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Our
many columns on surgical fires have focused on fires on or around the patient,
discussing both surgical fire prevention and immediate interventions to
minimize patient harm.
But
we haven’t discussed much about what happens in OR’s with more extensive fires
or fires elsewhere in the hospital. A recent AORN article (Ervine 2021) notes that, all too often, routine fire
drills in medical facilities “do not go beyond the red line of the OR”. Ervine
goes on to describe how to involve OR staff in fire drills. She highlights the
importance of involving all OR staff, including surgeons and anesthesiologists,
in the planning process as well as the drills themselves and the post-drill
evaluation.
The
planning phase includes establishing a date and time for the drill and alerting
the local fire department that this will be a drill. Ervine notes that planning
and drills may uncover unexpected vulnerabilities, such as strobe lights that don’t
work, audio alarms that cannot be heard, and fire doors that do not automatically
close. Another important facet is to determine the evacuation route for your
department. Do team members evacuate outside of the facility, or do they go to
the next fire compartment? Does your department have more than one fire
compartment?
Planning
also includes determining whether you have the appropriate fire extinguishers
located throughout your department. (See our comments below on appropriate location
and type of fire extinguishers in the OR.) Ervine also notes you should know
where the fire pulls are located. Knowing the location of the closest fire pull
is paramount in promptly alerting all staff quickly. And, as part of the
planning, you should review your facility’s policy and procedure on who is
responsible and allowed to shut off medical gases.
One
facet we find deficient in drills of almost any kind in medical facilities is
lack of appropriate monitoring on compliance with required steps and overall
performance in the drills. Ervine notes that the “facilitator” of the fire
drill needs to make sure the monitors of the drills have all the tools they
need to evaluate the actions of staff during the drills. Those tools should
include a checklist of items to record and some sort of scoring system. Monitors
are present in each room and there should be an additional monitor in the hall
near the entrance to your OR. The latter evaluates who is responding to the
alarm, how promptly they arrived, and if they brought fire extinguishers with
them.
Ervine
assembles the perioperative team for a briefing just before starting the drill.
The acronyms RACE (Rescue, Alarm, Confine, Extinguish/Evacuate) and PASS (Pull,
Aim, Squeeze, Sweep) are reviewed. The different types and locations of fire
extinguishers are discussed, as well as each team member’s assignment during
the drill. Room and hallway monitors and charge nurse monitor
review the evaluation forms with the facilitator.
Ervin
holds a debriefing with the entire team at the end of the evacuation. Each team
monitor reads the scenario from his or her room and reports how they were
notified of the emergency; what decisions they made to care for the patient; if
they could hear the alarm, see the flashing strobe lights, and hear any
overhead paging that might have occurred during the drill.
Either
the facilitator or the safety officer should provide feedback to the team of
their observations during the fire drill and evacuation. During the debriefing,
team members should also provide their feedback for the drill itself.
Note that Ervine recommends the debriefing take place at
the end of the evacuation. We’d actually take
it a step further and include as part of the drill restoration of the activities
which had been ongoing in each OR prior to the fire alarm being pulled. For
example, you might find that no one has turned medical gases back on, or that
shortcuts were taken in re-establishing sterile procedure.
There is often confusion about fire extinguishers and the
OR. Are they required in the OR? What type? A recent APSF “Rapid Response” (Williams
2021) clarifies these issues.
It highlights discrepancies between recommendations of the National Fire
Protection Association (NFPA) and those of ASA, APSF, and ECRI. NFPA and The
Joint Commission require a fire extinguisher within 75 feet of every working
location and that “clean agent-or water mist-type fire extinguishers shall be
provided in operating rooms.” ASA, APSF, and ECRI do not believe the regulatory
requirements are sufficient for protecting patients or staff in the event of a
fire in the operating room. Specifically, the recommendation is that CO2
extinguishers be available. APSF also agrees with the specific ECRI
recommendation that a 5 lb. CO2 extinguisher be mounted just inside the
entrance of each operating room. (The APSF Rapid Response notes that a comment
in the Annex (A.16.10.1.4) of the NFPA-99 document states that a CO2
extinguisher could be used in lieu of a clean agent extinguisher and that this
comment can be cited if there is local resistance to supplying CO2
extinguishers in each operating room.)
The
APSF “Rapid Response” makes a very important point about differences when the
fire is on the patient vs. elsewhere in the OR. Specifically, it notes that in
the event of a fire on the patient, a fire extinguisher is not
the first method for extinguishing the fire. All surgical procedures that have
a high risk of a fire (see our many columns on surgical fires listed below)
must have a basin of water or saline readily available on the OR table. That
would be the fastest method of dousing a fire on the patient. If the drapes are
on fire, they should be pulled off the patient onto the floor and then a fire
extinguisher could be used on the burning drapes. It would be an unusual
occasion to require that a fire extinguisher be used on the patient. They also note
that most OR drapes are impervious to water, which is why an extinguisher is
needed if they are on fire. Just a reminder – materials that are said not to
support combustion in room air, such as drapes and surgical gowns, may quickly
ignite in oxygen-enriched environments (Culp 2013).
We
like the way that Ervine has included multiple scenarios into the drills to
account for circumstances that might complicate responses. You’ll recall we
sometimes have added 2 drills together. For example, 2 incidents sometimes take
advantage of fire alarms – behavioral health patients absconding
or infants being abducted. We don’t think you need to add those to an OR fire
drill (the perpetrators in these 2 scenarios would not likely pull a fire alarm
in the OR). But the idea of adding complicating factors into your fire drills
remains a good consideration.
The Ervine article is a good reminder that you need to
prepare for potential fires in the OR. Of course, using drills to prepare for
fires elsewhere in your healthcare facility is also important. Another recent
AORN article has some good recommendations for those (Croke
2021). We also refer you back
to our October 21, 2014 Patient Safety
Tip of the Week “The
Fire Department and Your Hospital” which had lots of information about
hospital fires, including special considerations for fires in your MRI suites
or behavior health units.
And,
of course, don’t forget all our columns, listed below, on preventing and
responding to surgical fires.
Our prior columns on surgical fires:
References:
Ervine
HS. Conducting a Successful Fire Drill in the OR. AORN Journal 2021; 114(4):
287-289
https://aornjournal.onlinelibrary.wiley.com/doi/epdf/10.1002/aorn.13515
Williams
J, Feldman JM, Ehrenwerth J. Fire Extinguisher in the
Operating Room. APSF (Anesthesia Patient Safety Foundation) 2021; June 1, 2021
https://www.apsf.org/article/fire-extinguisher-in-the-operating-room/
Culp
WC, Kimbrough BA, Luna S. Flammability of surgical drapes and materials in
varying concentrations of oxygen. Anesthesiology 2013; 119(4): 770-776
Croke
L. Preparing for fires in health care settings. AORN Journal 2021; 114(4):
P7-P9
https://aornjournal.onlinelibrary.wiley.com/doi/10.1002/aorn.13524
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