Fire Prevention & Preparation
Surgical fires are relatively rare, with an incidence of about 1:87,000 cases, which is close to the incidence rate of other events such as retained foreign objects after surgery and wrong-site surgery.
Almost all surgical fires can be prevented. Unlike medical complications, fires are a product of simple physical and chemical properties. Occurrence is guaranteed given the proper combination of factors but can be eliminated almost entirely by understanding the basic principles of fire risk.
Likely the most common risk factor for surgical fire relates to the open delivery of oxygen
Situations classified as carrying a high risk for a surgical fire are those that involve an ignition source used in close proximity to an oxidizer. The simple chemical combination required for any fire is commonly referred to as the fire triad or fire triangle. The triad is composed of fuel, oxidizer, and ignition source (heat). Table 2-2 lists potential contributors to fires and explosions in the operating room. Surgical fires can be managed and possibly avoided completely by incorporating education, fire drills, preparation, prevention, and response into educational programs provided to operating room personnel.
Table 2-2 Potential Contributors to Operating Room Fires and Explosions. ||Download (.pdf)
Table 2-2 Potential Contributors to Operating Room Fires and Explosions.
- Flammable agents (fuels)
- Solutions, aerosols, and ointments
- Surgical drapes (paper and cloth)
- Surgical gowns
- Surgical sponges and packs
- Surgical sutures and mesh
- Plastic/polyvinyl chloride/latex products
- Endotracheal tubes
- Intestinal gases
- Gases supporting combustion (oxidizers)
- Ignition sources (heat)
- Electrosurgical units
- Fiberoptic light sources (distal tip)
- Drills and burrs
- External defibrillators
For anesthesia providers, fire prevention education should place a heavy emphasis on the risk relating to the open delivery of oxygen. The Anesthesia Patient Safety Foundation has developed an educational video and online teaching module that provides fire safety education from the perspective of the anesthesia provider.
Operating room fire drills increase awareness of the fire hazards associated with surgical procedures. In contrast to the typical institutional fire drill, these drills should be specific to the operating room and should place a greater emphasis on the particular risks associated with that setting. For example, consideration should be given to both vertical and horizontal evacuation of surgical patients, movement of patients requiring ventilatory assistance, and unique situations such as prone or lateral positioning and movement of patients who may be fixed in neurosurgical pins.
Preparation for surgical fires can be incorporated into the time-out process of the universal protocol. Team members should be introduced and specific roles agreed upon should a fire erupt. Items needed to properly manage a fire can be assembled or identified beforehand (eg, ensuring the proper endotracheal tube for patients undergoing laser surgery; having water or saline ready on the surgical field; identifying the location of fire extinguishers, gas cutoff valves, and escape routes). A poster or flowsheet to standardize the preparation may be of benefit.
Preventing catastrophic fires in the operating room begins with a strong level of communication among all members of the surgical team. Different aspects of the fire triad are typically under the domain of particular surgical team members. Fuels such as alcohol-based solutions, adhesive removers, and surgical drapes and towels are typically controlled by the circulating nurse. Ignition sources such as electrocautery, lasers, drills, burrs, and light sources for headlamps and laparoscopes are usually controlled by the surgeon. The anesthesia provider maintains control of the oxidizer concentration of oxygen and nitrous oxide. Communication between personnel is evident when a surgeon enters the airway and verifies the concentration of oxygen before using cautery, or when an anesthesiologist asks the circulator to configure drapes to prevent the accumulation of oxygen in a surgical case that involves sedation and use of a nasal cannula.
Administration of oxygen
in concentrations of greater than 30% should be guided by clinical presentation of the patient and not solely by protocols or habits. If oxygen
is being delivered via nasal cannula or face mask, and if increased oxygen
levels are needed, then the airway should be secured by either endotracheal tube or supraglottic device. This is of prime importance when the surgical site is above the level of the xiphoid.
When the surgical site is in or near the airway and a flammable tube is present, the oxygen concentration should be reduced for a sufficient period of time before use of an ignition device (eg, laser or cautery) to allow reduction of oxygen concentration at the site. Laser airway surgery should incorporate either jet ventilation without an endotracheal tube or the appropriate protective tube specific for the wavelength of the laser. Precautions for laser cases are outlined below.
Alcohol-based skin preparations are extremely flammable and require an adequate drying time. Pooling of solutions must be avoided. Large prefilled swabs of alcohol-based solution should be used with caution on the head or neck to avoid both oversaturation of the product and excess flammable waste. Product inserts are a good source of information about these preparations. Surgical gauze and sponges should be moistened with sterile water or saline if used in close proximity to an ignition source.
Should a fire occur in the operating room it is important to determine whether the fire is located on the patient, in the airway, or elsewhere in the operating room. For fires occurring in the airway, the delivery of fresh gases to the patient must be stopped. Effective means of stopping fresh gases to the patient can be accomplished by turning off flowmeters, disconnecting the circuit from the machine, or disconnecting the circuit from the endotracheal tube. The endotracheal tube should be removed and either sterile water or saline should be poured into the airway to extinguish any burning embers.
The sequence of stopping gas flow and removal of the endotracheal tube when fire occurs in the airway is not as important as ensuring that both actions are performed quickly. Often the two tasks can be accomplished at the same time and even by the same individual. If carried out by different team members, the personnel should act without waiting for a predetermined sequence of events. After these actions are carried out, ventilation may be resumed, preferably using room air and avoiding oxygen
or nitrous oxide-enriched gases. The tube should be examined for missing pieces. The airway should be reestablished and, if indicated, examined with a bronchoscope. Treatment for smoke inhalation and possible transfer to a burn center should also be considered.
For fires on the patient, the flow of oxidizing gases should be stopped, the surgical drapes removed, and the fire extinguished by water or smothering. The patient should be assessed for injury. If the fire is not immediately extinguished by first attempts, then a carbon dioxide (CO2) fire extinguisher may be used. Further actions may include evacuation of the patient and activation of the nearest pull station. As noted previously, prior to an actual emergency, the location of fire extinguishers, emergency exits, and fresh gas cutoff valves should be established by the anesthesia provider.
Fires that result in injuries requiring medical treatment or death must be reported to the fire marshal, who retains jurisdiction over the facility. Providers should gain basic familiarity with local reporting standards, which can vary according to location.
Cases in which supplemental delivery of oxygen is used and the surgical site is above the xiphoid constitute the most commonly reported scenario for surgical fires. Frequently the face or airway is involved, resulting in life-threatening injuries and the potential for severe facial disfigurement. For the most part, these fires can be avoided by the elimination of the open delivery of oxygen, by use of an oxygen blender, or by securing the airway.
For fires not suppressed by initial attempts or those in which evacuation may be hindered by the location or intensity of the fire, the use of a portable fire extinguisher is warranted. A CO2 extinguisher should be safe during external and internal exposure for fires on the patient in the operating room. CO2 readily dissipates, is not toxic, and as used in an actual fire is not likely to result in thermal injury. FE-36, manufactured by DuPont, also can be used to extinguish fires but is expensive. Both choices are equally effective and acceptable agents as reflected by manufacturers’ product information.
“A”-rated extinguishers contain water, which makes their use in the operating room problematic because of the presence of so much electrical equipment. A water mist “AC”-rated extinguisher is excellent but requires time and an adequate volume of mist over multiple attempts to extinguish the fire. Furthermore, these devices are large and difficult to maneuver. Both can be made cheaply in a nonferromagnetic extinguisher, making them the best choice for fires involving magnetic resonance imagers. Halon extinguishers, although very effective, are being phased out because of concerns about depletion of the ozone layer, as well as the hypoxic atmosphere that results for rescuers. Halotrons are “greener” halon-type extinguishers that may have fewer effects on the ozone layer.
Lasers are commonly used in operating rooms and procedure areas. When lasers are used for airway surgeries or for procedures involving the neck and face, the case should be considered as high risk for surgical fire and managed as previously discussed. The type of laser (CO2, neodymium yttrium aluminum garnet [NG:YAG], or potassium titanyl phosphate [KTP]), wavelength, and focal length are all important considerations for the safe operation of medical lasers. Without this vital information, operating room personnel cannot adequately protect themselves or the patient from harm.
Before beginning laser surgery, the laser device should be in the operating room, warning signs should be posted on the doors, and protective eyewear should be issued. The anesthesia provider should ensure that the warning signs and eyewear match the labeling on the device as protection is specific to the type of laser. The American National Standards Institute (ANSI) standards specify that eyewear and laser devices must be labeled for the wavelength emitted or protection offered. Some ophthalmologic lasers and vascular mapping lasers have such a short focal length that protective eyewear is not needed. For other devices, protective goggles should be worn by personnel at all times during laser use, and eye protection in the form of either goggles or protective eye patches should be used on the patient.
Laser endotracheal tube selection should be based on laser type and wavelength. The product insert and labeling for each type of tube should be compared to the type of laser used. Certain technical limitations are present when selecting laser tubes. For instance, tubes less than 4.0 mm in diameter are not compatible with the ND:YAG or argon laser nor are ND:YAG-compatible tubes available in half sizes. Attempts to wrap conventional endotracheal tubes with foil should be avoided. This archaic method is not approved by either manufacturers or the U.S. Food and Drug Administration, is prone to breaking or unraveling, and does not confer protection against laser penetration. Alternatively, jet ventilation without an endotracheal tube can offer a reduced risk of airway fire.
Crew Resource Management: Creating a Culture of Safety in the Operating Room
Crew resource management (CRM) was developed in the aviation industry to allow personnel to intervene or call for investigation of any situation thought to be unsafe. Comprising seven principles, its goal is to avoid errors caused by human actions. In the airline model CRM gives any crew member the authority to question situations that fall outside the range of normal practice. Before the implementation of CRM, crew members other that the captain had little or no input on aircraft operations. After CRM was instituted, anyone identifying a safety issue could take steps to ensure adequate resolution of the situation. The benefit of this method in the operating room is clear, given the potential for a deadly mistake to be made.
The seven principles of CRM are (1) adaptability/flexibility, (2) assertiveness, (3) communication, (4) decision making, (5) leadership, (6) analysis, and (7) situational awareness. Adaptability/flexibility refers to the ability to alter a course of action when new information becomes available. For example, if a major blood vessel is unintentionally cut in a routine procedure, the anesthesiologist must recognize that the anesthetic plan has changed and volume resuscitation must be made even in presence of medical conditions that typically contraindicate large-volume fluid administration.
Assertiveness is the willingness and readiness to actively participate, state, and maintain a position until convinced by the facts that other options are better; this requires the initiative and the courage to act. For instance, if a senior and well-respected surgeon tells the anesthesiologist that the patient’s aortic stenosis is not a problem because it is a chronic condition and the procedure will be relatively quick, the anesthesiologist should respond by voicing concerns about the management of the patient and should not proceed until a safe anesthetic and surgical plan have been agreed upon.
Communication is defined simply as the clear and accurate sending and receiving of information, instructions, or commands, and providing useful feedback. Communication is a two-way process and should continue in a loop fashion.
Decision making is the ability to use logical and sound judgment to make decisions based on available information. Decision-making processes are involved when a less experienced clinician seeks out the advice of a more experienced clinician or when a person defers important clinical decisions because of fatigue. Good decision making is based on realization of personal limitations.
Leadership is the ability to direct and coordinate the activities of other crew members and to encourage the crew to work together as a team. Analysis refers to the ability to develop short-term, long-term, and contingency plans, as well as to coordinate, allocate, and monitor crew and operating room resources.
The last and most important principle is situational awareness; that is, the accuracy with which a person’s perception of the current environment mirrors reality. In the operating room, lack of situational awareness can cost precious minutes, as when readings from a monitor (eg, capnograph or arterial line) suddenly change and the operator focuses on the monitor rather than on the patient, who may have had an embolism. One must decide whether the monitor is correct and the patient is critically ill or the monitor is incorrect and the patient is fine. The problem-solving method utilized should consider both possibilities but quickly eliminate one. In this scenario, tunnel vision can result in catastrophic mistakes. Furthermore, if the sampling line has come loose and the capnograph indicates low end-tidal CO2, this finding does not exclude the possibility that at the same time or even a bit later, the patient could have a pulmonary embolus resulting in decreased end-tidal CO2.
If all members of the operating room team apply these seven principles, problems arising from human factors can almost entirely be eliminated. A culture of safety must also exist if the operating room is to be made a safer place. These seven principles serve no purpose when applied in a suppressive surgical environment. Anyone with a concern must be able speak up without fear of repercussion. Chapter 58 provides further discussion of these and other issues relating to patient safety.
Future Design of Operating Rooms
Safety Interlock Technology
Despite heightened awareness of safety factors and increased educational efforts among operating room personnel, harm to patients still occurs at a rate that most industries and the public deem unacceptably high. Similarly, despite threats of payment withholding, public scoring of medical personnel and hospital systems, provider rating web sites, and punitive legal consequences, the human factors resulting in medical errors have not been completely eliminated. In future, safety-engineered designs may assist in the reduction of medical errors. One developing area is the use of interlock devices in the operating room. An interlock device is simply a device that cannot be operated until a defined sequence of events occurs. Anesthesia personnel use interlock technology with anesthesia vaporizers that prevent the use of more than one vaporizer at a time. Expansion of this technology might prevent release of a drug from an automated dispensing device until a barcode is scanned from a patient’s hospital armband or, at a minimum, the patient’s drug allergies have been entered into the machine’s database. Other applications might include an electrosurgical device or laser that could not be used when the FiO2 content was higher than 30%, thus eliminating the risk of fire. Likewise, computers, monitors, and other devices could be designed to be inoperable until patient identification was confirmed.
Coordinating the activities of surgical personnel, anesthesia providers, and operating room nurses is essential to the day-to-day running of a surgical suite. Clinical directors in facilities ranging from one- or two-room suites to multiroom centers must accommodate surgical procedures of varying durations, requiring varying degrees of surgical skill and efficiency, while allowing for sudden, unplanned, or emergency operations. The need to monitor workflow and analyze data for optimizing scheduling and staffing prompted the development of software systems that anticipate and record the timing of surgical events; these systems are constantly being refined.
Surgical suites are also being designed to augment workflow by incorporating separate induction areas to decrease nonsurgical time spent in operating rooms. Several models exist for induction room design and staffing. Although uncommon in the United States, induction rooms have long been employed in the United Kingdom.
One induction room model uses rotating anesthesia teams. One team is assigned to the first patient of the day; a second team induces anesthesia for the next patient in an adjacent area while the operating room is being turned over. The second team continues caring for that patient after transfer to the operating room, leaving the first team available to induce anesthesia in the third patient as the operating room is being turned over. The advantage of this model is continuity of care; the disadvantage is the need for two anesthesia teams for every operating room.
Another model uses separate induction and anesthesia teams. The induction team induces anesthesia for all patients on a given day and then transfers care to the anesthesia team, which is assigned to an individual operating room. The advantage of this model is the reduction in anesthesia personnel to staff induction rooms; disadvantages include failure to maintain continuity of care and staffing problems that occur when several patients must undergo induction concurrently. This model can utilize either a separate induction room adjacent to each operating room or one common induction room that services several operating rooms.
The final model uses several staffed operating rooms, one of which is kept open. After the first patient of the day is transferred to the initial room, subsequent patients always proceed to the open room, thus eliminating the wait for room turnover and readiness of personnel. All of these models assume that the increased overhead cost of maintaining additional anesthesia personnel can be justified by the increased surgical productivity.
Radio Frequency Identification (RFID)
Radio frequency identification (RFID) technology utilizes a chip with a small transmitter whose signal is read by a reader; each chip yields a unique signal. The technology has many potential applications in the modern operating room. Using RFID in employee identification (ID) badges could enable surgical control rooms to keep track of nursing, surgical faculty, and anesthesia personnel, obviating the need for paging systems and telephony to establish the location of key personnel. Incorporating the technology in patient ID bands and hospital gurneys could allow a patient’s flow to be tracked through an entire facility. The ability to project an identifying signal to hospital systems would offer an additional degree of safety for patients unable to communicate with hospital personnel. Finally, RFID could be incorporated into surgical instruments and sponges, allowing surgical counts to be performed by identification of the objects as they are passed on and off the surgical field. In the event that counts are mismatched, a wand could then be placed over the patient to screen for retained objects.