Risk Management

Preventing and Managing Surgical Fires

Anne M. Menke, RN, PhD, OMIC Risk Manager

Digest, Summer 2006

As the Closed Claim Study in this issue illustrates, there is much ophthalmologists, anesthesiologists, nurses, and surgical facilities can do to avert these rare but devastating occurrences. Accordingly, many professional organizations have issued guidance, most of it based upon the research of ECRI’s Accident and Forensic Investigation Services. Moreover, accrediting organizations have made minimizing OR fires a compliance issue for many ophthalmologists who own or operate accredited office-based surgery suites or ambulatory surgery centers. The Joint Commission on Accreditation of Healthcare Organizations included surgical fire prevention in its 2005 and 2006 National Patient Safety Goals, and the Centers for Medicare and Medicaid regards this risk management effort as a condition of participation. This Hotline article will present actions ophthalmologists can take to protect themselves, their patients, and the entire surgical staff.

Q  What causes surgical fires?

A  Three elements are needed: oxygen, fuel, and a spark, and all are present wherever surgery is performed.Oxygen is abundant in the operative setting; heavier than air, it pools under drapes. The list of fuels is extensive, and includes prep solutions, ointments, cotton balls, drapes, sponges, endotracheal tubes, masks and tubing, and the patient’s hair, especially the fine hair on the face. The spark is provided by electrosurgical units, electrocautery units, and lasers.

Q  What precautions need to be taken before the surgery begins? As the surgeon, am I responsible for these?

A  The entire surgical team must cooperate to prevent fires, and as the surgeon, you can take a leadership role. If flammable preps such as alcohol are used, allow them to fully evaporate and dry before draping the patient, and check for pooling or wicking.[1] Arrange the drapes to fullyexpose the face; this helps minimize oxygen and nitrous oxide buildup underneath. Place suction under the drapes to scavenge oxygen and further reduce the concentration of pooled oxygen. Use a properly applied incise drape, if possible, to help isolate head and neck incisions from oxygen-enriched atmospheres and from flammable vapors under drapes. As a general policy, use air or ≤ 30% oxygen for open delivery during procedures. Coat facial hair near the surgical site with water soluble surgical lubricating jelly to make it nonflammable. Moisten sponges, gauze, and pledgets (and their strings) to make them resistant to ignition; keep a water sponge on the Mayo stand for this purpose.

Q  Are there steps I should take when using electrosurgery, electrocautery, or laser surgery?

A  Yes. Communicate with anesthesia personnel about the need for oxygen and inform them of planned use of equipment that could cause sparks, such as cautery units and laser. Ask the anesthesia provider to stop using supplemental oxygen (if > 30%) at least one minute prior to and during the use of the unit if possible. Use clear methods to communicate the use of oxygen, i.e., “Oxygen on!” and “Oxygen off!” Activate the unit only when the active tip is in view, and deactivate the unit before the tip leaves the surgical site. Place electrosurgical electrodes in a holster or another location off the patient when not in active use. Place lasers in standby when not in active use. Do not place rubber catheter sleeves over electrosurgical electrodes; instead, use manufactured insulated electrodes. Keep the endoscope light away from drapes to prevent heat from igniting the drapes.

Q  What should I do if I notice a surgical fire?

A  First, the fire needs to be extinguished. If it is small, pat out or smother it, or remove the burning material from the patient.[2] For large fires on the patient, stop the flow of breathing gases to the patient, and remove the burning material from the patient. At times, a fire extinguisher may be needed. Next, care for the patient by resuming ventilation, controlling bleeding, evacuating from the room if there is ongoing danger from smoke or fire, examining the patient for injuries, and treating as needed. If the fire cannot quickly be controlled, notify other operating room staff and the fire department. Save all involved materials and devices for later investigation. Contact the risk manager of the facility, as well as OMIC’s Risk Management Department, for assistance in discussing the fire with the patient and in determining reporting obligations.

1. Recommendations are from “Only You Can Prevent Surgical Fires: Surgical Team Communication is Essential.” ECRI. This free poster is available at ecri.org.

To order in color or to obtain more information about surgical fires, contact ECRI at 1-(610) 825-6000.

2. Recommendations are from “Surgical Fires,” Operating Room Risk Management, ECRI, 2004.