Patient safety
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| Surgical fires are a serious issue that every hospital should be taking steps to prevent, regardless of whether a fire has occurred at their facility. Although nurses and physicians in the OR are at the scene, there are steps that materials managers can take to prevent fires that can cause life-threatening burns to patients and also threaten the lives of caregivers. Something as simple as communicating when a skin-prep solution has been switched to one with a higher alcohol content has the potential to save lives. |
When a full-fledged surgical fire happens, it can be terrifying for the OR staff and especially for a patient.
In the oxygen-enriched atmosphere for many surgeries, an electrosurgical unit inadvertently touching a drape or a tracheal tube can flash into a fire in just seconds. Even if it is put out immediately, it may leave life-threatening burns on a patient.
One anesthetized patient who woke up in the middle of a 2003 fire told U.S. News & World Report that she felt a severe pain in her head and screamed, “I’m on fire!” It took months for her to recover from her burns.
Patients can be seriously burned because usually the fire starts on them or even in them. ECRI, the health services research agency in Plymouth Meeting, Pa., reports that 28 percent of surgical fires start on a patient’s head or neck and 33 percent within a victim’s airway, while only 24 percent start away from a patient.
Materials managers hearing about these dreadful events might wonder what they can do to help.
Plenty, says Sharon Giarrizzo-Wilson, R.N., a specialist in OR fires at the Center for Nursing Practice at the Association of periOperative Registered Nurses (AORN), Denver.
She says they should be collecting safety alerts on devices implicated in surgical fires, arranging for training on such devices by the vendor and continually informing OR staff of product changes.
An ounce of prevention
Giarrizzo-Wilson says materials management needs to have “some ownership in the process” of preventing surgical fires, but in many cases they may not necessarily know their role.
For example, she says failure to communicate materials management’s switch to a new brand of wound packing strips containing alcohol may have contributed to a small surgical fire that was reported as a near miss to AORN’s anonymous database.
In that case, “an existing product was switched out by materials management without communication to the [OR] staff,” she explains. “The alcohol content of the new product was more concentrated than the previous product. The surgeon took an electrosurgical pencil to control bleeding after the packing was in place and inadvertently ignited the alcohol fumes from the packing.” Luckily, the flame was extinguished without injury.
Many materials managers are not used to having a key role in preventing surgical fires. “This is not the direct line of business of materials managers,” says John Siedlinski, a supply chain consultant based in Naperville, Ill., who has helped out many materials management departments. “On the list of people who would get involved with this issue, materials management is on there but probably the last to know.”
Susan Kreiss, immediate past president of the Association for Healthcare Resource & Materials Management, Chicago, says materials managers are already involved in surgical fire prevention, but could talk more with OR personnel about product safety.
“All materials managers are aware of NFPA (National Fire Protection Association, Quincy, Mass.) ratings of the products they purchase, but discussions with the professionals directly involved are much more helpful because they provide insights not available in any literature,” says Kreiss, who is manager of contract administration at 20-hospital Bon Secours Health System, Columbia, Md.
Sometimes it takes an actual surgical fire for a hospital to appreciate the importance of preventive measures such as sharing manufacturers’ warnings.
In July 1998, at 365-bed University Medical Center (UMC), Tucson, Ariz., a fire broke out under a patient’s drape due to a higher concentrated alcohol prep used before electrosurgery.
Kathryn V. Knak, R.N., the corporate safety and emergency preparedness officer at UMC, says the patient received burns to his head, neck and shoulder but recovered nicely.
After the fire, UMC removed alcohol-based preps from its ORs and, working with ECRI, began a root cause analysis. The analysis determined that alcohol-based preps could be used, but not for head and neck surgery.
In those cases, the hospital uses a nonalcohol product instead. Knak reports that there have not been any fires in the OR since. But Knak says this accident might have been prevented.
Just a week before the fire, she says, the prep’s manufacturer sent a letter warning about the flammability hazards of the product. She says the letter reached offices outside the hospital but never reached materials management or surgery.
Reacting to the misplaced warning letter, UMC has designated materials management “the gatekeeper for all hazard warnings, safety alerts and recalls for the hospital,” Knak says. “People are much more aware after we had the fire that if you get this kind of notice, you have to pass it on.”
Also, she reports that the products standardization committee, which reviews new products and product changes, examines the flammability of all products. “We try to anticipate dangerous combinations,” Knak says. “If there has to be some kind of prep and a device such as an ESU (electrosurgical unit) has to be used, the first question we ask is, does the prep have any alcohol in it?”
Since the victim was a journalist, the fire received a great deal of media attention, she says. Her advice to other hospitals: “You don’t want to be the hospital that has the next fire and has to explain to the patient, the family, your staff, the state licensure agency, the Joint Commission and the media.”
Although surgical fires have been a serious problem for many decades, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Oakbrook Terrace, Ill., has recently stepped up warnings.
JCAHO involvement
In 2003, JCAHO issued a sentinel event alert to hospitals on surgical fires. And in both 2005 and 2006, it issued national patient safety goals on reducing the risk of surgical fires for ambulatory care and office-based surgery.
JCAHO states that for scoring purposes, the 2006 goal was made applicable to the nonhospital entities, but “we still encourage hospitals to implement the recommendations” listed in the 2003 sentinel event alert.
The sentinel alert advises hospitals to develop, implement and test procedures to ensure an appropriate response to such fires and inform staff on proven measures to reduce fires such as minimizing oxygen concentration under drapes.
Because surgical fires usually begin on or in a patient, burns are the overwhelming injury and malpractice payments are common.
The American Society of Anesthesiologists, surveying its own database of malpractice claims for various kinds of burns, found that surgical fires was the only category where there was a payout in 100 percent of cases.
These cases also had the highest median payout—$167,500—from an anesthesiologist. Similar studies for surgeons’ and hospitals’ payouts could not be found. Based on known reports, ECRI estimates there are about 100 surgical fires a year, resulting in up to 20 serious injuries and one or two patient deaths.
That’s a trickle compared with the 50 million U.S. surgeries performed annually, according to the National Hospital Discharge Survey. But some argue that the number of fires could be much higher.
The Anesthesia Patient Safety Foundation, Indianapolis, reports that there is no centralized reporting system for surgical fires. It says only three states—California, Tennessee and Washington—require such fires to be reported and the FDA requires reports only on fires linked to a device malfunction or faulty design.
JCAHO says hospitals must log all fires and show the log to surveyors, but the foundation speculates that only one-tenth or even one-hundredth of all surgical fires are reported.
Flaring up
Operating rooms are perfect breeding grounds for fires because they have all three parts of the fire triangle: an ignition source, a fuel source and oxygen.
ECRI reports that with a high-temperature surgical device and highly enriched oxygen for anesthetized patients, it can take just 30 seconds to produce a life-threatening fire. In the category of ignition sources, ECRI says electrosurgical equipment is responsible for igniting 90 percent of surgical fires, while lasers cause 10 percent.
A defective ESU may issue sparks or the surgeon may absent-mindedly bring the tip into contact with a fuel source, while lasers do not have to touch a surface to ignite it, ECRI adds.
Fires also can be started by fiberoptic light cables, light source boxes, drills, saws, burrs, handheld electrocautery devices, argon beam coagulators, defibrillators and even MRIs, according to ECRI and other authorities. Turning to fuels, drapes are “by far the most implicated fuel” in surgical fires, according to a 1997 report by the American College of Surgeons (ACS), Chicago.
But anything that burns can be a fuel source, including endotracheal tubes, sponges, prepping agents, gauze, ointments, bandages and even surface hairs on the patient’s body, ACS and others say.
The normal oxygen level of a room, which is about 21 percent, is sufficient to start a fire, but ECRI reports that three-quarters of surgical fires, including the very scary “flash” fires, are started in an oxygen-enriched atmosphere.
Since a high level of oxygen is heavier than air, it can sink into the folds of a “flame-retardant” drape and help it ignite instantaneously.
Fire prevention
Mark E. Bruley, vice president for accident and forensic investigation at ECRI, who has been studying surgical fires for 28 years, says materials managers should be aware of preventive measures that involve products in the OR including:
- Use bipolar electrosurgery, in which current flows between two tips of the device, rather than monopolar, in which current flows through a patient’s body. But Bruley adds that in some cases only monopolar can be used. ECRI provides ratings for four monopolar technologies.
- Drapes are the most common fuel in surgical fires and “people ask which surgical drapes are less flammable,” Bruley says. “The answer is it doesn’t matter because no surgical drape is treated to be fire-retardant.” He notes that polypropylene “melts away from a heat source, but it will still ignite and burn in typical surgical settings.”
- Laser-resistant tubes can be used to prevent fires during all upper-airway surgery. But Bruley says no safety tube is best for all lasers; one works best with a CO2 laser and another with Nd:YAG.
- Use a prepackaged prepping solution rather than an open bottle with a sponge, which is more likely to dribble and leave excessive amounts that take longer to evaporate.
- Place one 5-pound CO2 cartridge fire extinguisher in each OR. But Bruley cautions: “There is no time to get a fire extinguisher when your patient is on fire.”
- Fire blankets, wrapped around someone on fire, “have no place in the OR,” Bruley says. They work in industrial settings, but “in oxygen-enriched environments like the OR they can trap oxygen and burn.”
JCAHO adds the following preventive measures:
- Use incise drapes, which adhere to a patient, preventing oxygen-enriched atmospheres or flammable vapors to well up underneath.
- Question the need for 100 percent oxygen. Try to use oxygen at plus-30 percent, “consistent with a patient’s needs.”
Giarrizzo-Wilson also adds a few preventive measures of her own:
- Electrosurgical pencils with active electrodes must match the ESU they are being used with.
- When a refurbished unit is purchased, the manufacturer should document that it meets FDA specifications and fire safety standards.
- Do not use mist extinguishers, which can be effective on fires but produce water that could short out electrical equipment.
Giarrizzo-Wilson adds that while materials managers may not be the first in the hospital to know about the hazards, they need to be able to apply this knowledge to purchases and product switches.
“If you wait until there is a fire,” she warns, “someone will say, ‘Why didn’t you alert us?’”
Leigh Page is a freelance writer based in Chicago.
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