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Four steps can reduce the risk of surgical fires
Control O2, drapes, placement of electrodes
Of the more than 27 million outpatient surgeries performed each year, approximately 100 surgical fires occur, resulting in up to 20 serious injuries and one or two patient deaths annually, according to the Food and Drug Administration (FDA) and ECRI, a Plymouth Meeting, PA-based nonprofit health research firm.1,2,3
"I believe that surgical fires are more common than the numbers indicate because near misses such as a tonsil sponge that catches on fire but is put out before any injury occurs is not considered a surgical fire by many people because the fire was easily put out," says Vangie Dennis, RN, CNOR, advanced technology coordinator in the surgical services support department at Promina Gwinnett Hospital System in Lawrenceville, GA.
The belief that surgical fires are underreported, along with the serious threat to patient safety that a surgical fire represents, were reasons that the Joint Commission on Accreditation of Healthcare Organizations has issued a sentinel event alert on surgical fires, says Richard J. Croteau, MD, executive director for strategic initiatives.
"While a surgical fire that results in a patient death or permanent loss of function is a reviewable sentinel event that should be reported to Joint Commission, our sentinel event system is a voluntary reporting system," he says.
Near-miss events that do not result in death or injury are not reviewable by Joint Commission, but the agency encourages every organization to perform a root-cause analysis on each incident to determine how it happened and what can be done to prevent it from happening again, Croteau says.
Analysis of case reports show that the most common ignition sources of surgical fires are electrosurgery (68%) and lasers (13%). The most common locations of surgical fires are in the airway (34%) and head or face (28%).3
Prevention of surgical fires requires a collaborative effort between nursing, surgeons, and anesthesiologists to develop protocols that minimize the risks, says Dennis. Her first electrosurgery and laser policies that address fire risks were developed almost 15 years ago, she says.
"It was a tough sell to surgeons to have them change some of their traditional ways because I had to prove that a fire in an airway could happen when none of them had ever seen one occur," she says.
After literature searches and reviews of FDA alerts, Dennis was able to convince surgeons of the need to approach electrosurgery and laser surgery in a different manner because they do carry a higher risk of fire.
"Our anesthesiologists have been extremely supportive of our efforts to reduce the risk of fire and developed their own, very aggressive practice guidelines specifically for head and neck procedures to eliminate factors that contribute to surgical fires," says Dennis. [To review a copy of Gwinnett Hospital System’s laser, electrosurgery, and anesthesia guidelines, go to www.samedaysurgery.com and click on the "toolbox." Your subscriber number on your mailing label is your user name. Your password is sds (lowercase) plus your subscriber number (no spaces).]
Some of the steps recommended by ECRI, many of which have been incorporated into Gwinnett Hospital System’s policies, include:
• Question the need for 100% O2 during facial surgery; as a general policy, use air or FiO2 at 30% or less for open delivery.
"Our anesthesiologists primarily use compressed air or straight air to maintain patients oxygen levels and only use a level of O2 needed to maintain the patient’s SAO2 at 92% at a minimum," says Dennis.
Her policy currently calls for a maximum FiO2 at 40% at this time, but she is planning to reevaluate this policy in light of ECRI’s recommendations, she adds.
• Do not drape the patient until all flammable preps have fully dried.
"Another safety step we take is to use drapes that allow us some reaction time if a fire should occur," says Dennis. She purchases Kimberly Clark (Roswell, GA) drapes that melt away if they ignite as opposed to producing a flash fire.
"Although there is a potential for second- or third-degree burns to the patient, this is less dangerous than the potential injuries from a flash fire," Dennis adds.
• Keep sponges wet during oropharyngeal surgery.
"The policy that our surgeons found most irritating 15 years ago was the one that prohibits dry sponges in the area of any laser or electrosurgery equipment," says Dennis. While surgeons insisted that wet sponges would not control bleeding, Dennis and her staff explained that they could use dry sponges if the electrosurgery equipment was not in the area, but they had to replace them with wet sponges while operating.
"We explained that if a flash fire occurred in the airway, it was far more serious than some bleeding," she adds.
• Place electrosurgery electrodes in a holster or away from the patient and lasers in standby mode when not in active use.
"Electrosurgery electrodes stay hot for a short time after they are shut off, so we make sure they are never near a drape," Dennis points out. "We also don’t allow metal clamps to be used to hold electrosurgical equipment because the metal can conduct any heat or electrical current that could trigger a fire."
Another change in anesthesiology practice that improves patient safety is the elimination of nitrous oxide in any cases in which O2 is used, says Dennis. "Nitrous oxide is flammable when in the presence of O2, so it cannot be used for induction in tonsillectomies," she says.
While cuffed endotracheal tubes are preferred because they minimize any leaking of O2, one exception is tonsillectomy in a young child in which an uncuffed endotracheal tube must be used, points out Dennis. "In these cases, nitrous oxide may be used to induce the patient; then it is turned off, and the O2 is raised," she explains.
Dennis also recommends that every policy include a description of how to manage the treatment of a patient during and after a surgical fire.
"Although surgical fires are not a common occurrence, there are few other incidents that can happen during surgery that can be as life-threatening and devastating to a patient," she says. "We need to make sure that anesthesiologists, surgeons, and nurses work together to minimize any risk of fire during surgery."
1. Hall MJ, Owings MF. 2000 National Hospital Discharge Survey. Advance data from vital and health statistics. Hyattsville, MD: National Center for Health Statistics; 2002.
2. Hall MJ, Lawrence L. Ambulatory surgery in the United States, 1996. Advance data from vital and health statistics. Hyattsville, MD: National Center for Health Statistics; 1998.
3. ECRI. A clinician’s guide to surgical fires: How they occur, how to prevent them, how to put them out. Health Devices 2003; 32:5-24.
Sources and Resources
For more information, contact:
• Richard J. Croteau, MD, Executive Director for Strategic Initiatives, Joint Commission on the Accreditation of Healthcare Organizations, One Renaissance Blvd., Oakbrook Terrace, IL 60181. Telephone: (630) 792-5000. Fax: (630) 792-5005. E-mail: firstname.lastname@example.org.
• Vangie Dennis, RN, CNOR, Advanced Technology Coordinator, Surgical Services Support, Promina Gwinnett Hospital System, 1000 Medical Center Blvd., Lawrenceville, GA 30045. Telephone: (678) 442-4179. Fax: (678) 442-2936. E-mail: email@example.com.
ECRI offers a clinical web site that includes published articles and educational posters on surgical fires that are free. Go to www.mdsr.ecri.org and enter "fires" into the Search Terms line.
To read the sentinel alert regarding surgical fires, go to www.jcaho.org. Under "Latest Newsletters," click on "Sentinel Event Alert — Issue 29."