APSF Fire Safety Video Contributes to 44% Decrease in Intraoperative Fires Since 2011

July 5, 2018

The Anesthesia Patient Safety Foundation (APSF) is pleased to announce the ECRI Institute (Emergency Care Research Institute) and the Pennsylvania Patient Safety Authority (PSA) have updated the statistics on surgical fires in a year-long analytical effort. The 2018 study, which used the confidential reports in the PSA’s Patient Safety Reporting System (PA-PSRS), reveals that the number of reported fires has dropped by 44% in Pennsylvania since 2011 and by 71% since 2004 (p <0.001). Separately, the ECRI Institute has used this analysis to estimate that 88-105 surgical fires occur in the United States each year. This is down significantly from their 2007 estimate of 550-650 per year.

APSF played a significant role in conjunction with ASA (American Society of Anesthesiologists), ECRI, the FDA and other stakeholders to bring about this reduction in intraoperative fires. Efforts included issuing practice advisories and new standards for electrosurgery as well as educational campaigns and the development of fire safety tools and resources.

One popular resource, “Prevention and Management of Operating Room Fires”, is a free 18-minute video produced by APSF with the assistance of the ECRI Institute for all professionals who work in an operating room. More than 4,000 requests were made for the DVD version of the video in the first year of its release in February 2010, and the streaming version on the APSF website is currently viewed more 1,000 times per month. A 2010-11 survey suggests that the video has been effective in changing anesthesia professionals practice with a majority of viewers indicating a policy change was implemented as a result of viewing the video.

While preventive recommendations and initiatives appear to be working, more needs to be done. Intraoperative fires that still occur are primarily the result of the use of electrosurgical active electrodes around the head and neck in the presence of supplemental oxygen. Methods for mitigating risk include: (1) limiting supplemental oxygen to only the amount required for adequate arterial oxygen saturation and (2) requiring occlusive draping techniques during supplemental oxygen delivery via an open source. Additionally, professionals in the operating room are encouraged to use the Fire Risk Assessment Score process and consider recommendations found on the Pennsylvania Patient Safety Reporting System’s “Airway Fires during Surgery” flyer and resources that the Council on Surgical & Perioperative Safety has posted on its website.

Additional resources provided by the APSF that can assist in understanding the risks of fire in the operating room include: printable posters and visual aids, commentary for the ENT surgeon and commentary for the anesthesia professional.