Welcome to the next installment of the Anesthesia Patient Safety podcast hosted by Alli Bechtel. This podcast will be an exciting journey towards improved anesthesia patient safety.
Today, we are going to dive back into our 35th Anniversary APSF Newsletter, the Jade edition. You can find the Newsletter here. https://www.apsf.org/newsletter/october-2020/
Did you know that APSF is registered as an AmazonSmile Charitable Organization? For more information, check out this link! https://www.apsf.org/donate/
At the top of the show, we talk about “What Then?” when it comes to OR fires by reviewing the 1991 article by Chester Lake, MD, “From the Literature: ECRI Review Explains, Warns of OR Fires.” You can find the article here. https://www.apsf.org/article/from-the-literature-ecri-review-explains-warns-of-or-fires/
For more information on Fire Safety, we hope that you will check out the APSF Fire Safety Training Video. You can find the video here. https://www.apsf.org/videos/or-fire-safety-video/
The conversation heats up as we look at the article by Cowles, Lake, and Ehrenwerth, “Surgical Fire Prevention: A Review” that you can find in the 35th Anniversary APSF Newsletter. https://www.apsf.org/article/surgical-fire-prevention-a-review/
Here is the APSF Safety Algorithm for Operating Room Fires. There are several options for downloading the PDF and printing these resources to use in your operating room and institution. https://www.apsf.org/wp-content/uploads/collateral/posters/ORFireAlgorithmPoster8.5×11.pdf.
Here is the link to the Fuse Program – Fundamental Use of Surgical Energy by the Society of American Gastrointestinal and Endoscopic Surgeons. https://www.fuseprogram.org/
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© 2020, The Anesthesia Patient Safety Foundation
Hello and welcome back to the Anesthesia Patient Safety Podcast. My name is Alli Bechtel and I am your host. Thank you for joining us for another show.
This special 35th Anniversary Jade Edition APSF Newsletter is live and there is so much to talk about!! In creating this special Newsletter, the APSF Editorial Board put on their reading glasses and read through 35 years of APSF Newsletter articles (and this was done prior to the onset of the Covid-19 pandemic) before voting on the top 10 most impactful articles to include in this newsletter and review through the lens of What then and What now with the help of our current editorial team and past editors.
Today, we are going to talk about something that requires 3 ingredients and is a threat to patient safety during anesthesia care in the operating room.
You’ve heard me recognize our corporate sponsors on this show, but there’s another supporter who is absolutely essential – YOU! Did you know that APSF is registered as an AmazonSmile Charitable Organization? All you have to do is select Anesthesia Patient Safety Foundation as your Amazon Smile designee and then every time you make a purchase on AmazonSmile, the AmazonSmile Foundation will donate 0.5% of the purchase price to APSF from your eligible AmazonSmile purchases. I will include a link to more information in our show notes.
The 3 ingredients that we are going to be talking about today are Fuel, Ignition, and Oxygen. That’s right we will be talking about the #2 article from the Special Edition Newsletter, “From the Literature: ECRI Review Explains, Warns of OR Fires” by Chester Lake to discuss, “what then” since this article was published in the Winter 1991 Newsletter. You can find this article by clicking on the Newsletter heading, 4th one down is Newsletter archives and then scroll down to Winter 1991. The article is listed on the left column, 5th one down. I will also include a link in the show notes.
This article is a review of an article published by the Emergency Care Research Institute entitled “The Patient is On Fire.” Have you witnessed a fire in the operating room? This is a pretty rare event, but it has the potential to cause significant patient and OR team member harm as well as damage to equipment and supplies in the OR. Now, just a little background information on the ECRI, this is the world’s largest independent, nonprofit evaluator of medical devices and this organization participates in accident investigation for hospitals and risk management consultation. Health Devices is the ECRI journal that publishes information about equipment evaluation work and related general news.
Now, let’s return to those 3 ingredients that you can find in every operating room…meaning that this is a constant threat to patient safety. The fire triangle involves #1 a heat source or ignition source. This may be a laser, electrocautery, or fiberoptic light cord. A common culprit is accidental activation of the electrosurgical unit foot or hand switch leading to a spark. #2 is an oxidizer which may be oxygen or nitrous oxide since this will support and accelerate combustion. Finally, #3 is fuel for the fire which may include surgical drapes, sponges, egg crate, foam mattresses, alcohol or acetone-based solutions, GI tract gas, shoe covers and so many other things in the OR that will burn readily. After a fire starts that products of combustion include oxides, carbon dioxide, nitrogen dioxide, carbon monoxide, and unburned carbon. What about plastic material that is found throughout the OR? In normal fires, plastics do not burn in room air. However, plastic material will burn in an environment that contains ample oxidizer, such as oxygen, which is often the case in the OR. Burning plastic material produces the most toxic products such as hydrogen chloride, hydrogen fluoride, cyanide, mustard gas, phenol, and poisonous complex hydrocarbons.
Now that we have talked about how a fire may start in the OR, let’s talk about how we can prevent this from occurring. First, it is important to understand the fire triangle and use this knowledge to prevent these ingredients from coming together in the operating room keeping in mind that it is not possible to remove any one of these ingredients from the OR environment. For anesthesia professionals who are turning on or up the oxygen flows in the OR, we must remain vigilant. The author provides an example of a MAC case with supplemental oxygen during surgery on the head or neck. There is an increased risk for a fire since there is an oxygen-rich environment and a heat source such as an electrosurgical unit or laser depending on the case. It may be necessary to use saline-soaked sponges around the surgical field to decrease the availability of dry fuel for combustion.
OR fire safety also depends on an emergency plan with regular practice and easy access to the plan during the emergency so that everyone knows what to do and can move safely and quickly. In-service educational sessions are also helpful for anesthesia professionals, surgeons, and all operating room team members. This is a good opportunity to head over to the Simulation Center to practice the emergency plan in the case of an OR fire. Here are the vital steps to stopping an OR fire.
First, discontinue to oxygen flow and/or anesthesia gases! If the fire continues to burn, extinguish the fire with a nonflammable liquid such as saline from a basin on the scrub table or use an extinguisher. Small flames may be extinguished quickly by patting out with a gloved bad or a wet towel. The next step is to remove the burning or burned material and finally provide supportive care to the patient. Hospitals often partner with local fire departments for fire drills and proper techniques and equipment for extinguishing OR fires as well as for developing proper safety protocols. You can find additional information from the National Fire Protection Association and the American Society for Testing and Materials. Lake advocates for vigilance, knowledge of fire, and quick action to minimize the risk of a fire and fire-related injuries. All OR team members need to be educated on fire extinguisher location, type, proper use, and the emergency plan in order to help keep patients and staff safe. Do you know where the oxygen shutoff is located for the whole room? You may need to know how and when to use this and in a large fire, this knowledge can save lives!! During fire safety drills it is important to include information about notification of hospital and fire officials and how to get help quickly!!
For more information on Fire Safety, we hope that you will check out the APSF Fire Safety Training Video. You can find this from the APSF homepage, clicking on the Videos heading, first one down is the Operating Room Fire Safety Video. We will talk more about this video in a future show, but we hope that you will check it out!
For now, we are going to travel back to the present and talk about What Next for fire safety by looking at the article, “Surgical Fire Prevention: A Review” by Cowles, Lake, and Ehrenwerth in the 35th Anniversary Newsletter. The authors start with a call to action since a fire in the operating room with its dreaded complications can be completely prevented with minimal cost and this is such an important area to focus on so that no patient shall be harmed by anesthesia care. We have seen a decrease in this event from an estimated 650 surgical fires annually to about 217 each year in the United States. It appears that we are making progress, but the actual number of OR events annually is probably much higher since reporting OR fire events is not required in half of the states. In addition, the rate of anecdotal incidents and legal proceedings has not changed over the years. Looking at the ASA closed claims database reveals that surgical fires made up 1.9% of the liability claims and there is a higher percentage of fires ignited by electrocautery up from less than 1% in 1985 until 1994 to 4.4% from 2000-2009. The most common scenario continues to be open oxygen delivery of 100% O2 from the auxiliary oxygen outlet by face mask or nasal cannula plus a monopolar electrical surgical device for a procedure located near the head and neck. The majority of claims take place in outpatient care areas with monitored anesthesia care. The vast majority, 97%, of OR fire events under general anesthesia occur with otolaryngology procedures that use an FiO2 greater than 30%.
For cases when the auxiliary oxygen outlet is used, the risk for fire can be decreased if the machine has the ability to blend O2 and air to reduce the FiO2. Another important consideration is the use of high flow nasal oxygen delivery which provides 50-100L/min of 100% oxygen unless an O2/air blender is used. You can imagine that at these high rates of oxygen flow, the risk for fire greatly increases.
Another feared OR fire occurs when an endotracheal tube is ignited by a laser or electrosurgical units leading to a “blowtorch” effect and devastating complications for the patient’s airway and lungs. It is important to use the proper endotracheal tube that is protective to the wavelength of the laser. You will also need to stay vigilant during tracheostomy procedures since can OR fire can occur when the surgeon uses an ESU to enter the trachea and there is a high concentration of oxygen in the trachea.
An important update is that we know that alcohol-based surgical prep is flammable, but the alcohol vapors that are formed during evaporation are also combustible. As a result, it is important for the OR team to make sure that the prep has completely dried and any alcohol-soaked towels are removed and discarded prior to draping. Many institutions use a timer from the time that the prep is applied until the drapes may be applied to ensure complete drying.
The authors highlight some additional safety resources for the prevention of OR fires. You can find an updated safety algorithm for operating room fires on the APSF website and I will include a link in the show notes. You can also use this as a cognitive aid for healthcare professionals to help prevent high-risk situations. In 2013, the ASA published a practice advisory for health care providers to prevent surgical fires. We are going to review it now. First, Perform a fire risk assessment during the time out or safety checklist for every surgery. The fire risk assessment must evaluate for the use of an open oxygen source, the presence of an ignition source, a procedure location at or above the xiphoid process and the use of a flammable surgical prep solution. The next step is to support effective communication among surgical staff. Step 3 involves the safe use and administration of oxidizers and this means using the minimum concentration of oxygen that is necessary to meet the needs of the patient. The fourth step is to ensure the safe use of any equipment that may be an ignition source. Next, make sure that you safely use surgical items than can become fuel. Step 6 reveals the steps to manage surgical fires including eliminate the primary ignition source, extinguish the fire and remove sources of fuel. For airway fires, discontinue the patient from the breathing circuit and remove the tracheal tube, then move the patient to safety and re-establish the airway. Finally, make sure to review the entire scene and remove any potential flammable materials.
In case of an OR fire, everyone in OR should know the location of the fire extinguishers as well as how to use it. The most appropriate extinguisher in the operating room is the carbon dioxide extinguisher.
Surgical fire prevention requires daily preparation as well as yearly education and simulation programs. I already mentioned it, but the authors also point out that the APSF’s fire safety video continue to be useful and the information remains accurate for 2020 and beyond. So, what is next for fire safety prevention? It is a big ask…we likely need a culture change. Many institutions are starting to do this with integration of fire risk assessments and preventive actions in surgical safety checklists. In addition, this is a great opportunity to use the simulation center to practice and refine fire safety protocols and management. It is important to collaborate with surgeons who perform cases with high risk for fire to minimize the risk and be prepared to act quickly in case a fire occurs. Another resource is the “FUSE program” or the Fundamental Use of Surgical Energy by the Society of American Gastrointestinal and Endoscopic Surgeons and I will include a link to this in the show notes as well. Going forward, we need to continue to work on increasing knowledge and surgical fire prevention practices. The authors wrap up their article by emphasizing that fire prevention does not cost anything and it can be 100% effective. We need to remain vigilant to help keep our patient safe from fire in the operating room.
That’s all the time we have for today!! We can’t wait to get back into the Jade Edition Newsletter again in a future show!! Thank you so much for joining us today on this journey towards improved patient safety. If you have any questions or comments from today’s show, please email us at [email protected].
Visit APSF.org for detailed information and check out the show notes for links to all the topics we discussed today. Plus, you can find us on Instagram at APSForg! Follow along with us for anesthesia patient safety pictures and stories!!
Until next time, stay vigilant so that no one shall be harmed by anesthesia care.
© 2020, The Anesthesia Patient Safety Foundation