Patient Safety Tip
of the Week
September 11, 2018
Lessons from a
Surgical Fire
We often lament the fact that in healthcare we seldom share
root cause analyses (RCA’s) or results of investigations of adverse events.
These are excellent learning tools. The California Department of Public Health
periodically releases statements of deficiency and plans of corrections for
hospitals under its purview. These often have valuable lessons learned that
need to be shared with other hospitals. So we
sometimes will include cases from the CDPH releases as learning tools. There is
no intent to demean the hospitals. The events that occurred have the potential
to be repeated at many other hospitals and the goal is to decrease the
likelihood of such occurrences.
In the most recent batch of CDPH releases
there was one example of a surgical fire that has several lessons we all can
learn from (CDPH
2018). The patient was having a lipoma removed from the right side of the
forehead. The surgeon discussed with the patient the different methods of
anesthesia, including the risk of fire if general anesthesia with endotracheal
intubation was not used. The patient apparently indicated he “wants local with
monitored anesthesia·care (MAC) only… and will take general
anesthesia only if needed as a last choice”. So the
patient, surgeon, and anesthesiologist agreed to MAC.
During the timeout the team did discuss fire risk and noted
this was a Level 3 (highest) risk, based on what most of you will recognize as
the Christiana Fire Risk Assessment Score, which assigns one point for each:
- Surgery above the xyphoid
- Open oxygen source
- Available ignition source
(e.g., electrosurgery, laser, fiberoptic light cord)
They also pointed out the location of saline that was
readily available in the event of a fire.
The procedure was
performed under MAC. Oxygen was delivered at 5 liter a minute per face mask. The
anesthesiologist used a mask and not a nasal cannula since the patient was “a
large guy and might need more oxygen than a nasal cannula can deliver”. When
the patient moaned and moved his arms as the incision was made, additional
Propofol was given.
When the surgeon
started cauterizing a vessel with the electrosurgical unit (ESU or Bovie), he noted a spark occurred, with ignition of the
patient’s hair. This was extinguished with gauze (gauze soaked in saline).
However, the nurse and surgical tech noted smoke emanating from under the
drapes. The nurse saw smoke, pulled the drapes off, and called for help. The
surgeon removed the face mask and the anesthesiologist turned off the oxygen.
The drapes were completely removed. No active fires were noted under the
drapes. Moist lap packs were then placed over the patient’s face and neck area.
The patient suffered second and third degree burns on the
left side of the face and neck and eyelashes and eyebrows were affected on both
sides. The burns were immediately attended to and the patient subsequently went
on to receive skin grafting to burned areas,
The intensity
setting of the ESU (Bovie) was set at 35/35. The
facility apparently normally sets the intensity at 20-30 for a procedure on the
face. The surgeon’s preference card, which apparently was not checked prior to
the case, calls for an intensity 30/30. The usual practice at that facility was
for the circulating nurse to check the preference cards prior to surgery, then
plug in the ESU and set the intensity when the case starts.
So what are the lessons? First, most
cases of surgical fires involve procedures above the xyphoid. In a recent PPSA
(Pennsylvania Patient Safety Authority) review (Bruley
2018), of 33 surgical fires reported to the PPSA over a 6-year
period, 5 involved the scalp, 14 the face, and 4 the neck.
Second, the case reinforces a point we have often made –
surgical fires are now most often occurring during what would be considered relatively
“minor” procedures (eg. temporal artery biopsies,
plastic procedures, or removal of skin lesions on the head/neck). We speculate
there may be a couple reasons for that. One is that we probably “let our guard
down” in dealing with such procedures, thinking they are simple procedures
where little can go wrong. The other is that in such cases there may be no need
for supplemental oxygen, yet supplemental oxygen is sometimes routinely
provided. In others, use of supplemental oxygen is not anticipated but
something occurs during the procedure that leads to its use.
The focus of the hospital’s POC (Plan of Correction) in the
CDPH report was on the intensity setting of the ESU:
- A process change was made
to include the RN Staff confirming the power setting before activating use
of the ESU, for cases with a level three fir1 risk. This ensures that the lowest
level setting required for the surgery is used, as directed by the
Surgeon.
- Educate staff
- Audit
We previously discussed many issues related to electrosurgery
unit safety in our September 5, 2017 Patient Safety Tip of the Week “Another
Iatrogenic Burn”.
Of course, we don’t know what else was discussed in the
hospital’s actual RCA. All we know is what was in the CDPH SOD (statement of
deficiencies) and the hospital’s POC (plan of correction).
But, while we agree the intensity setting of the ESU should
be set at the lowest necessary level, that would certainly not have been our main focus in doing an RCA on this case. In our opinion, the
most salient issue is the use of a heat
source in the presence of a
open oxygen source. In cases like this, there must be timely coordination
between the surgeon and anesthesiologist such that the oxygen is turned off
prior to any use of the ESU and enough time is allowed to
lapse for oxygen to dissipate from the area where the ESU will be used. The
AORN guideline recommends, when an open oxygen source is being used, stopping
supplemental oxygen for 1 minute before using an ESU or other heat source.
And since we are discussing oxygen, keep in mind that only
the lowest necessary concentration and flow of supplemental oxygen should be
used. Many patients don’t need any supplemental oxygen at all. But if they do
need it, the concentration and flow should be determined by pulse oximetry.
A second issue has to do with the fact that fire occurred
under the drapes. That suggests one of two possibilities. First consideration
would be that oxygen had accumulated under drapes that had been improperly placed.
Drapes should be “tented” to allow free air flow. The AORN guideline actually also recommends delivering 5 to 10 L/minute of
medical air under the drapes to flush out excess oxygen via a second
delivery system.
The second consideration might be that a flammable skin prep
had been used and had either pooled or had insufficient time for drying. We’d
also want to know if an appropriate-sized skin prep applicator had been used.
We’ve done several columns discussing the fire risk that occurs with use of the
26-ml applicator in head/neck cases (see our January 10, 2017 Patient Safety Tip of the Week “The
26-ml Applicator Strikes Again!”).
It’s also worth noting that several of the OR personnel in
this case never saw actual fire, but rather heard a “sound”. That is not
surprising. Sometimes the episode occurs so rapidly that flames are not seen.
It’s actually common for personnel to hear a “pop” or
a “whoosh” as the only indication a surgical fire has occurred.
When we do an RCA (root cause analysis) on any case, we
always make sure to look not only at what went wrong but also at what was done
correctly. In this case there were several things done appropriately:
- Fire risk was discussed
during the timeout, using a widely used tool (the Christiana Fire Risk
Assessment Score)
- It was pointed out where
water/saline was located in case of a surgical
fire
- The surgeon did discuss
with the patient the risks of using MAC rather than general anesthesia and
intubation
- Responses once fire
recognized were appropriate (stop oxygen, remove mask, douse with water,
rip off drapes and douse with water)
- Did attend to burn care once
the burns were recognized
We recommend that a fire risk assessment be done both during
the presurgical “huddle” and as part of the surgical “timeout”. We continue to
promote use of the SF
VAMC Surgical Fire Risk Assessment Protocol, developed at the San Francisco
VA as part of an effort to promote fire safety in the OR (Murphy
2010). and which can be embedded into your safe surgery checklist. But the Christiana
Fire Risk Assessment Score or the AORN
Fire Risk Assessment Tool are equally appropriate.
What should be asked during the timeout when the fire risk
is deemed to be high?
- Has there been adequate
time for any flammable skin prep to dry?
- Do we really need open
oxygen? Would a laryngeal mask airway or an endotracheal tube be more
appropriate?
- Is the lowest necessary
concentration/flow of oxygen being used?
- Are all drapes applied
appropriately to reduce the risk of oxygen accumulation?
- Anesthesiologist and
surgeon agree to coordinate cessation of oxygen flow when heat source to
be used
- Where are saline soaked
gauze pads in case of a fire?
- Where is the fire
extinguisher located?
- Does everyone understand
their role in a fire?
We think you will find the AORN
Fire Risk Assessment Tool Instructions to be your most important document
since it spells out in detail all the steps that need to be taken when you have
determined there is substantial risk for a surgical fire.
Fortunately, the incidence of surgical fires appears to be
declining, according to the Pennsylvania Patient Safety Authority (Bruley
2018). This likely is due to the increased attention by numerous
organizations over the past decade.
We hope you’ll look
at the many useful recommendations in our previous columns (listed below). And,
of course, we again refer you to the valuable resources on surgical fires
provided by ECRI Institute, AORN,
the FDA,
Christiana
Care Health System and the APSF.
Our prior columns on
surgical fires:
- December 4, 2007 “Surgical
Fires”
- April 29, 2008 “ASA
Practice Advisory on Operating Room Fires”
- November 2009 “ECRI:
Update to Surgical Fire Prevention”
- January 2011 “Surgical
Fires Not Just in High-Risk Cases”
- March 2011 “APSF
Fire Safety Video”
- November 2011 “FDA
Initiative on Preventing Surgical Fires”
- December 13, 2011 “Surgical
Fires Again”
- April 24, 2012 “Fire
Hazard of Skin Preps Oxygen”
- April 2013 “Reminder:
Hand Sanitizers Are Flammable”
- June 25, 2013 “Update
on Surgical Fires”
- October 1, 2013 “Fuels
and Oxygen in OR Fires”
- August 12, 2014 “Surgical
Fires Back in the News”
- December 16, 2014 “More
on Each Element of the Surgical Fire Triad”
- December 2015 “Unique
Ignition Sources in Surgical/OR Fires”
- January 10, 2017 “The
26-ml Applicator Strikes Again!”
- January 9, 2018 “More
on Fire Risk from Surgical Preps”
- June 2018 “ISMP
on Fire Risk from Skin Preps”
- July 2018 “FDA
on Surgical Fires”
References:
CDPH (California Department of Public Health). Complaint
Intake Number: CA00455976. CDPH 2018
Bruley ME, Arnold TV, Finley E, et
al. Surgical Fires: Decreasing Incidence Relies on Continued Prevention
Efforts. Pa Patient Saf Advis
2018 Jun;15(2).
http://patientsafety.pa.gov/ADVISORIES/Pages/201806_SurgicalFires.aspx
SF VAMC Surgical Fire Risk Assessment Protocol
https://www.patientsafety.va.gov/docs/TIPS/TIPS_NovDec10.pdf#page=3
Murphy J. A New Effort to Promote Fire Safety in the OR.
Topics In Patient Safety (TIPS) 2010; 10(6): 3
http://www.patientsafety.va.gov/docs/TIPS/TIPS_NovDec10.pdf#page=3
Christiana Fire Risk Assessment Score
AORN Fire Risk Assessment Tool
AORN Fire Risk Assessment Tool Instructions
AORN (Association of periOperative
Registered Nurses). AORN Fire Safety Tool Kit.
Accessed September 3, 2018
ECRI Institute. Surgical Fire Prevention.
https://www.ecri.org/surgical_fires
Christiana Fire Risk Assessment
https://christianacare.org/forhealthprofessionals/education/fireriskassessment/
FDA (US Food & Drug Administration). Recommendations to
Reduce Surgical Fires and Related Patient Injury: FDA Safety Communication. FDA
Safety Communication 2018; May 29, 2018
APSF (Anesthesia Patient Safety Foundation). Resources. Fire
Safety Video. Prevention And Management Of Operating
Room Fires.
http://www.apsf.org/resources/fire-safety/
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