Operating Room Safety Fires Grand Rounds Presentation June 18, 2009 John Chi, MD Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870

UCLA Medical Center, 1990

26 year-old female struck by auto Blunt injuries to abdomen, chest Endotracheal intubation Emergency surgery

OR Fire Surgery completed

OR Fire Surgery completed Drapes ignited by cautery device

OR Fire Surgery completed Drapes ignited by cautery device Flames spread rapidly and engulf patient

OR Fire Surgery completed Drapes ignited by cautery device Flames spread rapidly and engulf patient Smoke forces OR staff to evacuate

OR Fire Surgery completed Drapes ignited by cautery device Flames spread rapidly and engulf patient Smoke forces OR staff to evacuate OR sprinkler system does not activate

OR Fire Surgery completed Drapes ignited by cautery device Flames spread rapidly and engulf patient Smoke forces OR staff to evacuate OR sprinkler system does not activate Fire Department arrives and controls fire

Outcome Patient expires in the fire Operating room staff treated for minor burns and smoke inhalation

Safety “If you don't know what is going to happen, there is no way to stop it.”

OR Fires Introduction Causes Outcomes Prevention

Epidemiology >30,000,000 surgeries per year >2,000 reported hospital fires 30 reported OR fires Source: American College of Surgeons,1997.

Locations of Fires Source: Tyco Healthcare Valleylab 2006.

Locations of Fires ~ 65% of fires occur in the Head & Neck region because of the O 2 rich environment Source: ECRI. Devastation of patient fires. Health devices

OR Fires Introduction Causes Outcomes Prevention

Requirements for Fire Oxidizer + Fuel + Ignition = FIRE

Oxidizers

Oxygen

Oxidizers Oxygen –Oxygen is denser than air g/L O 2 > g/L N 2

Oxidizers Oxygen –Oxygen is denser than air g/L O 2 > g/L N 2 –Collects in low-lying areas

Oxidizers Oxygen –Oxygen is denser than air g/L O 2 > g/L N 2 –Collects in low-lying areas –Absorbed and retained by fabrics

Oxidizers Oxygen –Oxygen is denser than air g/L O 2 > g/L N 2 –Collects in low-lying areas –Absorbed and retained by fabrics Nitrous oxide

Oxidizers Oxygen –Oxygen is denser than air g/L O 2 > g/L N 2 –Collects in low-lying areas –Absorbed and retained by fabrics Nitrous oxide –Releases oxygen when heat is applied

OR Fuels Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

OR Fuels Patient Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

OR Fuels Patient Prepping agents Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

OR Fuels Patient Prepping agents Ointments Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

OR Fuels Patient Prepping agents Ointments Linens Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

OR Fuels Patient Prepping agents Ointments Linens Equipment Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

OR Fuels - Patient Hair Surgical cap Gown GI tract gases

OR Fuels – Prepping Agents Alcohol Chlorhexidine Acetone Betadine

Betadine??

Explodes in the presence of high oxygen or nitrous oxide concentrations at high temperatures Source: Briscoe et al, 1976.

Betadine?? Explodes in the presence of high oxygen or nitrous oxide concentrations at high temperatures Source: Briscoe et al, 1976.

Betadine

Flammability of the Product: May be combustible at high temperature.

Glycerin

Flammability of the Product: May be combustible at high temperature.

OR Fuels - Ointments Petrolatum Benzoin Paraffin Aerosols

OR Fuels - Linens Drapes Dressings, sponges Surgical gowns, masks, caps Mattresses Sheets, blankets Egg crates

OR Fuels - Equipment Flexible endoscopes ECG wires Blood pressure cuff Tubing Gloves Anesthesia machine

Flammability Standards OR equipment OR supplies OR gowns, masks, caps Anesthetics Source: Sommers JR. Flammability standards. SSM 1998;2:41-4.

Requirements for Fire Oxidizer + Fuel + Ignition = FIRE

OR Fire Survey Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

OR Fire Survey 8,523 questionnaires Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

OR Fire Survey 8,523 questionnaires 349 respondents Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

OR Fire Survey 8,523 questionnaires 349 respondents 88 respondents > 1 Fire Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

OR Fire Survey 8,523 questionnaires 349 respondents 88 respondents > 1 Fire 10 respondents = 2 Fires Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

OR Fire Survey 8,523 questionnaires 349 respondents 88 respondents > 1 Fire 10 respondents = 2 Fires 2 respondents = 5 Fires Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

Fire Scenarios 27% Endoscopic Airway Surgery 24% Oropharyngeal Electrocautery Surgery 23% Electrocautery Surgery under MAC 18% Tracheotomy 7% Endoscopic Light Cables 1% Anesthesia Machine

Endoscopic Airway Surgery

OXIDIZER: –Oxygen –Nitrous Oxide

Endoscopic Airway Surgery OXIDIZER: –Oxygen –Nitrous Oxide FUEL: –ET Tube, LASER ET Tube –Flexible Bronchoscope, Drapes

Endoscopic Airway Surgery OXIDIZER: –Oxygen –Nitrous Oxide FUEL: –ET Tube, LASER ET Tube –Flexible Bronchoscope, Drapes IGNITION: –LASER - CO 2 more often than KTP

Laser Ignition of Drapes Source: Wolf et al, 2004.

Laser Ignition of Drapes Surgical drapes tested for time to ignition Source: Wolf et al, 2004.

Laser Ignition of Drapes Surgical drapes tested for time to ignition CO 2 laser 15 W, 2 mm spot x 30 sec Source: Wolf et al, 2004.

Laser Ignition of Drapes Surgical drapes tested for time to ignition CO 2 laser 15 W, 2 mm spot x 30 sec 21% O 2 50% O 2 95% O 2 Source: Wolf et al, 2004.

Laser Ignition of Drapes Surgical drapes tested for time to ignition CO 2 laser 15 W, 2 mm spot x 30 sec 21% O 2 50% O 2 95% O 2 Primary ignition – drapes Secondary ignition – drapes on filter paper Source: Wolf et al, 2004.

Drapes Tested Nonwoven cellulose/polyester blend Polypropylene Reusable woven cotton/polyester blend Huck cotton towel drape adjunct Phenol polymer

Time to Primary Ignition 21% MaterialIgnited / TestedTTI Phenol polymer0 / 10N/A Polypropylene0 / 10N/A Huck towel8 / sec Cotton-poly10 / sec Cellulose-poly10 / sec

Time to Primary Ignition 50% MaterialIgnited / TestedTTI Phenol polymer10 / s Polypropylene9 / s Huck towel10 / s Cotton-poly10 / s Cellulose-poly10 / 10< 0.1 s

Time to Primary Ignition 95% MaterialIgnited / TestedTTI Phenol polymer10 / s Polypropylene10 / s Huck towel10 / 10< 0.1 s Cotton-poly10 / s Cellulose-poly10 / 10< 0.1 s

Time to Secondary Ignition 21% MaterialIgnited / TestedTTI Polypropylene & Filter Paper 10 / s Filter Paper alone 10 / s Filter paper was placed beneath the test material.

Laser Study Conclusions Time to ignition decreases with increasing O 2 concentration Polypropylene assumes the ignition characteristics of materials it contacts

Oropharyngeal Electrocautery

OXIDIZER: –Oxygen

Oropharyngeal Electrocautery OXIDIZER: –Oxygen FUEL: –ET Tube– Bovie Tip –Tonsil Sponge– Red Rubber Catheter

Oropharyngeal Electrocautery OXIDIZER: –Oxygen FUEL: –ET Tube– Bovie Tip –Tonsil Sponge– Red Rubber Catheter IGNITION: –Monopolar Electrocautery

Fire risk: Monopolar v. Coblator Source: Smith LP, Roy S, Laryngoscope, Accepted for publication.

Fire risk: Monopolar v. Coblator Monopolar –Coagulate: 15 W Coblator –Ablate: 9, 7, 3 –Coagulate: 5, 3 Source: Smith LP, Roy S, Laryngoscope, Accepted for publication.

Fire risk: Monopolar v. Coblator Degutted raw chicken 6.0 ET Tube 100% oxygen at 10 L/min 3 tonsil sponges Source: Smith LP, Roy S, Laryngoscope, Accepted for publication.

OP Fire Study Setup

Monopolar Electrocautery

After 45–55 secs of Monopolar

After the fire

Coblator Electrocautery

After 4 minutes of Coblator

After 20 minutes of Coblator

Back to Monopolar for 25 secs

OP Fire Study Conclusions Monopolar Electrocautery (>15 W) poses a fire risk Coblator Electrocautery did not produce fires

Electrocautery Surgery (MAC)

OXIDIZER : –Oxygen

Electrocautery Surgery (MAC) OXIDIZER : –Oxygen FUEL : –Flash Fire– Drapes –EtOH Prep– Sponges

Electrocautery Surgery (MAC) OXIDIZER: –Oxygen FUEL: –Flash Fire– Drapes –EtOH Prep– Sponges IGNITION: –Monopolar Electrocautery– LASER –Thermocautery –Oxidizer to ignition source <5cm

Arizona Medical Center,1998

73 year-old male with SDH for bilateral burr holes Oxygen via face mask at 6 L/min Iodofor surgical prep –(0.7% iodine, 74% Isopropyl EtOH) Drapes: Towels, Paper surgical drapes Monopolar Electrocautery

OR Fire

“Pop”

OR Fire “Pop” Smoke appears from beneath the drapes

OR Fire “Pop” Smoke appears from beneath the drapes Drapes quickly removed

OR Fire “Pop” Smoke appears from beneath the drapes Drapes quickly removed “Ball of flame” engulfs the patient’s head

OR Fire “Pop” Smoke appears from beneath the drapes Drapes quickly removed “Ball of flame” engulfs the patient’s head Oxygen mask on fire

OR Fire “Pop” Smoke appears from beneath the drapes Drapes quickly removed “Ball of flame” engulfs the patient’s head Oxygen mask on fire Fire smothered with drapes

OR Fire “Pop” Smoke appears from beneath the drapes Drapes quickly removed “Ball of flame” engulfs the patient’s head Oxygen mask on fire Fire smothered with drapes Oxygen flow turned off

Outcome Intubation 2 nd degree burns of face, neck ICU x 2 months Pneumonia, Respiratory Failure Inpatient rehabilitation

Simulated OR Fire

Life size manikin Oxygen supplied via face mask Positioned, prepped, and draped Monopolar electrocautery

Simulation Setup

Monopolar Electrocautery- POP

Smoke – POP + 5 seconds

Fire – POP + 13 seconds

Fire – POP + 24 seconds

Beneath the drapes

Simulation Fire Requirements Source: Barker SJ, Polson SJ, 2001.

Simulation Fire Requirements Supplemental oxygen Source: Barker SJ, Polson SJ, 2001.

Simulation Fire Requirements Supplemental oxygen Closed space formed by drapes (Tenting) Source: Barker SJ, Polson SJ, 2001.

Simulation Fire Requirements Supplemental oxygen Closed space formed by drapes (Tenting) Alcohol-based preparation solution –Manufacturer’s label drying time 2-3 minutes –Drying time > 5 minutes  No fire Source: Barker SJ, Polson SJ, 2001.

Oxygen Face Masks

Melt when exposed to open flame

Oxygen Face Masks Melt when exposed to open flame Do NOT burn without oxygen flow

Oxygen Face Masks Melt when exposed to open flame Do NOT burn without oxygen flow Ignite, burn with oxygen flow > 3 L/min

Tracheotomy

OXIDIZER: –Oxygen

Tracheotomy OXIDIZER: –Oxygen FUEL: –Flash Fire, ET Tube, Drape, Airway

Tracheotomy OXIDIZER: –Oxygen FUEL: –Flash Fire, ET Tube, Drape, Airway IGNITION: –Monopolar electrocautery Electrocautery to enter trachea Electrocautery after airway incision

Endoscopic Surgery

OXIDIZER : –Oxygen

Endoscopic Surgery OXIDIZER: –Oxygen FUEL: –Drapes Cellulose-based: IGNITE Polypropylene-based: MELT

Endoscopic Surgery OXIDIZER: –Oxygen FUEL: –Drapes Cellulose-based: IGNITE Polypropylene-based: MELT IGNITION: –Endoscopic Light Cable –Temperature > 200º Celcius

OR Fires Introduction Causes Outcomes Prevention

Outcomes

Analysis of Closed Claims Source: Bhananker et al, 2006.

Analysis of Closed Claims Analysis of the closed claims of 35 US professional liability insurance companies Source: Bhananker et al, 2006.

Analysis of Closed Claims Analysis of the closed claims of 35 US professional liability insurance companies 121 MAC-related claims reviewed 20 OR fires leading to burns Source: Bhananker et al, 2006.

OR Fires 95% involved head, neck, face

OR Fires 95% involved head, neck, face 50% cited for substandard care

OR Fires 95% involved head, neck, face 50% cited for substandard care 89% resulted in payment to plaintiff –Median $71,375 –Range $8,175 to $321,323

OR Fires Introduction Causes Outcomes Prevention

Communication with OR Staff, Anesthesia

Prevention Communication with OR Staff, Anesthesia Assess the OR fire risk

Prevention Communication with OR Staff, Anesthesia Assess the OR fire risk Electrocautery – avoid Fuels + Oxidizers

Prevention Communication with OR Staff, Anesthesia Assess the OR fire risk Electrocautery – avoid Fuels + Oxidizers Minimize available O 2

Prevention Communication with OR Staff, Anesthesia Assess the OR fire risk Electrocautery – avoid Fuels + Oxidizers Minimize available O 2 Prep Solutions – proceed with caution

Prevention Communication with OR Staff, Anesthesia Assess the OR fire risk Electrocautery – avoid Fuels + Oxidizers Minimize available O 2 Prep Solutions – proceed with caution Fire Safety Training

Summary

OR fires are preventable

Summary OR fires are preventable Be aware of your surroundings

Summary OR fires are preventable Be aware of your surroundings Oxidizer + Fuel + Ignition = FIRE

Thank You Lee Smith, MD James Kearney, MD Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870