Section of Pediatric Anesthesia and Operating Room Nursing Division, Riley Hospital for Children, 702 Barnhill Drive. Indianapolis, IN 46202
The emergency evacuation of an operating room may be required in the event of a fire or similar emergency. Although the vast majority of practicing anesthesiologists and nurse anesthetists will never participate in an operating room evacuation, it is important to be prepared for such an eventuality. The pediatric anesthesia group at our institution recently participated in a mock operating room evacuation drill. In this article we describe the planning and execution of this drill and some of the lessons that were learned as a result of the exercise.
Planning and Organization
The Institutional fire safety officers, the operating room fire safety officer, and nursing administration were responsible for the advance planning of the drill, which was designed to be consistent with our institutional health and safety policies. Riley Hospital for Children has 2 operating room suites. The main 13-bed operating room suite is located on the second floor of the main building in an area that is adjacent to the PACU, PICU, and immediately below the NICU. A second, 6-bed, operating room is located in the basement of the Riley Outpatient Center and is dedicated primarily to same-day surgery cases. The Riley Outpatient Center is located in a newer building that is connected to the main hospital by corridors, walkways, ramps, and steps. The emergency scenario involved a fire within the same fire zone as the main operating room, but on a different floor. The fire caused a loss of power to the main operating room and precluded evacuation to the adjacent PICU or PACU. The plan involved evacuation to the outpatient center operating rooms. The evacuation route was planned by the organizing committee prior to the drill and was approximately 300 yards in length and included 2 elevator rides. These elevators were outside the fire zone of the mock fire and were therefore thought to be safe for use. Five patient scenarios were created with volunteers or dolls representing patients undergoing surgery. The drill was performed during weekly morning conference time when the operating rooms were not occupied with elective cases. The organizers recruited a staff anesthesiologist to participate in each scenario. Each operating room had 4 nurses, 1 of whom played the role of the surgeon. Several anesthesia nurses, perfusionists, and respiratory therapists also participated. There were also several nurses acting as observers.
Conduct of the Drill
The 5 scenarios and their anesthesiologists’ response are briefly described below. The charge nurse distributed battery powered headlights to each anesthesiologist shortly after the power was interrupted. In each case, the anesthetic was continued using an intravenous technique during transport. Four of the five simulated patients arrived at the intended destination in less than 15 minutes.
- A 13-year-old undergoing a craniotomy in pins. The surgery was performed under a primarily intravenous anesthetic. At the time the power went out, the anesthesia machine and monitors were unplugged to model the power failure. There were no backup lights in the room; however, the anesthesia machine monitoring screen continued to have power from the anesthesia machine battery. This screen proved to be an unanticipated source of light. The operating room control nurse came to the room to direct the operating room team to move the patient to the outpatient OR suite. A transport monitor was sent for, which was set up as the patient’s monitor. In preparation for moving the patient, the surgeon modeled stapling the scalp closed and a portable oxygen source was obtained. With that and a flashlight, the operating room table was unlocked and the patient was moved on the OR table toward a set of elevators that was unaffected by the power failure. After navigation through the halls, an attempt was made to move the OR table into the elevator. In that process, it became apparent that the small wheels of the OR table along with the weight of the patient and table presented a significant risk of getting stuck while entering or exiting the elevator. At that point the mock drill was stopped for that patient.
- A 15-year-old undergoing a posterior spinal fusion. Because the patient was undergoing evoked potential monitoring, the anesthetic was primarily intravenous in nature; thus, it was relatively easy to prepare for transport. The wound was covered in a transparent adhesive sterile drape while illuminated by flashlight. The spine was unstable and it was thought that transport in the prone position on the operating room bed was the safest option. The patient was monitored with pulse oximetry during transport. Again, problems were encountered while moving the operating room bed in and out of elevators. An unanticipated issue was the difficulty encountered in maneuvering the heavy OR bed safely up and down the slopes connecting the 2 buildings.
- A 3-month-old undergoing a hernia repair. The wound was covered with a sterile dressing and the patient was transferred to a transport isolette, making transport through the hospital relatively straightforward. Ventilation was maintained with a self-inflating resuscitation bag. A pulse oximeter was used for monitoring during transport.
- 6-month-old undergoing a VSD repair. Initially there was confusion about how to transport all of the supplies needed to maintain anesthesia, such as drugs, intravenous fluids and tubing, extra endotracheal tubes, and other equipment. Most items were simply placed at the head of the operating room table by the patient’s head or in a large plastic bag found in the operating room. The biggest obstacle encountered involved the moving of the operating table in conjunction with the cardiopulmonary bypass machine. The transport was slow and was frequently interrupted in order to maintain appropriate CPB circuit length and tension. One unexpected challenge arose while transporting the cardiopulmonary bypass machine through the basement tunnels. The bypass machine had to be maneuvered through numerous, low-hanging maintenance pipes. This proved to be very time consuming and contributed to the 15-minute evacuation time.
- An 8-year-old undergoing a laparotomy. When the lights went out a flashlight was used to aid the surgeon. It was decided that the surgeon was far enough along to close the wound quickly and then plan to come to finish later. The anesthetic was converted to a TIVA technique using ketamine and propofol. Simultaneously, supplies were prepared in zip lock bags, and an oxygen tank and self-inflating resuscitation bag were obtained for the move. A decision was made to use a cart to move the patient to another location as the OR table would be difficult to move.
- The operating room lighting was designed to be backed up by the hospital back-up generator. As a result, there was no wall mounted emergency lighting designed to come on in the event of power failure coupled with a generator failure. We are evaluating the possible installation of such emergency lighting. Flashlights and/or headlights should be available at every anesthetizing location.
- The idea of moving a patient on the operating room table seemed like a good one. It probably remains a good one if the patient is to be moved laterally, perhaps to the adjacent ICU. However, moving the OR table into and out of an elevator proved to be a significant problem. In addition, ramps can present significant obstacles to transporting OR beds.
- We have sufficient portable monitors and portable oxygen sources to provide for close to half of the operating rooms. We would not have had sufficient monitors and oxygen sources had we needed to evacuate the entire operating room.
- Moving an intraoperative patient on an unexpected basis presents major challenges. The decision to move the patient needs to consider the urgency of the situation and the risk-benefit ratio of staying where you are vs. moving. In a real situation, accurate information would be essential to good decision making regarding patient management. If our drill had only been a power failure, it could have been better to have spent more time preparing for the transport. However, we expect accurate information might be difficult to obtain in a real situation.
- Our drill had the premise of a fire and power failure affecting adjoining units, but in fact those units were not involved in the drill. Had they also been involved, there would have been a major backup at the only set of functioning elevators.
- This drill has increased our awareness of the issues associated with emergency situations. We advocate the regular participation of the anesthesia department in such drills. The drills should be designed to simulate several different scenarios and evacuation routes. Anesthesiologists and nurse anesthetists should participate in the planning and execution of emergency evacuation drills.
- When moving an anesthetized patient there is a significant amount of ancillary equipment and supplies that are required. In our experience, a laptop bag or briefcase with a shoulder strap proved to be extremely useful.
We hope that our description of this experience will stimulate other anesthesiologists and nurse anesthetists to participate in mock emergency drills and become actively involved in their planning.
Corresponding author: Simon C. Hillier, MD, [email protected]