2017 AORN Fire Safety Tool Kit Fire: Team Responsibilities in the Perioperative Practice Setting

Goal The goal of this learning activity is to educate perioperative team members about their roles if a fire occurs in the perioperative practice setting.

Objectives After completing this activity, the participant will be able to: Discuss the roles of the perioperative team members during small fires. State roles of the perioperative team members during large fires. Identify two actions that each perioperative team member should take during a fire in the perioperative setting.

Topics Fire facts Locations Patient injuries Fire reports by procedure High-risk procedures Fire safety is a team effort Let’s look at these topics.

Fire Facts Estimated Frequency 200 to 240 per year in the United States 44% head, neck, or upper chest 26% elsewhere on the patient 21% in the airway 8% elsewhere in the patient We all have heard about fires in the OR, but there is no clear data regarding how many really occur. The estimates on this slide are based on the collective evidence. The estimate of 200 to 240 fires per year in the OR is down from the previous estimate of 550 to 650 per year. The anatomical location of the fires occurring on the patient include 44% on the head, neck, or upper chest and 26% elsewhere on the patient. Examples of fires on the patient include a fire on the drapes or the patient’s skin. It is also estimated that 21% of these fires occur in the patient’s airway and 8% occur elsewhere in the body (eg, within a body cavity).

Surgical Fires Can Occur: ANYWHERE Ambulatory surgery centers Hospitals Physicians’ offices Fires occur in every location where the three sides of the fire triangle—a fuel, an oxidizer, and an ignition source—come together. The fire triangle will be discussed in detail later. Fires can occur in any location including ambulatory surgery centers, large or small hospitals, and even in physicians’ offices where surgical procedures are performed.

Patient Injuries Of the 200 to 240 OR fires per year in the United States, 20 to 30 are serious and result in disfiguring or disabling injuries. 1 to 2 are fatal. The collective evidence states that 20 to 30 of the 200 to 240 OR fires are serious, which is defined as causing disfiguring or disabling patient injuries. Only one or two of the total fires per year are fatal. The fatal fires typically occur in the patient’s airway.

Surgical Fires Reported by Procedure Cervical conization Cesarean delivery Facial surgery Infant surgeries (eg, patent ductus arteriosus) Oral surgery Pneumonectomy Tonsillectomy Tracheotomy Surgical fires involving all of these procedures, different areas of the body, and all age groups have been reported to various reporting agencies.

High-Risk Procedures Surgical procedures performed above the xiphoid process and in the oropharynx carry the greatest risk Lesion removal on the head, neck, or face Tonsillectomy Tracheostomy Burr hole surgery Removal of laryngeal papillomas The procedures with the greatest risk for a fire to occur are those that are performed above the xiphoid process or on the head, neck, face, or upper chest. These procedures have the highest risk because of the high potential for the presence of an oxygen-enriched environment that is in close proximity to the incision site and where the ignition source is used. Ignition sources in these procedures may be the electrosurgical device, laser, drill, or burr.

Fire Prevention is a Team Effort Nurses Surgical technologists Surgeons Assistants Environmental Services associates Administration team members Everyone else not mentioned Fire prevention is truly a team effort, and the role that you will play in prevention depends on your job description.

Team Responsibilities in a Fire Depends on: Facility Time Personnel present Size of the fire Location of the fire Who is responsible for tasks and roles that must be rapidly accomplished in the event of a fire? This will vary depending on the type and size of the facility, the time of day, the number of people present, and the size and location of the fire. Because of these variances, all personnel should be aware of all actions that must be taken to extinguish a fire. An example of a variance may be the difference between a hospital that has a staff of 25 people in the OR and an ambulatory surgery center that has a staff of 5 people.

Facility Office based Small ambulatory surgery center Large ambulatory surgery center Small hospital Large hospital Teaching hospital University medical center The size of the facility may determine not only how many people are present at any given time but may also contribute to the familiarity of fire department personnel with the location of the perioperative services. In a complex, large teaching facility, which may have operating rooms in various buildings or on various floors, it may be challenging for fire department personnel to determine where the fire is located. In contrast, in a small rural facility, fire department personnel may be very familiar with the layout of the building because they have been there for other events, such as inspections.

Time Normal business hours Evenings Weekends On-call hours The time of day and the day of the week that a fire occurs affects the number of people present and the amount of traffic that fire department personnel may encounter while en route to the facility. In some facilities, the fire department is notified by a member of the surgical team calling 911 and in others this may be the responsibility of the switchboard operator. It is important to know the process that is in place for all hours and days of the week at your facility.

Personnel Present RN circulator Scrub person Anesthesia professional in the room Surgeon Supervising anesthesia professional Anesthesia assistant First assistant (eg, RNFA, surgical assistant) Charge RN Support personnel Administrator As mentioned previously, the time of day and the size of the facility will determine the number and types of personnel present. A surgeon, RN circulator, scrub person, and an anesthesia professional may be the only ones present when a fire occurs, such as in the early hours of the morning or in an ambulatory surgery center. Team members in these roles need the most extensive training in preventing and fighting fires. The responsibilities of each person will change depending on how many people are present.

Size and Location of Fire Small fire on the patient Large fire on the patient Fire in the patient Airway fire Equipment fire The size and location of a fire may also determine the responsibilities of the team members. If the fire is small, the surgeon may smother the fire with a towel or the scrub person may extinguish it using a solution such as water or saline. During this type of fire, the RN circulator will not be involved in extinguishing the fire, but he or she may have other roles, such as notifying the administration team. If the fire is larger or is spreading fast, the surgeon may remove the burning drapes from the patient, throwing them onto the floor where the RN circulator takes over extinguishing the fire using a solution or a fire extinguisher, depending on how large the fire is and what fire-fighting method will be the fastest and most effective.

Responsibilities - All Fires Alert team members to the presence of a fire. Stop the flow of breathing gases to the patient. Extinguish the fire by smothering or using water or saline. Push the back table away from the sterile field. Remove burning material from the patient. Assess for secondary fires. Assess the patient for injuries. These responsibilities or assignments are intended to be used as examples only and to alert personnel to the various responsibilities that need to be accomplished. The actions listed here must be carried out in every fire, but who will accomplish them will vary based on the people present at the time of the fire. These responsibilities will also occur simultaneously, so the order of when the events should occur is not implied in this listing, except for the notification of the team, which must occur first. In this presentation, the responsibilities listed will be linked to one of the four team members who are always present: RN circulator, surgeon, scrub person, and anesthesia professional. The person listed is the primary person to complete the responsibility, but that person may receive assistance from others because fighting a fire is a team effort. Many of these responsibilities fall to the RN circulator because the RN circulator is not working within the sterile field and has the ultimate responsibility for the operating room. Actions and the team members to take the action are: Alerts team members to the presence of a fire: whoever sees it first. Stops the flow of breathing gases to the patient: anesthesia professional. Extinguishes the fire by smothering or using a solution: surgeon or scrub person if the fire is on the patient. If it is a large fire, it may be the RN circulator who needs to take this action. Pushes the back table away from the sterile field: scrub person. This step is completed to help ensure the sterility of the back table and to prepare it for potential evacuation if necessary. Removes burning material from the patient: surgeon or scrub person. Assesses for secondary fire: surgeon or scrub person. Assesses the patient for injuries: surgeon or RN circulator.

Responsibilities - All Fires Notify appropriate personnel. Assign a liaison to the families. Act as a liaison to the families. Complete an occurrence report. Gather involved materials and supplies. Notifies appropriate personnel—next in chain of command: RN circulator. Assigns liaison to the families: The RN circulator is responsible, but this needs to be determined in collaboration with the surgeon and should be based on the stage of the procedure, injuries present, time of day, and the policy of the facility. For example, the facility may dictate that the only person allowed to talk to the family in this situation is the risk manager or maybe the surgeon. If the policy is in place for a perioperative team member to contact the appropriate risk management personnel, then this should be carried out by the RN circulator or surgeon. Acts as a liaison to the families: surgeon, RN circulator, or designee as determined by facility policy. Completes occurrence report: The entire team should assist in completing the report, and it needs to be completed only after the patient is out of the OR. In most facilities, the RN circulator has the ultimate responsibility of gathering the team together and completing the necessary forms. Gathers involved material/supplies: The entire team is responsible, but the RN circulator has the overarching responsibility to ensure the supplies are gathered and sent to the correct location within the facility.

Responsibilities - Large Fire on the Patient Perform the responsibilities for All Fires. Activate the alarm system. Turn off the oxygen shut-off valve outside of the room. Extinguish any burning material off of the patient. Communicate with personnel in the surrounding areas about the presence of fire. Delegate responsibilities for non-direct caregivers. Assign a traffic director. Show the fire response team or fire department personnel to the location. These responsibilities must be individualized to each fire and are for the fire that is rapidly spreading or is large and is on the patient. Other team members, including the ancillary team, may be involved depending on facility policy. These actions will be accomplished simultaneously and are in addition to the responsibilities for all fires discussed earlier. The RN circulator should activate the alarm system or instruct a team member to do this. This may involve yelling for help, dialing a number on the telephone and announcing it to the building or an operator, or pulling an alarm box on the wall. Turning off the oxygen shut-off valve outside of room can be done by the RN circulator but only after collaboration with the anesthesia professional. This will prevent oxygen from flowing into the atmosphere and creating an oxygen-enriched environment. This is not a first-line task but needs to be considered if the fire is growing. The RN circulator should extinguish any burning material off the patient by smothering or using water or saline or the appropriate fire extinguisher. The surgeon, anesthesia professional, and scrub person may or may not be able to assist with this task. Communicating with personnel in surrounding areas regarding the presence of a fire and to bring assistance is another task that may be accomplished by the RN circulator or delegated to other personnel. The RN circulator can delegate this task. If available, the charge RN or other supervisory personnel can delegate responsibilities to non-direct caregivers. If other personnel come directly into the OR where the fire is active, the RN circulator can also direct personnel. The RN circulator or other supervisory personnel should assign a traffic director as soon as possible. Others in the facility may be assigned to this responsibility, such as a charge RN or a secretary. The assigned traffic director assists the fire response team or fire department to the location.

Responsibilities - Large Fire on the Patient Assist with the decision to evacuate. Order the evacuation of perioperative areas. Communicate the need to evacuate with personnel in surrounding areas. Order evacuation of the unit. Compile a list of all people in the perioperative areas. Activate the disaster/emergency preparedness plan. These responsibilities are necessary only if evacuation is required. The collective evidence states that evacuation is rarely required for fires originating in an OR, but team members need to be aware of what to do should it be necessary. Assists with the decision to evacuate and orders evacuation of the room: This would be a discussion between all members of the team, and if available, will involve the fire department, and if applicable, the fire brigade. A facility-designated person not directly involved in the procedure or room in which the fire originated should assume these responsibilities: Communicates with personnel in the surrounding areas regarding the need to evacuate Orders the evacuation of the perioperative areas Compiles a list of all people in the perioperative area Activates the disaster plan

Responsibilities - Airway or ET Tube Fire Perform the responsibilities for All Fires. Disconnect and remove the breathing circuit. Discontinue the flow of breathing gases to the patient. Remove the ET tube and any segments of the burned tube that remain in the airway. Pour water or saline into the airway as directed. Examine the airway. Re-establish the airway. In a fire involves the airway or an ET tube, the anesthesia professional becomes the leader or chief. The majority of responsibilities listed here can only be accomplished by the anesthesia professional or in collaboration with the anesthesia professional. This is a situation in which clear communication is absolutely essential; without it, the amount of patient injury may increase.

Responsibilities - Equipment Fire Perform the responsibilities for All Fires. Disconnect the equipment from the electrical outlet. Remove the working end of the equipment from the sterile field. Shut off the electricity to the equipment if you are unable to remove the plug from the outlet. Shut off gases to the equipment. Assess the size of the fire. Determine if equipment can be safely removed from the OR. Determine if personnel should evacuate the OR. Extinguish the fire using an extinguisher, if appropriate. Equipment fires, though rare, do occur, and preparation assists with decreasing the risk of injury to the patient and personnel. These responsibilities will fall primarily to the RN circulator and other personnel who are not at the sterile field and are present in the OR. The first step is announcing the presence of fire to the team members and then disconnecting the equipment from the electrical outlet, if this can be accomplished safely. By completing this action, the ignition source is removed and the fire may be extinguished at this point. The remaining responsibilities can be carried out as required, including the responsibilities associated with all fires.

Responsibilities - Fire Department Internal fire brigade Responsibility varies with location. External fire department Should be notified of every perioperative fire. Follow the facility policy and procedures. Some facilities have an internal fire brigade. These are composed of people within the building who will leave their work stations to come and assist with a fire in your unit. They may bring fire extinguishers from other areas, or they may show up to provide extra manpower and to assist with evacuation if necessary. These brigades are not present in every facility. The external fire department should be notified of every fire in the perioperative area. Fire department personnel can assist not only in extinguishing the fire but in evacuation if necessary. Most important, for small fires, they can assist in investigating the situation. The facility fire plan should dictate how the fire department is notified and who is responsible for the notification. (INSERT HERE THE METHOD USED IN YOUR FACILITY). The fire department usually takes from 3 to 15 minutes to arrive (INSERT HERE THE TIME NEEDED TO YOUR FACILITY).

Contacting the Fire Department Authority having jurisdiction May assist with perioperative education programs Determines types of fire extinguishers Determines location, storage, and amounts of alcohol-based hand scrubs The term “authority having jurisdiction” is used for the person who has the final voice in a situation, such as which fire extinguishers are allowed in the OR. In some settings the authority having jurisdiction is the local fire marshal, and in other settings, it is a state government position. Contact the local fire department to determine who has jurisdiction over your facility. The local fire department is not just for fighting fires. They can also assist you with providing education for staff members on all aspects of fire prevention and fire fighting. Another service provided is consultation regarding decisions on the proper fire extinguisher or where and how much alcohol-based hand scrub may be stored.

Summary Steps for surgical fire prevention: Know your role in your facility. Know all the roles in your facility. In summary, to be able to effectively fight a fire, perioperative team members should be aware of their usual roles and the roles of all the other people in perioperative arena in case the person who usually fills that role is not present.

The End