R E V I E W S & A N A LY S E S Surgical Fires: Trends Associated with Prevention Efforts John R. Clarke, MD INTRODUCTION Editor, Pennsylvania Patient Safety Advisory Clinical Director, Pennsylvania Patient Safety Authority Fires on the operating field are rare events that should never happen, but do. They are Professor of Surgery, Drexel University dangerous not only to the patient but to the operating room (OR) team members as Mark E. Bruley, CCE well. The Pennsylvania Patient Safety Authority did an analysis of reports of surgical Vice President, Accident and Forensic Investigation, fires in its database for the primary purpose of determining if surgical fires continue ECRI Institute to be a problem, as identified by the Joint Commission,1 or if facilities have responded Editorial Advisory Board, Pennsylvania Patient Safety Advisory to advisories on prevention, such as those proposed by the American Society of Anesthesiologists.2 ABSTRACT METHODS Fires on the operating field are dan- A panel of patient safety analysts identified surgical fires reported to the Authority gerous to patients and providers. The between July 1, 2004, and June 30, 2011. Potential reports of interest were identified Pennsylvania Patient Safety Authority using the keywords “fire,” “flame,” “ignite,” and “extinguish.” A report was classified did an analysis of the reports of surgical as a surgical fire if it fires in its database. Analysts identified reports of fires submitted over seven — occurred on the sterile surgical field or in the airway and years that occurred in the operating — caused combustion of surgical or anatomic substance. room on the surgical field and involved The analysts excluded the following: combustion resulting from a combina- tion of heat, oxygen, and fuel. Seventy — Heat-related injuries caused by direct contact with a heat source, such as electro- events that met the analysts’ definition surgical active electrodes (Bovie units), lasers, fiberoptic light cord, surgical lights, of fires on the operating field were hot water, or hot instruments reported in the seven years between — Normal arcing from electrosurgical active electrodes between tip and tissue with- July 1, 2004, and June 30, 2011. Over out secondary ignition of a substance the past four years for which data was — Arcing or ignition of the insulation of electrosurgical active electrodes without available, the rate of surgical fires has secondary ignition of a substance varied from 0.63 per 100,000 opera- — Reports of smoke without evidence of combustion tions (1 per 157,545 operations) in the — Heat-related melting without evidence of combustion academic year 2007-2008 to 0.32 per 100,000 operations (1 per 309,305 — Fires off the surgical field operations) in the academic year 2010- To calculate the rates at which fires occurred, the Authority obtained the number of 2011. One-third of the reported events trips to the OR (operations) done in Pennsylvania hospitals and ambulatory surgical indicated harm to the patient. Risk to facilities from the Pennsylvania Health Care Cost Containment Council (PHC4).* providers, rather than patients, was cited Robust numbers of operations were available from July 1, 2007, through June 30, 2011. in 6% of reports. Surgical fires remain Those numbers were used to calculate the rate of fires per operation (see Figure). Prior a significant enough risk to justify use to July 1, 2007, only the number of patients having operations was reported under a of a Fire Risk Assessment Score and uniform format, not the number of operations. adherence to the recommendations of To extend observations of the rates of surgical fires to the entire period between July 1, the American Society of Anesthesiolo- 2004, and June 30, 2011, the number of surgical patients was used to calculate the rate gists Task Force on Operating Room Fires and those of the Anesthesia Patient Safety Foundation. (Pa Patient Saf Advis * The Pennsylvania Health Care Cost Containment Council (PHC4) is an independent state agency responsible for addressing the problem of escalating health costs, ensuring the quality of 2012 Dec;9[4]:130-5.) health care, and increasing access to health care for all citizens regardless of ability to pay. PHC4 has provided data to this entity in an effort to further PHC4's mission of educating the public and containing health care costs in Pennsylvania. Scan this code PHC4, its agents, and staff, have made no representation, guarantee, or warranty, express or with your mobile implied, that the data—financial, patient, payor, and physician specific information—provided device’s QR to this entity, are error-free, or that the use of the data will avoid differences of opinion or reader to access interpretation. the Authority’s This analysis was not prepared by PHC4. This analysis was done by the Pennsylvania Patient Safety surgical fires Authority. PHC4, its agents and staff, bear no responsibility or liability for the results of the analy- toolkit. sis, which are solely the opinion of this entity. Page 130 Pennsylvania Patient Safety Advisory Vol. 9, No. 4—December 2012 ©2012 Pennsylvania Patient Safety Authority Figure. Trends in Surgical Field Fires July 1, 2004, through June 30, 2005, to 0.33 per 100,000 surgical patients (1 per FIRES PER 300,973 surgical patients) from July 1, 100,000 2010, through June 30, 2011. This notice- 1.0 able downward trend is not statistically 0.90 significant by linear regression (R = –0.72, 0.9 R2 = 0.52, p < 0.10 by two-tailed levels of 0.8 significance). 0.71 The incidence of fires on the operating 0.7 0.68 0.65 fields in Pennsylvania hospital ORs and 0.57 0.6 ambulatory surgical facilities should be 0.63 0.66 considered within the context of initia- 0.5 0.41 tives to prevent surgical fires. Those initiatives have been as follows: 0.4 — 2003: Joint Commission Sentinel 0.39 0.33 0.3 Event Alert on preventing surgical 0.32 fires1 0.2 — 2005 to 2009: Joint Commission National Patient Safety Goal for 0.1 MS12726 ambulatory surgery 0.0 — 2008 to 2009: American Society of 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 Anesthesiologists’ “Practice Advisory for the Prevention and Management ACADEMIC YEAR of Operating Room Fires”2 Rate per patient Rate per operation Linear trend per patient — 2010: Anesthesia Patient Safety Foundation’s fire safety video3 — 2011 to present: Food and Drug of fires per surgical patient (see Figure). 36 fires on the operating field were Administration Preventing Surgical A surgical patient was a patient who had reported to the Authority during the same Fires initiative4 one or more operations during an admis- time period. The rate of surgical fires An analysis of the 70 reports of fires on sion. If the same patient had a second ranged from from 0.63 per 100,000 opera- the operating field reinforces the informa- admission, he or she was counted as a tions (1 per 157,545 operations) from tion driving the existing initiatives.1-4 second surgical patient. July 1, 2007, through June 30, 2008, Patient harm was reported in 23 reports Some facilities did not provide the num- to 0.32 per 100,000 operations (1 per (33%), and no harm was reported in 46 ber of surgical patients or operations for 309,305 operations) from July 1, 2010, (67%) of the 69 reports with information some quarters. However, no fires were through June 30, 2011. In the same about harm. Three events involved fires in reported from those facilities during those time periods, the number of operations the surgeons’ hands, and one involved a quarters. per patient averaged 1.03 operations fire on the scrub technician’s gown. None per patient. of these four events produced harm to the RESULTS A total of 11,651,199 patients were staff or patient. reported having operations during the Of the 65 reports with information about In the seven years between July 1, 2004, seven-year time period from July 1, the ignition source, the source of ignition and June 30, 2011, 70 reports met the 2004, through June 30, 2011 (see Table was an electrosurgical unit (Bovie unit) analysts’ definition of fires on the operat- 2). As noted above, a total of 70 fires in 38 reports (58%), a fiberoptic light ing field. on the operating field were reported cord in 25 reports (38%), and a laser in A total of 7,172,132 operations were to the Authority during the same time 2 reports (3%). reported to PHC4 during the four-year period. The rate of surgical fires ranged time period from July 1, 2007 through from 0.90 per 100,000 surgical patients The role of oxygen was highlighted in June 30, 2011 (see Table 1). A total of (1 per 110,649 surgical patients) from seven reports, with two specific mentions Vol. 9, No. 4—December 2012 Pennsylvania Patient Safety Advisory Page 131 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S Table 1. Rates of Fires per 100,000 Surgical Operations NO. OF RATE OF SURGICAL NO. OF NO. OF OPERATIONS SURGICAL OPERATIONS FIRES PER 100,000 YEAR PATIENTS* OPERATIONS* PER PATIENT FIRES† PER FIRE OPERATIONS July 2007 to June 2008 1,683,170 1,732,996 1.03 11 157,545 0.63 July 2008 to June 2009 1,727,387 1,775,920 1.03 7 253,703 0.39 July 2009 to June 2010 1,757,928 1,807,384 1.03 12 150,615 0.66 July 2010 to June 2011 1,805,835 1,855,832 1.03 6 309,305 0.32 Total 6,974,320 7,172,132 1.03 36 199,226 0.50 * Data obtained from the Pennsylvania Health Care Cost Containment Council. † Surgical fires reported to the Pennsylvania Patient Safety Authority. Table 2. Rates of Fires per 100,000 Surgical Admissions NO. OF PATIENTS RATE OF SURGICAL FIRES YEAR NO. OF PATIENTS* SURGICAL FIRES† PER FIRE PER 100,000 PATIENTS July 2004 to June 2005 1,549,082 14 110,649 0.90 July 2005 to June 2006 1,572,611 9 174,735 0.57 July 2006 to June 2007 1,555,186 11 141,381 0.71 July 2007 to June 2008 1,683,170 11 153,015 0.65 July 2008 to June 2009 1,727,387 7 246,770 0.41 July 2009 to June 2010 1,757,928 12 146,494 0.68 July 2010 to June 2011 1,805,835 6 300,973 0.33 Total 11,651,199 70 166,446 0.60 * Data obtained from the Pennsylvania Health Care Cost Containment Council. † Surgical fires reported to the Pennsylvania Patient Safety Authority. of nasal cannulas, one specific mention of Alcohol-based skin preparations were doused with saline. One surgical sponge a “leak” in the oxygen tubing, one specific mentioned in three reports. Two of the was moved to a basin of sterile saline. mention of an oxygen mask over a trache- reports stated the skin was dry when the Seven reports mentioned removing, dis- ostomy stoma, and one specific mention electrosurgical unit was used, igniting connecting, or turning off the light cord of using an electrosurgical unit to incise hair. The other report noted that a sponge when it was the source of igniting surgical a trachea during a tracheostomy. Nitrous used to help dry the skin was left on the drapes. Including the report of the flam- oxide was not mentioned as a source of field and was ignited by the electrosurgical ing surgical drape, just mentioned, and oxidizer in any reports. unit. the report of a tracheal fire below, five The locations of the fires were noted in reports mentioned dousing the fire with The materials that caught fire were noted 34 reports, with 3 noting more than one saline or water. Three fires were report- in 66 reports, with multiple materials site. Sites on the surface of the patient’s edly extinguished using towels, one noted noted in some reports. They included body were mentioned in 32 reports, inter- to be wet. One surgeon put out a bone surgical items and/or patient sources. Of nal sites were mentioned in 6, and fires cement fire with his or her hand. A fire the surgical items, drapes were most com- on the surgeons’ hands were mentioned caused by using the electrosurgical unit to monly ignited (involved in 30 reports), in 3 (see Table 3). Of the 38 surface and enter the trachea was extinguished with a followed by surgical sponges (13); bone internal patient sites mentioned, 25 were combination of the surgeon’s hand, fol- cement (3); surgical towel, gown, or gloves located in the head or neck areas. lowed by dousing the site with saline and (1 each); and accessory cable (1). Of the discontinuing supplemental oxygen. patient sources of combustion, hair and Twenty-three reports mentioned 26 ways tissue in the incision were most common in which the fire was extinguished. Six [The surgeon] was opening trachea (11 each), with individual mentions of lip, ignited surgical sponges were removed with cautery. A flash fire occurred palate, soft tissue, and bowel gas. from the surgical field and extinguished. at site and was immediately extin- One surgical drape was removed and guished with [the surgeon’s] finger Page 132 Pennsylvania Patient Safety Advisory Vol. 9, No. 4—December 2012 ©2012 Pennsylvania Patient Safety Authority followed by saline. Anesthesia also Table 3. Location of Surgical Fires as Reported to the Pennsylvania Patient Safety Authority immediately turned off [the supple- LOCATION NO. mental oxygen]. External 32 Head 18 DISCUSSION Scalp 2 A coordinated approach to surgical fire Face 13 prevention and response by the surgical Face 4 team is important to eliminate fire hazards Periorbital 9 and to minimize the time until the fire is Eyelid 1 extinguished.1-4 Three elements are neces- Eyebrow area 3 sary for a fire: a heat source, oxygen, and Eyebrow 2 a fuel. The surgeon is usually in control Eyelashes 3 of the heat source, most commonly an electrosurgical unit, and can remove it Ear 3 from the field. The anesthesia professional Neck 5 is usually in control of the supplemental Neck 4 oxygen source and can eliminate the Tracheal stoma 1 oxidizer component of the fire triangle. Shoulder 1 The circulating nurse or scrub technician Chest 2 can help ensure meticulous application of Legs 5 alcohol-containing skin-prepping solutions Legs 1 and ensure that they are dry before the Leg 2 application of surgical towels and drapes; can ensure occlusive draping when indi- Thigh 2 cated; can keep exposed ends of fiberoptic Trocar site 1 light cords off the surgical field; and can Internal 6 ensure the availability of moist sponges, Nasopharynx 1 towels, and aqueous solutions. Trachea 1 Chest cavity (surgical sponges) 2 Response to a Surgical Fire Abdominal cavity (bowel gas) 1 Surgical fires are preventable, but if a fire Hip incision (bone cement) 1 occurs, the surgeon and other surgical Surgeon’s Hand 3 team members can immediately remove Surgeon’s hand 2 burning materials from the patient and Surgeon’s finger 1 can help by extinguishing the fire with an aqueous solution, their hands, or a wet sponge or towel. Ideally, a wet sponge or be to avoid the risk by not incising the — Christiana Fire Risk Assessment wet towel is always available in the sterile setup for such an emergency. The anes- trachea with an electrosurgical unit in the Score: thesia professional should minimize the first place.2,5  Surgery above the xiphoid availability of oxygen. Burning materials The Christiana Care Health System in  Open oxygen source that have been removed from the patient Wilmington, Delaware, has developed a  Available ignition source can then be extinguished by other team simple, brief Fire Risk Assessment Score (e.g., electrosurgery, laser, members, if needed, with an aqueous to identify operations at increased risk fiberoptic light cord) solution, or in extreme cases, with a car- for surgical fires.6 The score assesses the The Fire Risk Assessment Score can easily bon dioxide fire extinguisher. presence or absence of three elements. A be included in either the WHO Surgical score identifying the following three ele- Safety Checklist preoperative briefing or Prevention of Surgical Fires ments present indicates a high risk for a the Universal Protocol time-out. More prudent than a coordinated team surgical fire: response to the tracheal fire above would Vol. 9, No. 4—December 2012 Pennsylvania Patient Safety Advisory Page 133 ©2012 Pennsylvania Patient Safety Authority R E V I E W S & A N A LY S E S A score of 3 indicates a high risk for a For such cases, fire risks will be reduced Care should be taken with alcohol preps. surgical fire. A score of 2 indicates a low by starting with an administered con- Of note, two of the reports involving alco- risk, with potential for conversion to high centration of oxygen of less than 30% hol preps said the skin was dry, but the risk. A score of 1 indicates low risk. When and titrating the oxygen to the lowest electrosurgical unit caused the hair an operation is assessed as being at high concentration needed to maintain an to catch fire. The prep should dry for at risk for a surgical fire, risk mitigation adequate arterial oxygen saturation. Risks least three minutes to allow full evapora- should be done to decrease the risk. ECRI will be reduced further by using occlusive tion of the alcohol, and longer for hairy Institute has summarized these mitiga- draping techniques to minimize the flow areas or areas involving body crevasses or tion strategies related to surgery of the of dangerously high concentrations of skin folds. Avoid pooling of the alcohol- head, face, neck, and upper chest and for oxygen from under the drapes onto the based solutions. Drape only after all oropharyngeal procedures, bronchoscopic surgical field.5,8 alcohol has dried.7 surgery, and tracheostomy.5 Electrosurgical active electrodes (Bovie The Authority offers a surgical fire tool- The American Society of Anesthesiologists units) should not be used, if possible, in kit at http://patientsafetyauthority.org/ Task Force on Operating Room Fires and high-risk situations. If used, the power EducationalTools/PatientSafetyTools/ the Anesthesia Patient Safety Foundation settings should be as low as possible for airway_fires/Pages/home.aspx. Additional have determined that the most important surgical needs.9 Bipolar electrodes could information about surgical fire prevention practice for managing the risk of a surgical also be used. is also available through ECRI Institute fire is to determine if supplemental oxygen It should also be noted that the end of a at https://www.ecri.org/Products/Pages/ is needed to maintain adequate arterial fiberoptic light cord is about as dangerous Surgical_Fires.aspx. oxygen saturation. This assessment is espe- to place on the surgical drapes as a lit cigar. cially important when the oxygen would Azizi notes that the temperature from a CONCLUSION be administered in an “open” fashion, via fiberoptic light cord with a new bulb in Surgical fires remain a significant enough a nasal cannula or face mask, thereby satu- the light source can reach 670 degrees risk to justify use of a Fire Risk Assess- rating the surgical field with high oxygen Fahrenheit.10 ment Score, the communication that concentrations. Keeping oxygen concentra- Moist sponges minimize the risk of setting should occur with a Fire Risk Assessment tions less than 30% is desirable to prevent a sponge on fire. A dry sponge can be Score of 2 or 3,6 and adherence to the rapidly spreading fires. When there is a ignited easily, especially in the presence recommendations of both the Anesthesia risk of fire and the patient requires supple- of an oxygen-enriched atmosphere, Patient Safety Foundation3 and the Ameri- mental oxygen to maintain an adequate whereas a moist sponge resists ignition.8 can Society of Anesthesiologists Task arterial oxygen saturation, a controlled Water or saline should also be available Force on Operating Room Fires.2,5 airway, such as an endotracheal tube or laryngeal mask, is recommended to help for dousing a fire. A five-pound carbon Acknowledgments isolate the oxidizer from the heat source.2,7 dioxide fire extinguisher should be avail- Edward Finley, BA, Pennsylvania Patient Safety able in the OR.2,7 Authority, and Art Augustine, BS, formerly of the There are defined exceptions in which Pennsylvania Patient Safety Authority, contributed supplemental oxygen delivery may be The number of fires involving bone to the data analysis. required via an open source on the face.5,8 cement was the same as the number involving alcohol preps. Page 134 Pennsylvania Patient Safety Advisory Vol. 9, No. 4—December 2012 ©2012 Pennsylvania Patient Safety Authority NOTES 1. The Joint Commission. Preventing reduce preventable harm [online]. [cited Winter;26(3):42-3. Also available at surgical fires [Sentinel Event Alert 2012 October 12]. http://www.fda.gov/ www.apsf.org/newsletters/pdf/ online]. 2003 Jun 24 [cited 2012 Oct Drugs/DrugSafety/SafeUseInitiative/ winter_2012.pdf. 12]. http://www.jointcommission. PreventingSurgicalFires/ucm20026140.htm. 8. ECRI Institute. New clinical guide to org/sentinel_event_alert_issue_29_ 5. ECRI Institute. Only you can prevent surgical fire prevention. Health Devices preventing_surgical_fires. surgical fires [poster online]. 2009 2009 Oct:38(10):314-32. 2. American Society of Anesthesiologists Oct [cited 2012 Oct 12]. https://www. 9. Haith LR Jr, Santavasi W, Shapiro TK, et Task Force on Operating Room Fires, ecri.org/Documents/Surgical_Fire_ al. Burn center management of operating Caplan RA, Barker SJ, et al. Practice advi- Poster(2009).pdf. room fire injuries. J Burn Care Res 2012 sory for the prevention and management 6. Christiana Care Health System. Surgical Sep-Oct;33(5):649-53. of operating room fires. Anesthesiology fire risk assessment [website]. [cited 2012 10. Azizi J. Practical advice for preventing sur- 2008 May;108(5):786-801. October 12]. Wilmington (DE): Chris- gical fires: safety strategies from the front 3. Anesthesia Patient Safety Foundation. tiana Care Health System. http://www. lines. Presented at: FDA Preventing Surgi- Fire safety video [online]. 2010 Feb [cited christianacare.org/fireriskassessment. cal Fires Initiative Webinar; 2012 Jun 2012 Oct 12]. http://www.apsf.org/ 7. Anesthesia Patient Safety Foundation. 12. Transcript available at http://www. resources_video.php. Surgical fire injuries continue to occur: fda.gov/downloads/Drugs/DrugSafety/ 4. US Food and Drug Administration. prevention may require more cautious SafeUseInitiative/PreventingSurgical- Preventing surgical fires: collaborating to use of oxygen. APSF Newsletter 2012 Fires/UCM309268.pdf. Vol. 8, No. 1—March 2011 Pennsylvania Patient Safety Advisory Page 135 ©2011 Pennsylvania Patient Safety Authority PENNSYLVANIA PATIENT SAFETY ADVISORY This article is reprinted from the Pennsylvania Patient Safety Advisory, Vol. 9, No. 4—December 2012. 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