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:
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:
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 “”).
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:
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?
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:
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).
SF VAMC Surgical Fire Risk Assessment Protocol
Murphy J. A New Effort to Promote Fire Safety in the OR. Topics In Patient Safety (TIPS) 2010; 10(6): 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.
Christiana Fire Risk Assessment
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.