Prevention and
Management of an OR Fire
Speaker
Sue Dill Calloway RN, Esq
AD, BA, BSN, MSN, JD CPHRM
President
Patient Safety and Health Care
Consulting
5447 Fawnbrook Lane
Dublin, Ohio 43017
614 791-1468
sdill1@columbus.rr.com
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Headlines You Don’t Want to See
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A Patient Seriously Burned from an OR Fire
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Another Patient Seriously Burned
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4 Year Old in OR Fire Case
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Surgeon Accused of Covering Up OR Fire
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New Clinical Guide to Surgical Fires
 ECRI and the Anesthesia Patient Safety Foundation
have issued new clinical guidelines to surgical fire
prevention
 Recommendations include two important things
 Eliminate the traditional practice of open delivery of 100%
oxygen during sedation
 Securing the airway is recommended if the patient
requires an increased oxygen concentration
 The surgery team should talk about the risk of a
surgical fire before each surgery
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New Clinical Guide to Surgical Fires
 Surgical fires is one of the three never events along with
wrong site surgery and leaving an instrument in the
patient
 65% of fires occur with high concentrations of oxygen
around the face, neck, and upper chest
 Fires in oxygen rich atmospheres ignite more easily,
burn hotter, and spread quicker
 The goal is to stop open oxygen delivery around the
head and upper chest
 If oxygen is needed use the minimum and follow the
new guidelines
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New Clinical Guide to Surgical Fires
Carefully arrange surgical drapes to minimize
oxygen build up underneath
Always make sure the surgical prep is dry
before draping
Use only air for open delivery to the face
 Provided that a spontaneously breathing sedated
patient can maintain his or her blood oxygen
saturation without extra oxygen
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New Clinical Guide to Surgical Fires
 If the patient cannot maintain safe blood oxygen
saturation without supplemental oxygen, secure the
airway by using a laryngeal mask airway or tracheal
tube, so that oxygen-enriched gases do not vent under
the surgical drapes
 Discontinue the traditional practice of open delivery
of 100% oxygen with limited exceptions
 Suggest may want to require that all staff watch the
video on surgical fire prevention and management
 It includes the new recommendations for controlling oxygen
delivery by minimizing the presence of oxygen rich
environment of the head, face, neck and upper chest
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Fire Safety Video
http://www.apsf.org/resour
ces_video.php
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Fire Safety Video
APSF or Anesthesia Patient Safety
Foundation, with the assistance of ECRI, has
a 18 minute video
On Prevention and Management of an OR
Fire
Anyone can watch the video on their
computer
Can also request a complimentary DVD copy
 Available at http://www.apsf.org/resources_video.php
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ECRI’s Surgical Fire Prevention Website
www.ecri.org/surgical_fires
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ECRI Has 2 Posters for Your OR
 Only You Can Prevent Surgical Fires
– Oxygen and nitrous oxide increase the flammability of
drapes, plastics, and hair
– Do not apply drapes until all flammable preps have
dried as oxygen can be trapped under the drapes
– Moisten sponges to make them ignition resistant in
oropharyngeal and pulmonary surgery
– Fiberoptic light sources can start a fire. Complete all
cable connections before activating the source. Place
the source in the standby mode when disconnecting
cables
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ECRI Has 2 Posters for Your OR
 Only You Can Prevent Surgical Fires (continued)
 Has important recommendations for surgery during head,
neck, face, and upper chest surgery since 65% of the
burns occur here
 Begin with a 30% delivered O2 and increase if necessary
 For unavoidable open O2 delivery above O2, deliver 5 to
10 L/min of air under the drapes to wash out the excess
O2
 Poster includes recommendations during
oropharyngeal surgery, tracheostomy,
bronchoscopic surgery and when using
electrosurgery, lasers, or electrocautery
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Posters for the OR
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Emergency Procedure Extinguishing a Surgical Fire
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AORN Poster
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Could You Catch Fire During Surgery?
 Fires in operating rooms happen at
least 600 times a year
 ECRI has 1 to 2 fires reported to
them per week
 Pa Patient Safety Authority cited the
chances of a surgical fire in Pa at 1 in
87,646 operations
 For Pa this averages 28 surgical fires
per year
Could You Catch Fire During Surgery?
 Only 5% of the fires cause harm to patients
 10-20 patients are seriously burned every year
 1 to 2% are fatal
 Mostly involving airway fires
 70% of fires involve electrosurgery equipment
 10% involve lasers
 20% are electrocautery equipment and fiberoptic
light sources
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What Are the Highest Surgical Fire Risks?
 The following examples of high-risk procedures
provided by ASA are ranked in descending order
based on fire incidence:
 Removal of lesions on the head, neck, or face
 Tonsillectomy
 Tracheostomy
 Burr hole surgery
 Removal of laryngeal papillomas
 Source: American Society of Anesthesiologists (ASA) Task Force on Operating Room Fires.
Practice advisory for the prevention and management of operating room fires. Anesthesiology 2008
May;108(5):786-801.
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Pa Patient Safety Authority
http://patientsafetyauthority.org/ADVISORIES/AdvisoryLibrary/2010/Jun7(2)/
Pages/60.aspx
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Airway Fires During Surgery
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Did You Know?
 75% involve oxygen enriched
atmospheres under surgical
drapes
 Oxygen enriched
atmosphere are created
when oxygen at
concentrations above 21% in
ambient air provided by face
mask, ET tubes or nasal
cannula
 4% involve alcohol-based
skin prepping agents
Location of Surgical Fires
 44% face, head, neck and
chest
 Another source (APSF) says
65%
 21% airway
 26% elsewhere on the
body
 8% elsewhere in the body
 Source: ECRI Surgical Fires July 2010
Fire Triangle
 Preventing OR fires is a
team approach
 Each member of the
surgical team is involved
with one or more sides
of the triangle
• Ignition sources
• Oxidizers
• Fuels
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Ignition Sources
 Surgeons usually have the ignition source
 Electrosurgical or Electrocautery devices
 Lasers, heated probes
 Drills and burrs, argon bean coagulators
 Fiberoptic light cable sources
 Defibrillators paddles or pads
 Ignitions sources are 70% electrosurgery, 10%
laser, and 20% are cautery, light sources, bur
sparks, or defibrillators
Oxidizers
 Anesthesia usually bring the
oxidizers
 Oxygen-enriched
atmospheres
 Nitrous oxide
 Medical compressed air
 Ambient air
Fuels
 Nurses usually bring the fuel
 Make sure the surgical prep is dry!!!
 Surgical drapes, mattresses, sheets, gowns, towels, etc
 Volatile organic chemicals, packing material
 Body hair, gloves, smoke evacuator hoses, flexible
endoscopes
 Intestinal gases and tracheal tubes
 Body tissue, adhesive tape, ointments
 Aerosol adhesives, Alcohol, Degreasers (ether, acetone)
 Tinctures and surgical skin prep (Hibitane, DuraPrep,
Chloraprep, etc.)
– The list is seemingly endless
Do You Know the Following?
 Is the hallway free of clutter?
 Where is the oxygen or medical gas shut-off valve?
 What is the coverage area of this zone?
 Where is the fire alarm pull stations and exits?
 Where is the hallway fire extinguisher, and what
type is it?
 Who is the spread of smoke prevented?
 By closing the doors or using smoke doors and air-duct
dampers
 Source:. Steelman VM. Where there's smoke, there's ...
AORN Journal 2009; 89:825-827.
Do You Know the Following
 Where is the fire extinguisher in the OR, and what
type is it?
 Does top management create a culture that is
supportive of fire prevention?
 How would you evacuate from this OR?
 Stretcher or OR table in corridors
 When and how do you communicate with the OR,
within the suite, with the rest of the facility and with
the local fire department?
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Do You Know the Following?
How do you operate the fire extinguisher?
Is the path to the extinguisher accessible?
Is there saline on the sterile field?
Where is the self-inflating ambu bag?
Where is the flashlight?
Can also use these during practice drill
Perioperative briefing to identify high risk
procedures before every case
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www.mdsr.ecri.org/static/surgical_fire_poster.pdf
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ASA Practice Advisory
 ASA or the American Society of Anesthesiologists
has a free 16 page practice advisory on the
prevention and management of operating room fires
 Published in 2008
 Defines the following;
 Operating room fires are defined as fires that
occur on or near patients who are under
anesthesia care, including surgical fires, airway
fires, and fires within the airway circuit
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ASA Practice Advisory
 A surgical fire is defined as a fire that occurs on or
in a patient
 An airway fire is a specific type of surgical fire that
occurs in a patient’s airway.
 Airway fires may or may not include fire in the attached
breathing circuit
 OR fires can cause burns, inhalation injuries,
infection, disfigurement, and death
 ASA recommends that every anesthesiologist
should have knowledge of OR fire safety protocols
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ASA Practice Advisory
 ASA recommends that every anesthesiologist
participate in OR fire safety education
 Education should emphasize the risk created by an
oxidizer enriched atmosphere
 ASA recommends that anesthesiologist participate
in OR fire drills and simulation training with the
entire OR team
 Team should determine if high risk situation exists
 If yes then a discussion of the strategy to prevent an OR
fire
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ASA Practice Advisory
 The protocol to prevent and manage fires should be
posted in each location where a procedure is
performed
 Each team member should be assigned a specific
fire management task to perform in the event of a
fire
 Remove the ET tube, stop the flow of airway gases, douse
with saline, etc.
 Study showed that the configuration of surgical
drapes can result in oxygen build up increasing the
risk of fire
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ASA Practice Advisory
 Studies show that replacing oxygen with
compressed air or discontinuing supplemental
oxygen for a period of time will reduce the oxygen
build up without reducing oxygen saturation levels
 Studies found that lasers, electrosurgical or
electrocautery devices are a common source of
ignition for many OR fires
 Cases found the alcohol based skin prep agents
generate volatile vapors that ignite easily
 Insufficient drying time is cause of many fires
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ASA Practice Advisory
 Studies show that conventional tracheal tubes are
more likely to ignite or melt that laser resistant
tracheal tubes when exposed to a laser
 Dry sponges and gauzes are common sources of
fuel
 Flammability of sponges, cottonoids, or packing material
is reduced when wet
 ASA has an operating room fire algorithm
 Is it a high risk procedure, are there early warning signs of
a fire, airway or non-airway fire
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ASA Practice Advisory
 Surgeon should be notified when an ignition source is
in proximity to an oxidizer enriched atmosphere or
when the concentration of oxidizer has increased
 Oxygen delivered to the patient should be as low as
clinically feasible when ignition source is in proximity
to an oxygen enriched atmosphere
 Reduction of oxygen (fraction of inspired oxygen or FIO2) is
guided by monitoring the pulse ox
 This should include measuring inspired, expired, and or
delivered oxygen
 Use of nitrous oxide should be avoided in settings that are
considered high risk for fire
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ASA Practice Advisory
 For laser surgery, the cuff of the ET tube should be
filled with saline instead of air
 The saline should be tinted with methylene blue to act as
a marker for cuff puncture by a laser
 For cases involving surgery inside the airway, a
cuffed tracheal tube should be used when
medically appropriate
 Surgeons should be advised not to enter the
trachea with an ignition source such as an
electrosurgical device
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ASA Practice Advisory
 If surgery around the face, head, or neck and
sealed gas delivery device is needed then use a
cuffed tracheal tube or laryngeal mask
 Sealed gas should be considered if exhibits oxygen
dependency during moderate or deep sedation
 If open gas system is using, such as a facemask or nasal
cannula is used, and surgery around face, neck or head,
surgeon needs to give notice before ignition source is
activated
 Anesthesiologist need to stop the O2 or reduce delivery
and wait a few minutes before activation of the ignition
source
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ASA Practice Advisory
 Management of OR fires
 Early signs of a fire may be a flame or flash,
unusual sounds, odors, smoke, or heat
 Halt the surgery
 Remove the tracheal tube for an airway fire or fire
in the breathing circuit and stop the oxygen
 Pour saline into the tracheal tube
 If fire in the patient or elsewhere remove all
drapes and burning material and extinguish
(saline, water, smothering)
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ASA Practice Advisory
https://ecommerce.asahq.org/p-303-practice-advisory-forthe-prevention-and-management-of-operating-roomfires.aspx
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ASA Practice Advisory
https://ecommerce.asahq.org/p-303-practice-advisory-for-theprevention-and-management-of-operating-room-fires.aspx
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TJC – Sentinel Alert #29
 TJC issues Sentinel Event Alert (SEA) 29 on June
24, 2003 on Preventing Surgical Fires
 Also issued SEA 17 on Fires in the Home Care
Setting
 SEA 39 focused on understanding & mitigating fire
risks rather than prohibiting patient care products
 Discusses how you need all three things of the fire
triangle to start a fire
 Heat fuel, and oxygen
www.jointcommission.org/sentinel_event_a
lert_issue_29_preventing_surgical_fires/
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SEA 17 Fires in the Home Care Setting
www.jointcommission.org/sentinel_event_alert_issue_
17_lessons_learned_fires_in_the_home_care_setting/
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TJC 3 Recommendations
 Everyone should be aware of the importance of controlling
heat sources by following laser and electrosurgical units
(ESU)
 Manage fuel by making sure all preps (chloraprep,
etc.) have had enough time to dry
 Establish guidelines for minimizing oxygen
concentration under the drapes
 Develop, implement, and test procedures to ensure
appropriate response to all surgical team members in the
event of an OR fire
 Report any surgical fires to TJC, ECRI, FDA, state agency
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TJC Data on Sentinel Events
 TJC reported 7391sentinel events from January of
1995 through December 31, 2010
 There were 68 fires
 TJC evaluated these fires to determine their root
causes
 The most common root cause was communication
which resulted in 33 fires
 If a hospital experiences a surgical fire TJC has a
matrix which includes which issues should be
evaluated
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Root Cause of Fires by TJC
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TJC Sentinel Event Alert 29 Preventing Fires
www.jointcommission.org/sentinel_event_alert_i
ssue_29_preventing_surgical_fires/
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CMS Hospital CoP
 Hospitals that accept Medicare or Medicaid
reimbursement must follow the hospital conditions
of participation
 The CoPs requires hospitals to have a safe
environment
 Tag 702 requires hospital to comply with the LSC
National Fire Protection Amendment or NFPA 101
 Tag 709 states must ensure life safety from fire
 Tag 714 requires the hospital to have written fire
control plans that contain provisions for prompt
reporting of fires
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www.cms.hhs.gov/manuals/downloads/som107_Appendi
cestoc.pdf
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CMS Hospital CoP
 Must report all fires to the state fire marshal
 This would include having procedures to prevent
and respond to a surgical fire
 CMS has the following on page 327 Tag 951
 Use of Alcohol-based Skin Preparations in
Anesthetizing Locations. Alcohol-based skin
preparations are considered the most effective
and rapid-acting skin antiseptic, but they are also
flammable and contribute to the risk of fire
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CMS Hospital CoP
 CMS also note the following under tag 951
 There is concern that an alcohol-based skin
preparation, combined with the oxygen-rich
environment of an anesthetizing location could ignite
when exposed to a heat-producing device in an
operating room. Specifically, if the alcohol-based skin
preparation is improperly applied, the solution may
wick into the patient’s hair and linens or pool on the
patient’s skin, resulting in prolonged drying time.
Then, if the patient is draped before the solution is
completely dry, the alcohol vapors can become
trapped under the surgical drapes and channeled to
the surgical site.
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CMS Prep Must Be Dry
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CMS Hospital CoP
 This would include having procedures to prevent and
respond to a surgical fire
 CMS issued a memo in 2004 on the procedure to follow in
the event of a fire
 Fires are to be considered a priority assignment of
immediate jeopardy
 CMS will consider all fires with serious injury or death to
be entered into their computer system as a complaint or
self reported incident
 State agency will compile information about the fire and
perform a life safety code investigation
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CMS Memo
http://www.cms.hhs.gov/SurveyCer
tificationGenInfo/downloads/SClett
er04-23.pdf
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Many Resources to Consider
 ECRI Institute
 ASA or American Society of Anesthesiologist
 APSF or Anesthesia Patient Safety Foundation
 AORN Fire Safety Toolkit or Association of
periOperative Nurses
 TJC Sentinel Event Alert
 National Guideline Clearinghouse
 MDSR – Medical Device Safety Reports
 ASHE
OR Fires Introduction
Develop a fire safety plan
Make sure OR has appropriate firefighting
equipment
 See later section on use of extinguishers
Focus on education
 Fires are less likely to occur if they act as a team
 And if surgical team understands their causes
and how to respond should one occur
OR Fires Introduction
 Develop an effective fire drill program
 Drills enable the staff to learn the plan and test the
effectiveness of he plan
 Helps to identify areas of improvement
 Schedule drills so surgeon and anesthesiologist can
participate
 Evaluate performance during surgical fire drill
 Have a competency tool for staff
 Do an annual literature review and update the policy
as needed
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OR Fires Introduction
 Have one person assigned to be the OR fire safety
officer
 Require mandatory education in orientation and
during annual skills lab
 Do a self assessment on risk of fires
 Report all fires and document
 Have policies in procedures in effect
 Watch the video on preventing fires by A
 Whatever you do don’t think this can’t happen to
you!
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Fire Risk Assessment
 AORN Fire Safety toolkit has a fire risk assessment
tool
 Circulating nurse completes the risk assessment to
determine the risk level
 Risk levels include A, B, C, D, or E
 Circulating nurse reports this during the time out
 The interventions are taken from the policy and
procedure for Fire Safety in the Perioperative
Setting
 It contains actions for each of the risks
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AORN Fire Risk Assessment Tool
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Fire Risk Assessment
 A. Is there an alcohol based prep or other volatile
chemical being used?
 If yes then prevent pooling of skin prep, removed
soaked linen, allow skin prep to dry, conduct skin
prep time out, etc
 B. Is the surgery being performed above the xiphoid
process?
 If yes then coat head and facial hair near the
surgical site with water soluble lubricant, use
adhesive incise drape etc.
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Fire Risk Assessment
 C. Is open oxygen being used?
 If yes, then configure surgical drapes to allow sufficient
venting of oxygen delivered by mask or cannula, deliver 5
to 10 L/min of air under the drapes to flush out excess
oxygen, titrate O2 to lowest %, use cuffed ET tube when
possible, stop supplement O2 for one minute before
electrosurgery, electrocautery or laser for head, neck, or
upper chest procedure etc.
 D. Is an ESU, laser, or fiber-optic light cord being
used?
 E. Are there other possible contributors like a
defibrillator, drills, saws, burrs etc.
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Prevent OR Fires During Prep
Be aware alcohol based preps are flammable
Avoid pooling or wicking of flammable liquid
preps
Allow flammable liquid preps to dry fully
before draping
Spilled or pooled agent should be soaked up
and removed from the patient
Prevent OR Fires During Prep
 Proper application of an incise drape ensures that there are
no gas communication channels from the under- drape
space to the surgical site
 Remove towels used to catch dripped flammable prep before
draping
 Keep fenestration towel edges as far from incision as
possible
 About 4% of all fires are due to alcohol bases surgical preps
 These fires are devastating because they are often
undetectable
 The blue-yellow flame of an alcohol fire can be invisible
under the bright surgical lights
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Preventing OR Fires During Electrosurgery
 Place electrosurgical pencil in holster when not in
use
 Place unit in standby mode when not in active use
 Allow the electrosurgical active electrode to be
activated only by the person wielding it
 Activate active electrode only when tip is under
surgeon’s direct vision
 Deactivate the unit before the active electrode tip
leaves the surgical site
 Instrument can momentarily retain sufficient heat for
fuel ignition
Preventing OR Fires During Electrosurgery
 If open O2 source is use,
use bipolar electrosurgery
when possible and
clinically appropriate since
bipolar creates little or no
sparking or arcing
 Never use electrosurgery
to enter the trachea
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Preventing OR Fires During Electrosurgery
Never use electrosurgery in close
proximity to fuels in oxidizer enriched
atmosphere
Never forget may need to turn off valve
for medical gases such as oxygen
Consider the use of non-thermal
surgical therapies for cutting and
coagulation
79
Reducing Likelihood of Airway Fires
 Have policy when electrosurgery will be removed
from the surgical field because of risk of fire
 Some hospitals remove the unit when the trach
tube is put on the surgical field
 Do not use electrosurgical units to cut tracheal rings
and enter the airway
 A hot electrode tip or ember could contact the tube
or tube cuff inside the trachea and ignite a fire
 Instead, use a “cold” scalpel or scissors to avoid
the risk of fire
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Reducing Likelihood of Airway Fires
 If long, insulated electrosurgical electrode probes
are needed to prevent mouth burns during
procedures such as tonsillectomies, use only
commercially available insulated probes
 Do not use red rubber catheters or other materials to
sheathe probes
 The heat from the active electrode will ignite the
rubber even in air
 When operating in the oropharynx, scavenge
around the surgical site with separate suction to
catch leaking O2 and nitrous oxide
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OR Fires in General
 Coat facial hair (including eyebrows,
beard, and mustache) near the surgical
site with water-soluble surgical
lubricating jelly to make the hair
nonflammable
 Be aware of the flammability of
tinctures, solutions, and dressings
(such as benzoin, phenol, and
collodion) used during surgery, and
take steps to avoid igniting their vapors
 Moisten sponges to make them ignition
resistant in oropharyngeal and
pulmonary surgery
Minimizing Fires During Laser Surgery
https://members2.ecri.org/Com
ponents/HRC/Pages/SurgAn17
.aspx
83
Prevention of Fires During Laser Use
 Lasers are used to cut, vaporize, or remove tissues
 Despite their many benefits, lasers can pose some
risks such as burns
 Patients have been severely burned by laser-ignited
fires
 Class 4 lasers are considered a fire hazard and
produce laser-generated air contaminants
 About 10% of all the fires are caused by lasers
 Source: ECRI Laser Use and Safety March 2011
84
Prevention of Fires During Laser Use
 Goal of the surgical fire prevention protocol includes
 Minimize or avoid oxidizer (such as oxygen) enriched
atmosphere near the surgical site as 75% of the fires
occur in oxygen enriched environments
 Safely manage the ignition source
 Safe manage the fuels
 Caution when performing laser surgery in the area
of the perineal area such as hair removal surgery
 Physicians will pack the rectum with saline
saturated gauze to prevent the unintentional
expulsion of gases (methane gas is highly flammable)
85
Prevention of Fires During Laser Surgery
 Limit the laser output to the lowest clinically
acceptable power density and pulse duration
 Test-fire the laser onto a safe surface (such as
laser firebrick) before starting the surgical
procedure to ensure that the aiming and
therapeutic beams are properly aligned
 Place the laser in standby mode whenever it is
not in active use
 Activate the laser only when the tip is under the
surgeon’s direct vision
Prevention of Fires During Laser Surgery
 Allow only the person using the laser to activate it
 Deactivate the laser and place it in standby mode
before removing it from the surgical site
 Use surgical devices designed to minimize laser
reflectance
 Never clamp laser fibers to drapes; clamping can
break the fibers
 Use a laser backstop to reduce the likelihood of
tissue injury distal to the surgical site
Prevention of Fires During Laser Surgery
 Place wetted gauze or sponges adjacent to the
tracheal tube cuff to protect the tube from laser
damage, and keep them wet
 Wet any gauze or sponges used with uncuffed
tracheal tubes to minimize leakage of gases into the
oropharynx, and keep them wet
 Keep all moistening sponges, gauze, pledgets, and
their strings moist throughout the procedure to render
them ignition resistant
 Consider the use of towels soaked in saline or sterile
water around the operative site to minimize the risk of
igniting the towels
So What’s In Your Policy?
89
Magnitude of the Problem
Known fires
•Unreported
•Near misses
ECRI Institute
 One of the richest sources
 Provide posters “Only You Can Prevent Surgical
Fires” (info@ecri.org)
 Fighting Fires on the Surgical Patient
 Extinguishing Airway Fires
 Many materials have an associated cost unless
subscriber to Healthcare Risk Control (HRC)
MDSR (Medical Devise Safety Reports)
 Excellent tool to be aware of specific equipmentboth the risk and recommendations
 Free poster
 Offers an “Electrosurgery Checklist”
 Examples
– Wrong gas in laparoscopic insufflator
– Excessive illumination during surgical microscopy
– Ignition of debris on active electrosurgical electrodes
 www.mdsr.ecri.org/summary/detail.aspx?doc_id=82
71&q=
Medical Devise Safety Report Website
http://www.mdsr.ecri.org/
93
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Electrosurgery Checklist
95
96
Can Search OR Fires
97
Fire Response
 Staff should know what to do in response to a fire
 If unexpected flash, unusual odors or unexpected
smoke
 Surgery team needs to halt the procedure
 If a fire is confirmed then stop the flow of gases
 Rapidly remove the burning material
 Water or saline fore quenching the fire should be immediately
available
 Use fire extinguisher if extensive, usually CO2 extinguisher
 Take care of the patient
98
Do Fire Drills
 Previously discussed the importance of doing fire drills
 Previous questions were provided that could be asked
during the fire drill
 AORN fire safety tool kit also has a tool on hospital fire
drill scenarios
 The scenarios have a corresponding set of roles and
checklist
 Alert team of a fire, smoother or extinguish, push back
table from field, remove burning material, assess for
secondary fire, assess patient for injuries, complete
incident report, assign person to family members, etc
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Sample Scenarios to Use for Fire Drill
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Surgical Fire
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Fire Extinguishers
 If airway fire, remove the ET tube and have another
member extinguish it and stop flow of gases
 Pour water or saline into the airway and care for the patient
 Review poster on fighting surgical fires before each
surgical procedure
 Fire extinguisher is one of those things that OR staff
seldom think about until it is needed
 OR fires occur in 3 possible locations
 In the airway
 Fires in or around the patient
 Fires elsewhere in the OR
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https://www.ecri.org/surgical_fires
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Fire Extinguishers
 Pull the pin and use sweeping motion at base of fire
 Be sure to select the right fire extinguisher
 This is decided by National Fire Protecting Agency
(NFPA) code and state law
 Fires are categorized by NFPA as:
 A Fires involving ordinary materials like burning paper, lumber,
cardboard, plastics, etc.
 B Fires involving flammable or combustible liquids such as gasoline,
kerosene, and organic solvents
 C Fires involving energized electrical equipment such as appliances,
electrical equipment, panel boxes, and power tools.
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Fire Extinguishers
 Fires are categorized by NFPA as (continued):
 D Fires involving combustible metals such as magnesium,
titanium, potassium, and sodium
 K Fires that occur in the kitchen
 The corresponding labeled fire extinguisher should
be used
 For airway fires the oxidizer is usually the sole
cause so turn the oxygen or nitrous oxide off
 Most ET tubes will not continue to burn without the
oxygen or other oxizider
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Fire Extinguishers
 PVC tubes melt and undergo a depolymerization
but does sustain the burning process
 Silicone tubes disintegrate into an ash powder
 The tube should be removed and the oxygen or
other oxidizer discontinued as previously mentioned
 Fires not extinguished by the removal of oxidizers
can usually be smothered or doused with water
 Persistent fires can be eliminated with a carbon
dioxide (CO2) extinguisher
 Make sure easy to use and readily available
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Types of Fire Extinguishers
 APSF Winter 2011 Newsletter includes information on
the types and also how they can cause medical
problems
 A: Plain water which delivers a stream of water to cool
the fire. These are prone to re-ignition and generally
not safe to use in the OR because of all of the
electrical equipment
 AC: Water mist which delivers a fine mist to cool the
fire. This is safe for electrical fires because the mist
does not allow an arc to be formed which could result
in electrocution. Need adequate volume to put out the
fire
107
108
Types of Fire Extinguishers
 BC: Dry chemical such as sodium or potassium
bicarbonate or Co2 which smoothers the fire. Fires
extinguished with CO2 are prone to re-ignition and
can cause frostbite of the skin.
 The dry chemical dust of BC and ABC can
cause respiratory irritation. The dust is
difficult to remove from moist tissue
ABC: Dry chemical and has ammonium
phosphate
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Types of Fire Extinguishers
 Halon and halotron: extinguishes the fire by
replacing oxygen and cooling and safe for electronic
devices
 Sensitizes myocardium to catecholamines and can cause
lethal arrhythmias
 Halon is being phased out because of ozone issues
 FE-36 (HFC-23fa): is a clean agent, non-toxic, ozone
safe and has no residue but is more expensive
 D and K: are only kept in locations where appropriated
and highly specific and would be used in places like the
kitchen
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Placement of Extinguisher
 Should be consistent with the local fire code and
NFPA guidelines
 NFPA recommends there should be one within 75
feet of any working area
 Should be mounted in a consistent location such as
near main door and on the left
 One hospital has a CO2 extinguisher in every OR room
and with the laser cart
 A rated extinguisher in the hall cabinets
 AC rated water mist for the MRI suite and halon and CO2
in the fire hose cabinet
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Fire Extinguishers
112
ECRI Institute Surgical Fires
113
Competency
 Hospital should make sure staff are evaluated on their
competency for fire safety
 AORN has a perioperative RN Performance Evaluation
Tool for fire safety
 AORN members have free access to their fire safety
toolkit
 Circulating nurse
 Reports and documents fire risk assessment
 Manages fuel source by preventing pooling of prep
solutions, removes prep soaked linen, provides
anesthesia a laser resistant coated ET tube
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Competency
 Circulating nurse manages ignition sources
 Keeps active electrode cords free of coils off of sterile field
 Places the electrosurgical unit (ESU) dispersive pad on a
large muscle close to the surgical site
 Inspects ESU or laser electrical cords and plugs for integrity
 Uses only connectors or adapters to connect to the ESU
which fit securely
 Sets the power setting as low as possible to achieve the
result
 Places light source in standby mode or turns it off when
cable is not in active use etc.
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AORN Competency Tool
116
Competency
 Circulating nurse manages oxidizers
 Use a pulse ox to determine oxygen level
 Titrates oxygen to lowest % to support patient’s
needs
 Configures drapes to help prevent oxygen
accumulation if mask or nasal cannula is used,
beneath the drapes
 Stops oxygen for 1 minute before using laser or
electrosurgery for head, neck, or upper chest when
requested
 Scrub nurse competencies follow
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AORN Perioperative Evaluation Tool
118
AORN Fire Safety Toolkit
http://www.aorn.org/Pr
acticeResources/Tool
Kits/
119
AORN Fire Safety Resources
120
Remember the Major Guideline Changes
 Remember the major changes in clinical practice for
face, neck, head, or upper chest surgery;
 Use only air for open delivery to the face,
provided that a spontaneously breathing sedated
patient can maintain his or her blood oxygen
saturation without extra oxygen
 Secure the airway by using a laryngeal mask
airway or tracheal tube if the patient cannot
maintain safe blood oxygen saturation without
supplemental oxygen, so that oxygen-enriched
gases do not vent under the surgical drapes
121
Remember the Major Guideline Changes
Discontinue the traditional practice of open
delivery of 100% oxygen with limited
exceptions
–Exceptions might include when the patient needs
to speak during procedure when oxygen is
delivered by a cannula or mask to maintain
adequate oxygen saturation
–Might include carotid artery surgery,
neurosurgery, and some pacemaker
implantations
122
In Summary
 Surgical fires are a preventable hazard
 Success requires understanding risks & promoting
perioperative communication among all members
of the team
 Educate staff about OR fire safety
 Have a plan to extinguish fire and protect patient
and staff
 Provide review of fire safety at least annually
 Conduct regular drills
In Summary
 Ensure staff are competent in fire safety
 Surgical Team Communication is vital and include
summary in time out
 Enriched O2 & N20 vastly increase flammability of
drapes, plastics & hair be aware of trapping under
drapes
 Delay draping until preps are completely dry
 Fiber optics can start fires complete cable connections
before activating source
 Moisten sponges to make ignition resistant in
oropharyngeal & pulmonary cases
In Summary
 If O2 & N20 are administered during oral or ophthalmic
surgery make hair near operative site nonflammable by
thoroughly coating with water-soluble surgical
lubricating jelly
 Position safety holsters for electrocautery or active
electrode in a convenient location and mandate use
 During oropharyngeal surgery scavenge deep within
oropharynx with separate suction to catch leaking O2 &
N20
 Soak gauze or sponges used with uncuffed tracheal
tubes to minimize gas leakage into oropharynx (keep
moistened)
In Summary
 Keep tip of any electrosurgical equipment in plain
view
 Eliminate the traditional practice of open delivery of
100% oxygen during sedation
 Securing the airway is recommended if the patient
requires an increased oxygen concentration
 Inspect every cable and electrical supply cord
before
 Update P&P on an annual basis and make sure
staff is aware of policy
In Summary
 Keep abreast of current literature to be aware of
newly discovered sources for fuel/ignition
 Thoroughly analyze any incidents including near
misses
 Report all fires to the fire marshal
 Be aware of the position statements of
organizations like AORN and ASA
The End
Questions
Sue Dill Calloway RN, Esq
AD, BA, BSN, MSN, JD CPHRM
President
Patient Safety and Health Care
Consulting
5447 Fawnbrook Lane
Dublin, Ohio 43017
614 791-1468
sdill1@columbus.rr.com
128
Resources
129
American College of Surgeon
http://www.facs.org/about/committees/cpc/ope
r0897.html
130
ASHE
 Organization associated with AHA
 Material covered by other resources
 Minimizing Fuel
 Risks during skin prep
 Be aware and alert to the flammability
of alcohol-based preps
 Avoid pooling or wicking of liquid preps
 Allow liquid to fully dry before draping
 Use a properly applied drape (no gas
communication channels
Other Factors Increasing Risk
 Only metal ones are nonflammable
 Endotracheal tubes most made of flammable
materials like silicone, rubber, and plastic
 Most made of flammable materials like silicone,
rubber, and plastic
 Only metal ones are nonflammable
 Increased use of disposable drapes
 Less expensive & more water resistant but burn more
readily
– Once ignited burn with alarming speed
ASHE Website
http://www.ashe.org/
133
134
SurgicalFire.org
135
Resources
 Petersen C, ed. Perioperative Nursing Data Set. 3rd ed.
Denver, CO: AORN, Inc; 2010.
 Recommended practices for electrosurgery. In:
Perioperative Standards and Recommended Practices.
Denver, CO: AORN, Inc; 2010:105-125.
 “Recommended practices for endoscopic minimally
invasive surgery.” In Standards, Recommended
Practices, and Guidelines. Denver, Co: AORN, Inc;
2010:139-174.
 “Recommended practices for laser safety in practice
settings.” In Standards, Recommended Practices, and
Guidelines. Denver, Co: AORN, Inc; 2010:133-138.
136
Resources
 Caplan RA, et al. Practice advisory for the prevention
and management of operating room fires. American
Society of Anesthesiologists Task Force on Operating
Room Fires. Anesthesiology. 2008;108:786-801
 National Fire Protection Association. NFPA 10,
Standard for portable fire extinguishers. 2011.
Chapter 5.2
 American National Standards Institute. American
national standard for safe use of lasers in health care
facilities. ANSI Z136.3 – 2005 C.9.35. Appendix: 52.
2005.
137
Resources
 ECRI. New clinical guide to surgical fire prevention.
Health Devices. 2009;38(10):314-332.
 Allen, G. “Evidence for Practice. Laser ignition of
surgical drape materials.” AORN J. 2004;80:577578.
 Andersen, K. “Safe use of lasers in the operating
room: what perioperative nurses should know.”
AORN J. 2004;79;171-178.
 Ball, Kay. Lasers: The Perioperative Challenge.
Denver, Co: AORN, Inc; 2004.
138
Resources
 Ossoff RH, Duncavage JA, Eisenman TS, Karlan
MS. Comparison of tracheal damage from laserignited endotracheal tube fires. Ann Otol Rhinol
Laryngol 1983;92:333-336.
 DuPont. DuPont fire extinguishants: DuPont FE-36
use as a fire suppressant in surgical operating
rooms. White Paper. Jan 2005. Available at:
http://www2.dupont.com/FE/en_US/products/fe36.ht
ml. Accessed January 6, 2011.
139
Resources
 Amerex Corporation. ABC dry chemical fire
extinguishant. Trussville, AL, June 2010. Available at:
http://www. amerex-fire.com/msds/msd/2. Accessed
January 6, 2011.
 H3R Aviation. Halon 1211. Larkspur, CA, August 18,
2009. Available at:
http://www.h3rcleanagents.com/downloads/Halon1211-Clean-Agents-MSDS.pdf. Accessed January 6,
2011.
 National Fire Protection Association. NFPA 10,
Standard for portable fire extinguishers. 2010. Table
6.2.1.1.
140
Resources
 Beyea, S.C. “Preventing fires in the OR. AORN
J. 2003;78:664-666.
 Flowers, J. “Code red in the OR—implementing
an OR fire drill.” AORN J. 2004;79:797-805.
 Hogan, C. “Responding to a Fire at a Pediatric
Hospital.” AORN J. 2002;75:793-800
 Salmon, L. “Fire in the OR—prevention and
preparedness.” AORN J. 2004;80:41-52.
141
Resources
 McCarthy, PM, Gaucher, KA. “Fire in the OR—
developing a fire safety plan.” AORN J.
2004;79:587-594.
 Smith, C. “Surgical fires—learn not to burn.” AORN
J. 2004;80:23-34.
 Stewart, D. “Fire and life safety for surgical
services: What’s new and what to review.” Surgical
Services Management. April 2003; 26-31.
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