if broken light bundles are visible.
• Secure the working end of telescope or cord on a
  moist towel, away from flammable materials.
• Select defibrillator paddles that are correct size.
• Use only manufacturer recommended defibrillator
  paddle lubricant.
• Place defibrillator paddle appropriately.
Ignition Control Interventions
• Inspect electrical cords and plugs for integrity
  and remove from service if broken.
• Check biomedical inspection stickers on
  equipment for currency and remove from
  service if not current.
• Do not bypass or disable equipment safety
  features.
• Follow manufacturer’s recommendations for
  use.
• Keep fluids off electrical equipment.
Oxidizers
• Oxygen (O2),
• Oxygen enriched environment,
• Nitrous oxide,
Oxidizer Control Interventions
• Tent drapes to allow for free air flow.
• Keep oxygen percentage low as possible.
• Deliver 5 L to 10 L/min of air under drapes.
• If >30% concentration required intubate or
  use laryngeal mask airway.
• Stop supplemental O2 or nitrous oxide 1
  min. before using ignition source.
• Use adhesive incise drape.
Oxidizer Control Interventions
• Inflate endotracheal tube cuff with tinted
  saline.
• Evacuate surgical smoke from small or
  enclosed spaces.
• Pack wet sponges around the back of the
  throat.
• If O2 used suction oropharynx deeply before
  using ignition source.
• Check anesthesia circuits for possible leaks.
• Turn off O2 at end of each procedure.
Fuels
• Patient and staff   • Bed linens,
  linens,             • Caps/hats,
• Drapes,             • Shoe covers,
• Gowns,              • Collodian,
• Towels,             • Alcohol-based skin
• Lap pads/Sponges,     preparations,
• Dressings,          • Human hair,
• Tapes,              • Endotracheal Tube,
Fuel Control Interventions
• Moist towel around the surgical site when
  using a laser.
• During throat surgery use moist sponge
  packing in throat.
• Water based ointment and not oil based
  ointment in hair.
Fuel Control Interventions
• Prevent pooling of skin prep solutions.
• Remove prep-soaked linen and disposable
  prepping drapes.
• Allow skin prep agents to dry and fumes to
  dissipate before draping.
• Allow chemicals (eg, alcohol, collodion,
  tinctures) to dry.
• Conduct a skin prep “time out”.
CMS Regulations Alcohol-Based Skin Preps
• Policies and Procedures to reduce risk of fire.
• Staff awareness.
• Products are packaged for controlled delivery
  with clear directions and they are followed.
• Documentation of implementation in patient
  medical record.
• Staff practice must demonstrate policy &
  procedure.
CMS, State Operations Manual , Appendix A - Survey Protocol, Regulations and Interpretive
  Guidelines for Hospitals http://cms.gov/manuals/Downloads/som107ap_a_hospitals.pdf
CMS Regulations Alcohol-Based
Skin Preps
• The CMS inspector approaches you and
  asks “What is your facility doing to reduce
  the risk of fires related to alcohol based
  skin preps?”
ECRI Revised Recommendation

Fire prevention is a team effort!
• Perform a Fire Risk Assessment.
• Surgeon must be made aware of open
  O2 use.
• Stop supplemental O2 before & during
  use of ignition source.

ECRI. New clinical guide to surgical fire prevention. Health Devices.
    2009;38(10):314-332.
ECRI Revised Recommendation
• Oxygen delivery during head, face, neck, and
  upper chest surgery:
  – Do not use open delivery of 100% oxygen;
  – Intubate or use laryngeal mask airway if supplemental
    oxygen needed;
  – If O2 >30% via open delivery use 5-10 L. of air /min
    under drapes.
• Exceptions:
  – Patient verbal response required during surgery (e.g.,
    carotid artery surgery, neurosurgery, pacemaker
    insertion);
  – Open oxygen delivery required to keep the patient safe.

  ECRI. New clinical guide to surgical fire prevention. Health Devices.
    2009;38(10):314-332.
Fire Risk Assessment
•   Performed before start of procedure,
•   All members of the team participating,
•   Communicated during the “Time Out”,
•   Documented in patient record,



ECRI. New clinical guide to surgical fire prevention. Health Devices. 2009;38(10):314-332   .
Fire Risk Assessment Tool
A. Is an alcohol-based prep agent or other volatile
   chemical being used preoperatively? Y or N.
B. Is the surgical procedure being performed above
   the xiphoid process? Y or N.
C. Is open oxygen or nitrous oxide being
   administered? Y or N.
D. Is an ESU, laser, or fiber-optic light cord being
   used? Y or N.
E. Are there other possible contributors? Y or N.
Fire Types
• ON the patient
• IN the patient
  – Includes airway fires
• ON or IN a piece of Equipment
Fighting Fires On A Patient
•   Announce the fire.
•   Attempt to extinguish with water or saline.
•   Remove burning materials from patient.
•   Extinguish on floor.
•   Turn off oxygen source.
•   Obtain fire extinguisher as last response.
•   Save all involved materials.
Fighting Fires Involving an Endotracheal Tube
• Announce the fire.

• Consult with anesthesia professional regarding:
   – disconnecting and removing the breathing circuit
   – turning off the flow of oxygen,
   – pouring saline or water into the airway

• Assist anesthesia care provider with:
   – removing the ET tube and any segments of the
     burned tube,
   – examining the airway,
   – re-establishing the airway.
Fighting Fires On or In A Patient
• Assess the surgical field for a secondary
  fire on the underlying drapes or towels.
• Assess the patient for injury.
• Report injuries to a physician.
• Document assessment.
• Activate alarms if necessary.
• Notify appropriate chain of command.
Fighting Fires On or In Equipment
• Communicate the presence of the fire to team
  members.
• Disconnect equipment from its electrical source.
• Shut off electricity to the piece of equipment at the
  electrical panel.
• Shut off gases to equipment, if applicable.
• Assess fire size and determine if equipment can
  be removed safely or if evacuation is needed.
• Extinguish fire with extinguisher if appropriate.
• Activate alarms if necessary.
• Notify appropriate chain of command.
How To   Extinguish A Fire using solution


• Nonflammable liquid such as saline or
  water,
• Aim at base of fire,
• Remember, drapes may be impermeable,
How To Smother A Fire
•   Hold towel between fire and patient airway
•   Drop one end of towel toward head
•   Drop other end of the towel over fire
•   Sweep hand over towel
•   Raise the towel
•   Keep your body away from fire
•   DO NOT PAT
How To Handle a fire in other part of building
• All rooms will be notified by the person in
  charge.
• No elective cases will be started.
• Prepare to evacuate.
Fire Blankets Not for Patient Fires

FIRE BLANKETS NOT EFFECTIVE
  – fire may be sustained
  – May trap fire next to/under patient
  – May displace instruments
  – May burn in oxygen-enriched
    atmospheres
NFPA Fire Classification*

• Class A: wood, paper, cloth, and most
  plastics (eg, combustible materials).
• Class B: flammable liquids or grease.
• Class C: energized electrical equipment.
• Combination: ABC, AC.



* NFPA = National Fire Protection Association
Recommended Fire Extinguisher

• ECRI : Class A, B, C.
• NFPA: Class A, B, C, or AC, which is a
  water mist extinguisher.
• Check with the Authority Having
  Jurisdiction (eg, local fire marshal) for your
  facility.
Fire Extinguisher Use (P.A.S.S.)

•   P—Pull the pin.
•   A—Aim nozzle at the base of the fire.
•   S—Squeeze the handle.
•   S—Sweep the stream over the base of the
    fire.
Shutting Off Gases
•   Valve location
•   Valve operation
•   Responsible person
•   Discuss with Anesthesia
Sprinklers
• Sprinklers and Smoke Alarms
• Triggering factors
• Coverage area
Evacuation Types & Areas

•   Who determines,
•   Lateral or horizontal or vertical,
•   Smoke Compartments,
•   Evacuation floor plan maps,
Evacuation Steps (R.A.C.E.)

• R—Rescue the individual
  involved in the fire.
• A—Alarm should be sounded as
  soon as possible.
• C—Confine the fire.
• E—Evacuate if required
Responsibilities In A Fire
Depends on:
  – Facility
  – Time
  – Personnel present
  – Size of fire
  – Location of Fire
Facility
•   Office based
•   Small ambulatory
•   Large ambulatory
•   Small hospital
•   Large hospital
•   Teaching hospital
Time
•   Normal business hours
•   Evening business hours
•   Emergency on call
•   Weekend
Personnel Present
•   Circulating nurse
•   Scrub
•   Anesthesia professional in the room
•   Surgeon
•   Supervising anesthesia professional
•   Anesthesia assistant
•   Surgical first assistant
•   Charge Nurse
•   Support personnel
•   Administrator
Size and Location Of Fire
•   Small fire on the patient
•   Large fire on the patient
•   Fire in the patient
•   Airway fire
•   Equipment fire
Responsibilities       All Fires


• Alert team members to the presence of a fire
• Stop the flow of breathing gases to the
  patient;
• Extinguish the fire by smothering or using a
  solution
• Push back table away from field
• Remove burning material from the patient
• Assess for secondary fire
• Assess patient for injuries
Responsibilities       All Fires


•   Notify next in chain of command
•   Assign liaison to the families
•   Liaison to the families
•   Complete occurrence report
•   Gather involved material/supplies
Responsibilities Large Fire On Patient
• Perform responsibilities for All Fires.
• Activate alarm system.
• Turn off oxygen shut-off valve outside of room.
• Extinguish any burning material off of patient
• Communicate with surrounding areas presence of
  fire.
• Delegate responsibilities for non-direct care givers.
• Traffic director.
• Assist fire response team or fire department to
  location.
Responsibilities Large Fire On Patient
• Assist with decision to evacuate.
• Order evacuation of room.
• Communicate with surrounding areas the
  need to evacuate.
• Order evacuation of unit.
• Coordinate list of all people in suite in case
  of evacuation.
• Activate disaster plan.
Responsibilities Airway or ET tube fire
• Perform responsibilities for All Fires.
• Disconnect and remove the breathing
  circuit.
• Discontinue flow of breathing gases to
  patient.
• Remove the ET tube and any segments of
  the burned tube that remain in the airway.
• Pour water or saline into the airway.
• Examine the airway.
• Re-establish the airway.
Responsibilities Equipment Fire
• Disconnect equipment from electrical outlet.
• Remove working end of equipment from sterile
  field.
• Shut off electricity to piece of equipment if unable
  to remove plug from outlet.
• Shut off gases to equipment.
• Assess size of fire and determine if equipment can
  be safely removed from room or to evacuate.
• Extinguish fire using extinguisher, if appropriate.
• Perform responsibilities for All Fires.
Responsibilities Fire Department
• Internal Fire brigade:
  – Responsibility is (Fill in for your facility)
• External Fire Department:
  – Responsibility determined by stage of the fire
  – How notified
  – Response time (Many are at least 15 minutes)
Contacting the Fire Department


• Fighting fires
• Authority Having Jurisdiction (fire
  marshall)
• Education offered
Summary
Steps for surgical fire prevention
  1. Know the components:
     a) Ignition sources
     b) Oxidizers
     c) Fuels
  2. Communicate:
     a) Fire Risk Assessment
     b) Presence of a Fire
Reference List
• ECRI. New clinical guide to surgical fire
  prevention. Health Devices.
  2009;38(10):314-332.
• NFPA 13
• NFPA 101
Other references/resources
• “Recommended practices for electrosurgery.”
• “Recommended practices for endoscopic minimally
   invasive surgery.”
• “Recommended practices for laser safety in practice
   settings.”
• “Recommended practices for product selection in
   perioperative practice settings.”
• “Recommended practices for safe environment of care.”
All found in the Standards, Recommended Practices, and
   Guidelines. Denver, Co: AORN, Inc; 2010
• Additional references are located in the Fire
  Prevention Resources and References in the AORN
  Fire Safety Tool Kit.
QUESTIONS?