Surgical Fire Prevention and
Management
Webinar Presented for:
November 13, 2012
Radisson Hotel
Trevose, Pennsylvania
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©ECRI Institute and ECRI Institute PSO 2012
New Clinical Guidance on Surgical
Fire Prevention and Management
Mark Bruley, BS, CCE
Vice President, Accident and Forensic Investigation
ECRI Institute
5200 Butler Pike, Plymouth Meeting, PA
Tel: 610-825-6000, Ext. 5223
Email: mbruley@ecri.org
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©2012 ECRI Institute
New Clinical Guide to Surgical
Fire Prevention1
New recommendations’ focus

Developed by ECRI Institute in collaboration with the Anesthesia
Patient Safety Foundation (APSF)
1. Eliminate open O2 delivery on the face
2. Secure patient airway if increased O2
needed
3. Use Pre-Op “Time-Out” to assess fire risks
1. Health Devices 2009 Oct;38(10): 314-332.
See www.ecri.org/surgical_fires.
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©2011 ECRI Institute
History – Surgical Fires
1800s-1980: Known and feared risk
 Flammable anesthetics
―Ether
―Ethyl
Chloride
―Cyclopropane
―Fluroxene
 Technological
―Antistatic
fixes
precautions
―Conductive breathing circuit components
―Equipment chassis snorkels for fresh air
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©2011 ECRI Institute
History – Surgical Fires
1980-2012: Insidious Hazard
 Oxygen enrichment under drapes
 Alcohol prepping agents
 Poor recognition of risk by clinicians
 No collaborating stakeholders
 NO technological remedies (e.g., no fire
retardant drapes)
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©2011 ECRI Institute
Low-Incidence Medical Errors
(Technology and “Wrong Site”)
Surgical Fire Prevention:
Need for Action is Now Acknowledged

1.
2.
3.
Top 3 Errors*:
Retained Instruments
“Wrong Site” Surgery
Surgical Fires

*Pennsylvania Patient Safety Authority. Three “never complications
of surgery” are hardly that. Pa Patient Saf Advis 2007 Sep;4(3):82.
[cited October 2, 2009]. Available from Internet:
https://www.ecri.org/Documents/PA_PSRS/2007.09_Advisory.pdf
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©2011 ECRI Institute
Others
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MRI Projectiles
Medical Gas Mix-ups
Transplant Tissue Matching Errors
Luer Mis-Connections
ECG/Apnea electrode
electrocutions
Endoscope Sterilization Failures
CP Bypass Gas Embolism
Bed Crushings
Suffocation (bed rail or mattress)
New Statistics: Surgical Fires
2007: Pennsylvania Patient Safety Reporting
System (PA-PSRS)*
 28 fires per year (based on 3 yrs of data)
 PA data scaled to USA

550 to 650 fires per year
Mostly minor

 2011 update review of PA-PSRS data underway
– Initial impression is of similar numbers.
*Pennsylvania Patient Safety Authority. Three “never complications
of surgery” are hardly that. Pa Patient Saf Advis 2007 Sep;4(3):82.
[cited October 2, 2009]. Available from Internet:
https://www.ecri.org/Documents/PA_PSRS/2007.09_Advisory.pdf
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©2011 ECRI Institute
Statistics: Anatomic Locations
Anatomic Locations
 44% Face, Head, Neck, Upper Chest
 21% Airway
 26% Elsewhere ON body
 8% Elsewhere IN body
>70% involve oxygen enrichment.
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©2011 ECRI Institute
Surgical Procedures and Fires
(11 Case Reports in Health Devices Jan 2003)
Facial surgery
ECMO cut down
Carotid
endarterectomy
Temporal arterectomy
Tracheostomy
Oral surgery
Tonsillectomy
Infant surgery (PDAs)
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©2011 ECRI Institute
Pneumonectomy
Bronchoscopic
surgery
Cervical conization
Hernia (infant)
Circumcision (infant)
C-section
Pacemaker replaced
Neurosurgery (laser)
News Media: Putting a Face on Patient Safety
Sept 25, 2008
August 18-25, 2003
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L.A. Times
October 7, 1988
News Media: Recent- November 2011
Medical References on Surgical Fires:
Hundreds published over past 30 years.
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Bibliography: www.ecri.org/surgical_fires
2003: Joint Commission
Sentinel Event Alert
 Administration should alert of surgical
staff on controlling ignition sources
 Manage fuels, especially flammable
preps
 Establish guidelines for minimizing
oxygen under drapes
 Establish testing procedure for staff
 Report fire incidents
JCAHO. Preventing surgical fires [Sentinel Event Alert]. 2003 June 24; Issue 29.
On Web: www.jcaho.org.
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©2011 ECRI Institute
2005-2009: Joint Commission
Patient Safety Goals for Ambulatory
and Office-based Surgery
 Educate staff on how to:
 Control heat sources
 Manage fuels
 Establish guidelines to minimize O2 under drapes
 Include independent licensed practitioners and
anesthesia providers
http://www.jointcommission.org/PatientSafety/NationalPatientSafetyGoals/06_npsg_amb.htm
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©2011 ECRI Institute
New Initiatives 2006-2009
 AORN Fire Safety Tool Kit (2006)
 Amer Soc Anesthesiologists (ASA): Practice Advisory
for the Prevention and Management of Operating
Room Fires (May 2008)
 Accepted by Amer Coll Surgeons and Amer Acad
Otolaryngologists - Head & Neck Surgeons
 ASA and (APSF) Educational Initiative with ECRI
Institute production of APSF peer-reviewed training video
 CME accredited online course coming 2012.
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©2011 ECRI Institute
New Initiatives 2010 - 2011
 APSF Educational video, produced by ECRI, released
in April 2010
 ECRI Institute completing APSF sponsored CME
accredited online course: coming 2011.
 FDA’s Preventing Surgical Fires initiative website
(new in Oct 2011)

Aggregates links to APSF, ASA, AORN, ECRI Institute
recommendations for surgical fire prevention.
www.fda.gov/preventingsurgicalfires
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©2011 ECRI Institute
Misconceptions
Drapes are fire retardant treated. NO*
Betadine™ skin prep is flammable. NO
Get a fire extinguisher first to fight the fire. NO
Lanugo hair is highly flammable in air. NO
* There are no fire retardant drapes. The technology
does not exist to make a textile that is fire retardant
in elevated O2 levels.
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©2011 ECRI Institute
How do we prevent
surgical fires?
Remedy lies within
surgical team.
Poster available free at:
www.ecri.org/surgical_fires
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©2012 ECRI Institute
APSF Surgical Fire Educational Video
www.apsf.org
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Surgical Fire –
Putting Prevention Into Action
Trans-disciplinary challenges
 Staff have different prevention responsibilities
at different times during surgery
Acute patient care needs vs. fire risks of open
O2 delivery on face
Continuing education is not a panacea
Do we accept that surgical fires may be
unavoidable?
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©2012 ECRI Institute
Trans-disciplinary Hazard
Surgical Fire Triangle
Shows the staff most capable of controlling the associated aspect.
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©2012 ECRI Institute
Oxidizers
O2 & N2O enriched atmospheres exacerbate fire risk.
Video –
O2 Enriched Ignition and Flame Spread
Royal Air Force Experiments c.1965
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©2012 ECRI Institute
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©2010 ECRI Institute
How do we prevent
surgical fires?
Remedy lies within
surgical team.
Poster available free at:
www.ecri.org/surgical_fires
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©2012 ECRI Institute
Prevention
 NEW: Control Airway to Prevent Oxygen
Enrichment Under Drapes
 Control Heat Sources
 Control Fuels
 Communicate
 Pre-Op Time Out
 Exception cases for open O2
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©2012 ECRI Institute
Pre-Op “Time Out”*
 Identify and assess fire risks
 Use of open oxygen sources on the
face?
 If YES for exceptional cases, then
what?
 Alcohol-based skin prep?
 If YES, must be dry before draping!
* Mathias JM. Scoring fire risk for surgical patients. OR Manager
2006 Jan;22(1):19-20.
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©2012 ECRI Institute
NEW APSF Prevention Algorithm 2012
Anesthesia Patient Safety Foundation. Surgical fire injuries continue to occur:
Prevention may require more cautious use of oxygen. APSF Newsletter Winter
2012; 26(3):42-43. (http://issuu.com/enews/docs/winter_2012/1)
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ECRI Institute. New clinical guide to surgical fire prevention [guidance article].
Health Devices 2009 Oct;38(10): 314-332.
©2012 ECRI Institute
NEW O2 RECOMMENDATIONS
ECRI Institute and Anesthesia Patient
Safety Foundation 2009

During Head, Face, Neck, and Upper-Chest
Surgery:
 Use only air for open delivery to the face if the
patient can maintain a safe blood O2
saturation without supplemental O2.
 If the patient cannot maintain a safe blood
O2 saturation without extra O2, secure the
airway with a laryngeal mask airway (LMA) or
tracheal tube.
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©2012 ECRI Institute
Supplemental Oxygen Exceptions
Exceptions for Open O2 Delivery on Face:
Where patient verbal responses may be required
during surgery (e.g., carotid artery surgery,
neurosurgery, pacemaker insertion) and where open
O2 delivery is required to keep the patient safe.
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©2012 ECRI Institute
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©2012 ECRI Institute
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©2012 ECRI Institute
Ignition Sources
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©2012 ECRI Institute
Heat, sparks, and flares from electrosurgery
are often ignition sources.
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©2012 ECRI Institute
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©2012 ECRI Institute
Extinguishing
Poster available free at:
www.ecri.org/surgical_fires
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©2012 ECRI Institute
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©2012 ECRI Institute
Extinguishing: Pat out if very small.
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©2012 ECRI Institute
Extinguishing: Rip off!
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©2012 ECRI Institute
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©2012 ECRI Institute
Extinguishing: Pull out!
• Burned tracheal tube (top) from
fatal fire during tracheostomy.
• Tube was not removed
immediately when fire started.
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©2012 ECRI Institute
Extinguishers: Rarely Needed in OR
For placement in each
O.R. and use on patient:
CO2 Extinguisher
Not:
Water, dry chemical,
water mist, or fire
blanket
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©2012 ECRI Institute
New Clinical Guide to Surgical
Fire Prevention1
 New recommendations’ focus
1. Eliminate open O2 delivery during
sedation for head, face, neck, and upper
chest surgery
2. Secure patient airway if increased O2
needed
3. Use Pre-Op “Time-Out” to assess fire
risks
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©2012 ECRI Institute
Starting point for
your policies and
procedures.
Full guidelines: see
Health Devices
2009 Oct; 38(10).
Poster available free at:
www.ecri.org/surgical_fires
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©2012 ECRI Institute
New Continuing Education Video and
On-line Web Course
 A new video on surgical fire prevention
has been produced by ECRI Institute
for the Anesthesia Patient Safety
Foundation (APSF). Released in April
2010. Free on the Web.
 On-line course with CME credits:
Fall 2012 (from APSF through
ECRI Institute)
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©2012 ECRI Institute
Questions?
Fire Prevention and
Management in the
Surgical Setting
Webinar Presented for:
Association of periOperative Registered Nurses
October 22, 2012
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©2012 ECRI Institute
For More Information
Posters and Bibliography: www.ecri.org/surgical_fires
Video, Algorithm, and CME course:
www.apsf.org
FDA Initiative: www.fda.gov/preventingsurgicalfires
 ECRI Institute. New clinical guide to surgical fire
prevention [guidance article]. Health Devices 2009
Oct;38(10): 314-332.
 Contact:
Mark Bruley
Vice President, Accident and Forensic Investigation
ECRI Institute
Tel: (610) 825-6000 ext. 5223 Email: mbruley@ecri.org