Operating room fires can be further eradicated by taking the time to work with other key administrators to implement a safety plan.

 The likelihood of a fire breaking out in any given operating room (OR) is small. But when it happens, the prospects for a catastrophic result are huge: The OR is home to localized oxygen-rich environments, meaning that flames tend to flash (rather than gradually build in intensity) and burn white hot. Although such fires last but a matter of seconds before they’re put out, they nonetheless pose grave danger because they usually occur on or very near the patient, producing injury and, in worst cases, disfigurement or death.

Clearly, the stakes are high, which is why the contributions of biomeds to the cause of fire safety in the OR are so important. “Hospitals are coming under greater pressure to be proactive in addressing the risk of fire in the OR, and are more and more turning to biomeds to help develop appropriate policies, procedures, and educational materials,” says Mark E. Bruley, vice president of the Accident and Forensic Investigation Group of ECRI (formerly the Emergency Care Research Institute), a nonprofit health services research agency and an evidence-based practice center of the Agency for Healthcare Research and Quality in Washington, DC.

Since 1971, ECRI—which produces more than 30 publications and databases dealing with the selection, safe use, and management of technology—has operated a medical device problem-reporting program that tracks the incidence of OR fires. ECRI finds that these happen at a rate of about twice per week. Albert de Richemond, associate director of ECRI’s Accident and Forensic Investigation Group, thinks it’s possible that many more OR fires occur than are reported because they’re deemed too small or inconsequential to bother disclosing.

Three Types of Events
According to Bruley, approximately 70% of OR blazes are sparked by monopolar electrosurgical cutting and cauterizing equipment. Lasers are blamed for about 10% of reported incidents. Other sources of ignition include defibrillators, battery-powered electrocautery pencils, and fiber-optic light systems.

Adds de Richemond, “In the last 18 months, we’ve seen two incidents of fires starting within surgical booms, those telescoping columns and mobile arms a number of hospitals have taken to utilizing in recent years as a means of getting power cords and medical gas lines up off the floor. What we believe happened both times was the fittings that connect the gas lines to the outlets at the end of the boom became loose, which allowed oxygen or nitrous oxide to flow into the space inside the boom and create an oxygen-enriched environment there. Electrical lines are also inside these booms, so all it takes to get a fire going is for someone to plug in a device with its switch already in the ‘on’ position [thereby causing arcing].”

OR fires fall into three categories. One, says Bruley, is a fire that involves the patient; these are properly called surgical fires. The second category is device fires (such as an item of powered equipment that bursts into flames when a capacitor fries and touches off the entire circuit board). The third category is “other” (for instance, a blaze that begins in a trash receptacle after someone carelessly discards an uncapped cautery pencil).

OR fires merit the label “serious” when they cause patients to suffer second- or third-degree burns. As many as 20% of the OR fires in a typical 12-month span are classified as serious. Serious OR fires claim one or two patient lives annually, de Richmond says. With regard to surgical fires, roughly 44% occur in the vicinity of the patient’s head and neck. That’s up from 34% about a decade ago. Bruley attributes the rise to the greater use of open oxygen sources (such as nasal cannulas or face masks) in minor procedures. Device fires often result in total loss of the involved equipment, but not always.

“Sometimes the device is only partially damaged and can be repaired,” de Richemond says. “And sometimes it’s damaged not by the fire but by having been saturated with the spray from a fire extinguisher.”

Biomeds as a Key Resource
Relatively few though the number of OR fires may be, the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) thinks even one is too many. Peter B. Angood, MD, vice president and chief patient safety officer for JCAHO, says the Joint Commission is striving to build awareness of the problem and “set the expectation that, related to the perioperative environment, there should be no fires, no burns.”

But what a hospital must have in place in the way of fire safety to receive the Joint Commission’s blessings are not clearly delineated for a reason. Says Angood, “Although historically the Joint Commission sets standards and heightens awareness, we don’t in all circumstances prescriptively mandate specific actions. We recognize that each institution in its own environment is unique. Therefore, we want each hospital to demonstrate the fire-safety processes and systems that work specifically for it as an individual institution.”

Bruley contends that JCAHO’s stance on fire safety empowers biomeds, transforming them into an indispensable resource for hospitals seeking to formulate such programs. “Biomeds are being invited to work with OR directors and risk-management officers to ensure that the correct policies, procedures, and educational programs are developed for the surgeons, the anesthesiologists, and the OR nurses,” he says.

That’s close to what’s transpired at Hanover Hospital in Hanover, Pa, where biomeds helped put in place (and now are active participants in) a fire-safety plan first articulated in 2002. A key feature of that plan is its unannounced fire drills, conducted at least once per year.

“We stage these drills at times when surgeons are performing operations in order to make the simulation as close to real life as possible,” says Joseph V. Bellino, CHPA, HEM, CSE, director of safety, security, and emergency management at the 120-bed, acute-care/community hospital.

A mock evacuation is included in the drill, but only one of the hospital’s eight ORs is in fact cleared out (so as not to disrupt in-progress surgeries any more than necessary). Following a real fire, the hospital’s clinical engineer would be called in to perform an after-action investigation, Bellino indicates.

But that’s only one piece of the biomed role at Hanover Hospital. Along with it are several other essential tasks.

“The clinical engineering department makes sure electrically operated equipment in the OR is in good working order and properly grounded,” Bellino says. “They conduct safety inspections in accordance with manufacturer-recommended PM schedules. They also keep an eye open for newly introduced products that promote OR fire safety.”

Since the fire-safety plan was implemented, no hazardous situations have cropped up at Hanover Hospital.

“We have been really good about doing what we are supposed to in order to be in compliance with the plan,” Bellino says.

Unquestionably, a single serious fire in the OR can ruin a hospital’s whole day, with liability running into the multiplied millions of dollars after the civil damage awards, attorney fees, and, possibly, regulatory fines or criminal prosecutions are tabulated. “Accidents happen,” Bellino says. “But if at least you’ve got in place a good fire-safety plan, then everyone is going to know you did everything humanly possible to protect people. Protecting people is what’s most important in all this.”

Rich Smith is a contributing writer for 24×7.

Fire Safety Dos and Don’ts
A fire ignites in the operating room (OR), right on top of the patient. Should a fire extinguisher be used to quell the flames? Probably not, says Albert de Richemond, associate director of the Accident and Forensic Investigation Group at ECRI.

The reason: not enough time to find it, pull the pin, aim, and squirt. “Usually, in a surgical fire, the doctor or nurse will have an instinctive reaction to the sight of the flame, and that is to grab the source of the fire and yank it off the patient, so no one in those initial seconds is really going to be thinking about getting an extinguisher,” he says. However, that doesn’t mean fire extinguishers shouldn’t be available in the OR. de Richemond recommends the CO2 type (not water or dry chemicals, either of which can contaminate the incision area or, in the case of water, present an electrical hazard). Extinguishers also should be the easily handled 5-pound size.

Sometimes found in an OR are fire blankets. The ECRI strongly argues against their use for the reason that they can put the patient at greater risk of injury than might otherwise be the case.

“If you throw a fire blanket over the patient and there’s oxygen flowing underneath it, the fire will continue to burn,” says ECRI’s Mark E. Bruley, vice president of the Accident and Forensic Investigation Group. “And if there’s not oxygen flowing underneath, at the very least you’re going to trap heat and smoke against the patient’s body.”

Other advice from ECRI for biomeds with regard to OR fire safety:

• Make sure that user manuals for electrosurgical units and lasers are readily available for review by OR staff. Proper use of those devices can help reduce the risk of fire, Bruley explains. If your hospital provides annual or biannual fire-safety training to the staff, offer to assist with that activity. For example, “Many hospitals show an educational video on fire prevention; you should make yourself available to answer viewer technical questions afterward,” Bruley says.

• Know who’s responsible for taking care of what in the OR; otherwise, certain preventive maintenance (PM) chores might fall through the cracks. PMs not done increase the risk of electrical faults sufficient to spark a fire, Bruley reminds.

• Stick to your PM schedule. In particular, if your ORs are equipped with surgical booms, be sure to periodically check the gas-line fittings and the integrity of the electrical wiring, de Richemond says. —RS