Fire Prevention in the Perioperative Practice Setting 2015 AORN Fire Safety Tool Kit

Overview and Goal Recent statistics indicate there are 200-240 surgical fires per year. The goal of this learning activity is to educate perioperative RNs about fire safety in the perioperative practice setting. Proactive tools to promote fire prevention, plan effective responses, and develop perioperative evidence-based policies to protect perioperative patients and personnel will be discussed.

Objectives After completing this continuing nursing education activity, the participant will be able to: Identify the locations where a fire may occur. Identify the three components of the fire triangle. Identify fire prevention interventions. Describe the fire risk assessment. The objectives for this segment are to : Identify the locations where a fire may occur. Identify the three components of the fire triangle. Identify fire prevention interventions. Describe the fire risk assessment.

Fire Facts 200-240 per year in the U.S. Estimated Frequency 200-240 per year in the U.S. 44% on 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 upon the collective evidence. The estimate of 200-240 fires per year in the OR is down from the previous estimate of 550-650 per year. The anatomical location of the fires occurring on the patient include 44% on the head, neck, or upper chest and 26% are elsewhere on the patient. Examples of fires on the patient include a fire on the drapes or the skin of the patient. It is also estimated that 21% of these fires occur in the patient’s airway and 8% elsewhere in the patient (eg, within a body cavity).

Surgical Fires can occur: ANYWHERE Ambulatory surgery centers Physicians’ offices Hospitals 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 200-240 OR fires per year in the U.S. 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 200-240 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 section 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 surgeries 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 is dependent upon your job description.

Fire Triangle Here is the fire triangle. For a fire to occur, three things need to be present, and each is represented by one of the corners of the triangle: a fuel, an ignition source, and an oxygen source—commonly referred to as an oxidizer, which includes room air. In the perioperative setting, these three things are present on a regular basis—in fact, in almost every case. As you can see on the slide, these three things may be under the influence of three different people. The ignition source is frequently under the control of the surgeon or the assistant, with a lesser amount of influence by the scrub person. The oxidizer is usually under the influence of the anesthesia professional but may be under the influence of the perioperative RN, such as during a procedure using moderate sedation or local anesthesia. The third side of the triangle, the fuel, is primarily influenced by the RN circulator, but the fuel is also under the influence of the scrub person and the surgeon because they are responsible for the draping and the use of sponges and other flammable materials. As you can see on this slide, the entire perioperative team is involved at various times with all or any portions of the fire triangle.

Ignition Sources Electrosurgical unit (ESU) Argon beam coagulator Power tools (eg, drills, burrs) Laser Fiber-optic light Defibrillator Electrical equipment Let’s take a more detailed look at the first side of the fire, the ignition sources. Here is a partial listing of the potential ignition sources present in a perioperative setting. An ignition source is defined as anything that provides enough energy to start a fire. This energy may be in the form of a visible spark or just heat at a temperature high enough to cause a fire to ignite. Remember, a spark is not always necessary to start a fire. The electrosurgical unit is the most frequent ignition source, being involved in approximately 70% of the fires, while 20% of the fires involve other heat sources, such as hand-held battery operated devices, fiber-optic light sources, or defibrillators, and 10% of the fires involve lasers.

Controlling Ignition Sources: Interventions Place the patient return electrode on a large muscle mass close to the surgical site Keep active electrode cords from coiling Store the ESU pencil in a safety holster when not in use Keep surgical drapes or linens away from activated ESU Moisten drapes or place absorbent towels and sponges in close proximity to the ESU active electrode The next several slides show the interventions the surgical team should take to control the ignition sources just mentioned. The first group of interventions applies to the use of an electrosurgical unit. The first intervention, which is placement of the patient return electrode, takes place before the patient is draped. The perioperative RN should place the patient return electrode on a large muscle mass close to the surgical site. This placement provides for the least amount of resistance in the electrical circuit, as does keeping the active electrode cords from coiling. These actions decrease the heat produced and the amount of power required to accomplish cauterization. Storing the ESU pencil in a safety holster when not in use helps to keep the ignition source and the fuel separated and decreases the potential for accidental activation of the active electrode. Keeping the surgical drapes or linens away from the activated ESU also keeps the ignition source and the fuel separated. Moistening drapes or placing absorbent towels and sponges in close proximity to the ESU active electrode is recommended. Moistening the drapes increases the temperature required to cause the towels, drapes, or sponges to ignite.

Controlling Ignition Sources: Interventions Do not use an ignition source to enter the bowel when it is distended with gas Keep the ESU active electrode away from oxygen or nitrous oxide Keep the active electrode tip clean Use active electrodes or return electrodes that are manufacturer-approved for the ESU being used Use approved protective covers as insulators on the active electrode tip, NOT red rubber catheter or packing material Activate the active electrode only in close proximity to target tissue and away from other metal objects This is additional information related to the electrosurgical unit as the ignition source: The first intervention shown on this slide is “do not use an ignition source to enter the bowel when it is distended with gas.” The reason for this is that the gas in the bowel is flammable methane gas, which requires a low temperature or a very small spark to ignite. The next intervention is “keep the ESU active electrode away from oxygen or nitrous oxide” because oxygen and nitrous oxide both create an oxygen-enriched environment in which a lower temperature is required to cause ignition. The third intervention on this slide is “keep the active electrode tip clean.” This intervention works because less power is required and the electrode will perform better. You should use only active electrodes or return electrodes that are manufacturer-approved for the type and model of ESU being used, because others may not fit correctly and thus require a higher energy level or even create sparks at the connection. Do not use red rubber catheters or packing materials as protective covers or as insulators on the active electrode tip. Use approved insulators because the other products may melt or even catch fire during the procedure. The final intervention here is that the active electrode should be activated only when in close proximity to the target tissue and away from other metal objects. These objects could conduct heat or cause arcing, thereby providing the spark to cause a fire.

Controlling Ignition Sources: Interventions Inspect minimally invasive electrosurgical electrodes for impaired insulation; remove electrode from service if not intact Use “cut” or “blend” settings instead of coagulation Use the lowest power setting for the ESU Only the person controlling the active electrode activates the ESU Remove the active electrode from electrosurgical or electrocautery unit before discarding Inspect minimally invasive electrosurgical electrodes for impaired insulation and remove the electrode from service if the insulation is not intact because when activated, a spark may be created at the point of the break in insulation. “Cut” or “blend” settings on the ESU use less power and create less sparking than “coagulation” settings. This is the reason you should use the lowest possible power setting for the ESU. The person who is controlling the active electrode should be the only one who activates it. This can help to avoid accidental activation, which may result in a fire away from the surgical site. When the procedure is completed, remove the active electrode tip from electrosurgical or hand-held battery powered electrocautery device before discarding it. When the tip of the device has been removed, these devices cannot cause sparking or remain at an increased temperature that could result in a fire.

Controlling Ignition Sources: Interventions Use a laser-resistant endotracheal tube when using a laser during upper airway procedures Place wet sponges around the endotracheal tube cuff if the surgeon is operating in close proximity to the endotracheal tube Use wet sponges or towels around the surgical site Only the person controlling the laser beam activates the laser Have water or saline and the appropriate type of fire extinguisher available The next 5 interventions cover the use of a laser as the ignition source. It is recommended to use a laser-resistant endotracheal tube if an upper airway procedure is being performed with a laser. Laser-resistant endotracheal tubes help to decrease the potential for a fire because they have a very high ignition point. Wet sponges should be placed around the endotracheal tube cuff if the surgeon is operating in close proximity to the endotracheal tube. Place wet sponges around the surgical site for all laser procedures. As mentioned earlier, the wet towel or sponge requires a higher temperature to ignite compared with dry items. Just as when operating the ESU, the only person activating the laser should be the person controlling the laser beam. Before using the laser, the team member should verify that water and the appropriate type of fire extinguisher are available. It is better to be prepared than to regret not being prepared in these situations.

Controlling Ignition Sources: Interventions Place the light source in standby mode or turn it off when not in use Inspect light cables before use and remove them from service if broken light bundles are visible Select defibrillator paddles that are the correct size for the patient Use only manufacturer-recommended defibrillator paddle lubricant Place defibrillator paddles appropriately The next grouping of interventions is carried out if there is a light source or a defibrillator present. When using a light source, it should be placed in standby mode or turned off when the cable is not in active use (eg, used within 5 to 10 seconds). These cords do not produce a spark like the ESU or the laser, but they produce a very high temperature, which is why they are considered an ignition source. The light cables should be inspected before use and removed from service if broken light bundles are visible. If there are broken light bundles, a high temperature will be created at the break and not at the end as may be expected, potentially leading to a fire at the site of the break. Defibrillators can cause fires by sparking during discharge. To help prevent this sparking, you should select defibrillator paddles that are the correct size for the patient, use only manufacturer-recommended products for defibrillator paddle lubrication, and place the paddles correctly to allow optimal skin contact.

Controlling Ignition Sources: Interventions Inspect electrical cords and plugs for integrity and remove from service if broken Check biomedical inspection stickers on equipment for a current inspection date and remove the equipment from service if not current Do not bypass or disable equipment safety features Follow manufacturer’s recommendations for use Keep fluids off of electrical equipment Another ignition source is any piece of equipment that is connected to an electrical outlet. The actual energy in this situation is the electricity. To prevent sparking resulting in a fire, you should inspect electrical cords and plugs for integrity and remove the item from service if broken. Electrical safety and prevention of fire are two reasons for checking biomedical inspection stickers on equipment. The sticker date should be current and, if not current, the item should be removed from service. The equipment has audible alarms and other safety features to decrease the risk of fire. You should not bypass or disable these safety features by turning the volume down or off. All medical devices should be used according to manufacturer’s recommendations because that is the way the safety features have been tested and verified. Keep fluids off of the electrical equipment. When water and electricity mix, there may be sparks and electrical shocks created that can cause either a fire or an electrocution. .

Oxidizers Oxygen Oxygen-enriched environment Nitrous oxide The next side of the fire triangle is the oxidizers that are present in every perioperative setting. An oxidizer is defined as the gases that can support combustion. This includes the ambient air that we breath every day. Oxygen by itself is not flammable, but as the concentration of oxygen that is present is increased, the temperature required for ignition is decreased. An oxygen-enriched environment is defined as an environment where the oxygen percentage is greater than 21%. The reason this is important is that many items will not burn in ambient air but will burn when the oxygen concentration is elevated. 75% of the OR fires occur in an oxygen-enriched atmosphere. For example, an endotracheal tube that is made of polyvinylchloride (PVC) will not burn in ambient air but will burn when the oxygen concentration is at 26%. An oxygen-enriched environment is easily created when oxygen is administered to the patient at greater than 30% via an open delivery system and in a confined area, such as under drapes that are close to the patient’s face. The same fire precautions when using 100% oxygen should be instituted when nitrous oxide, an anesthetic agent, is present.

Controlling the Oxidizer: Interventions Tent drapes to allow for free air flow Keep the oxygen percentage as low as possible Use an adhesive incise drape The interventions to control oxidizers all attempt to decrease the potential for an oxygen-enriched environment to be created. The first intervention is when draping the patient to configure the surgical drapes to allow sufficient venting of oxygen that is being delivered to the patient via mask or nasal prongs. Oxygen delivered in this manner is also referred to as “open oxygen delivery.” If supplemental oxygen is required and the patient cannot be intubated, oxygen should be titrated to the lowest percentage necessary to support the patient’s physiological needs. If the oxygen is being administered via a mask or nasal prongs, then it is recommended to use a separate administration system to deliver 5 liters to 10 liters per minute of air under the surgical drapes. This will help flush out the excess oxygen when greater than 30% oxygen is required, and if possible, the patient should be intubated using a cuffed endotracheal tube. The cuff helps restrict the flow of the oxygen into the throat or into the surgical field. The supplemental oxygen or nitrous oxide should be stopped for 1 minute before use of an ignition source during procedures of the head, neck, or upper chest procedures. Stopping the supplemental oxygen or nitrous oxide for 1 minute will also help to decrease the oxygen concentration in the air under the drapes. This is a measure that can only be accomplished if the patient can tolerate it. The use of an adhesive incise drape limits the effects of the oxidizers by keeping the oxygen away from the surgical site. For the adhesive incise drape to be effective, it must be sealed with no leaks.

Controlling the Oxidizer: Interventions Inflate the endotracheal tube cuff with tinted saline Evacuate the surgical smoke from small or enclosed spaces Pack wet sponges around the back of the patient’s throat If O2 is being used, suction the patient’s oropharynx deeply before using the ignition source During procedures in the oropharynx, the endotracheal tube cuff should be inflated with tinted saline to make it easier to see if there has been a rupture to the cuff. The saline can be tinted with methylene blue or even food coloring. Evacuate surgical smoke to prevent accumulation in small or enclosed spaces (eg, back of throat), because the smoke can be very flammable. Pack wet sponges around the back of the throat to help retard oxygen leaks. If oxygen is used, the oropharynx should be suctioned deeply before an ignition source is used to remove as much of the oxygen as possible that may have escaped around the cuff of the endotracheal tube.

Controlling the Oxidizer: Interventions Inform the surgeon that an open O2 source is being used Stop supplemental O2 or nitrous before and during the use of an ignition source Check the anesthesia circuits for possible leaks Turn off the O2 at end of each procedure The first two of these interventions involve communication between the team members: The anesthesia professional or the perioperative RN who is monitoring the patient should tell the surgeon that the patient is receiving oxygen from an open source, and the surgeon should notify the anesthesia professional that he or she is about to use an ignition source so the supplemental oxygen can be discontinued for 1 minute before use. As we all know, this maybe very difficult to accomplish but communication is still very important. The cessation of the supplemental oxygen applies to only surgical procedures that are performed above the patient’s xiphoid process. It is important to communicate to all team members that the free-flowing oxygen is being used for the patient. Check the anesthesia circuits for possible leaks. This is important because a leak may create an oxygen-enriched environment under the drapes. The last intervention is to turn off the flow of oxygen at the end of each procedure to decrease the potential that an oxygen-enriched environment will be created. Turning off the flow of oxygen at the end of each procedure also helps to prevent a fire from occurring due to an open oxygen source when an OR suite is not occupied.

Controlling the Oxidizer: Interventions Oxygen delivery during head, face, neck, and upper chest surgery: Do not use open delivery of 100% oxygen Intubate or use a laryngeal mask airway if supplemental oxygen needed If O2 is greater than 30% via open delivery, use 5-10 L of air/minute under the drapes Exceptions: Patient verbal response required during surgery (eg, carotid artery surgery, neurosurgery, pacemaker insertion) Open oxygen delivery required to keep the patient safe These interventions can be performed by the anesthesia professional as well as the RN circulator, and/or the RN who is monitoring the patient during a procedure in which the patient is receiving moderate sedation or local anesthesia. If you are aware of the method of delivery and the percentage of oxygen the patient is receiving, then you can be better prepared to react in case of an emergency situation. “Open oxygen delivery” is defined as oxygen that is being delivered via a face mask or nasal cannula. Historically, 100% oxygen has been delivered because it is the easiest way to oxygenate the patient and it keeps the patient’s oxygen saturation values within a safe range. The recommendations state you should start with 30% oxygen and increase or decrease as appropriate for each patient. The patient should be monitored with an oxygen saturation monitor to help ensure the patient is receiving an adequate amount of oxygen but no more than necessary. The second portion recommends that the patient be intubated using an endotracheal tube or a laryngeal mask airway if greater than 30% oxygen is required. When there are valid reasons for open oxygen delivery, such as that the patient’s verbal response is required, then room air at 5-10 liters per minute should be administered under the drapes via a second administration set. This helps to flush away the oxygen, therefore decreasing the oxygen-enriched environment that may occur under the drapes.

Fuels Patient Personnel Drapes Gowns Towels Sponges Dressings Tapes Linens Head coverings Shoe covers Collodion Alcohol-based skin preparations Human hair Endotracheal tubes Here is a partial list of the fuels present in the perioperative setting. A fuel is defined as anything that will burn. Some of these items, such as the alcohol-based skin antiseptics, give off fumes that are very flammable. When trapped under the surgical drapes, these fumes greatly increase the risk of fire. Many of these items will burn in ambient air, but if an oxygen-enriched environment is present, they will all burn and will burn faster than in the normal atmosphere. In addition, in the OR, we frequently see a combination of these fuel sources, which decreases the amount of energy (ignition source) required to start a fire. For example, an alcohol-soaked towel will ignite faster than a dry towel will ignite. It is important to note that at the present time there are no fire-retardant drapes being manufactured. A few drapes currently manufactured may have some degree of resistance to ignition in ambient air, but they will all burn in an oxygen-enriched environment and none are treated with flame-retardant chemicals. We hear frequently of the fires associated with alcohol-based surgical prepping agents, but this is the fuel in only about 4% of the surgical fires.

Controlling Fuels: Interventions Use moist towels around the surgical site when using a laser During throat surgery, use moist sponges as packing in the throat Use water-based ointment and not oil-based ointment in facial hair and other hair near the surgical site During surgical procedures the fuel side of the triangle can be easily controlled by completing a few interventions. These interventions are not applicable to all procedures but will assist with prevention when applied. The interventions include using a moist towel around the surgical site when using a laser, and if doing throat surgery, using moist sponge packing in the throat to help protect the endotracheal tube. These are effective because water-soaked items, such as sponges or towels, require tremendously higher temperatures to ignite compared to what is required when they are dry. Use a water-based ointment and not an oil-based ointment on the facial hair and the hair close to the surgical site. The water-based ointment requires a very high temperature to ignite the hair beneath it.

Controlling Fuels: Interventions Prevent pooling of skin prep solutions Remove prep-soaked linen and disposable prepping drapes Allow skin-prep agents to dry and fumes to dissipate before draping Allow chemicals (eg, alcohol, collodion, tinctures) to dry Conduct a skin prep “time out” Some additional interventions to decrease the availability of the fuels include: When prepping, attempt to prevent pooling of skin prep solutions on or around the patient because some of these solutions, especially if they contain alcohol, will release fumes that are highly flammable. If you are using a prepping drape or towel to catch the pooled solution it needs to be removed before the patient is draped. Allow skin prep agents and, if used, chemicals such as alcohol, collodion, and any tinctures to dry and fumes to dissipate before draping the patient and before using an ignition source, such as an electrosurgical unit or laser. Remember, many tinctures contain alcohol, and that is why they are mentioned here. The fumes are the actual fuel that burns with some chemicals, including any product that contains alcohol. Conduct a skin prep time out to validate that the prepping agent is dry before draping the patient.

CMS Regulations Alcohol-Based Skin Preps Policies and procedures must be in place to reduce risk of fire Personnel must be aware of these policies Products are packaged for controlled delivery with clear directions that must be followed Documentation of implementation of fire prevention practices must be present in the patient’s medical record Personnel must demonstrate practice of the policies and procedures The Medicare payment system, also known as CMS, has rules and regulations that dictate actions required when alcohol-based skin preps, one of the fuels, are used. The regulations related to the use of alcohol-based skin preps are stated on the slide. The facilities must have policies and procedures to reduce risk of fire and the staff must be aware of them. Staff in this situation includes the entire perioperative team. The alcohol-based skin prep products must be packaged for controlled delivery with clear directions, and the directions, such as dry time, must be followed. Another requirement is that the patient medical record must contain documentation of implementation of the fire prevention policies and procedures. This documentation may be in the form of documentation of the time out associated with the fire risk assessment discussed later in this presentation. The last regulation is that the staff must actually practice what is stated in the policy and procedure and not just be able to verbally recite the information to an inspector.

CMS Regulations Alcohol-Based Skin Preps The CMS inspector approaches you and asks, “What is your facility doing to reduce the risk of fires related to alcohol-based skin preps?” The Centers for Medicare & Medicaid Services (CMS) performs random inspections of health care facilities. Let’s review a scenario. You receive a call from the front desk secretary who tells you the CMS inspectors have arrived and they want to talk to you. You know there are regulations regarding fire safety in the CMS Conditions of Participation, but it is too late to read the regulations to review what you should be doing to follow these regulations. The inspector approaches you and asks “What is your facility doing to reduce the risk of fires related to alcohol-based skin preps?” Would you be able to respond correctly? Here is one example of a response to this question: “As the patient is being prepped with an alcohol-based skin prep agent, the RN circulator uses towels to blot any of the excess prepping agent. After completing the prep, the RN circulator removes these towels and checks to make sure there is no excess solution on the patient’s bed sheets. Next, the RN circulator starts the timer to time the drying time of the alcohol-based solution. After the drying time has elapsed and the skin prep solution is dry, the RN circulator will notify the scrub person and the surgeon that they can being to drape the patient. Then, during the time-out procedure before the surgeon makes the incision, a fire risk assessment is completed and discussed with all team members present. The policy and procedure we have outlines the associated risk-reduction strategies we take for each of the assessment scores. Also, on a wall in the OR, we have the scoring system posted to help all of the team members recall the risks associated with each value. After the fire risk assessment is complete and reported, the RN circulator documents the results in the patient record.” Next, the inspector walks into an OR to see if what was reported is practiced in reality. It must be. All team members, including the surgeon, scrub person, RN circulator, anesthesia professional, and others, must be aware of the preventative measures and how to handle a fire. The CMS inspector is really from an accrediting organization that represents CMS, which may include a representative from The Joint Commission, a state department of health, or the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF).

Fire Risk Assessment Perform before start of procedure All members of the team participate Communicate this assessment during the “time out” Document this assessment in the patient’s record . The timing of when the OR fire risk assessment should occur is a facility decision. It should be completed before the procedure has started. This will enable the team to be better prepared for an emergency should it occur. Fire prevention is a team effort and the information needs to be communicated to all members of the team. For this reason, all team members must be present to participate in the fire risk assessment. A good time to conduct the fire risk assessment is during the time-out procedure. The fire risk assessment should also be documented in the patient’s record. Documentation of the fire risk assessment will assist other facility personnel with quality or risk management projects and, if there was a fire, documentation can provide information and support the actions that were taken during the fire.

Fire Risk Assessment Tool Is an alcohol-based prep agent or other volatile chemical being used preoperatively? Y or N Is the surgical procedure being performed above the xiphoid process? Y or N Is open oxygen or nitrous oxide being administered? Y or N Is an ESU, laser, or fiber-optic light cord being used? Y or N Are there other possible contributors? Y or N This risk assessment tool uses the letters A through E which, you will note, is similar to the types of fire extinguishers that are available for use. The questions reflect the five different high-risk factors that contribute in different ways to creating a fire, and they are related to all three sides of the fire triangle. Letters, not numbers, were assigned to these risks. To use this tool, the RN circulator and any other team member should review the items listed and determine which of the lettered items (A-E) apply to the current procedure. The RN circulator then reports during the time out which of the letters (such as A, D, E ) will apply. This information should be documented in the patient’s medical record. Here are three examples to help to clarify how to use the fire risk assessment tool: Example 1: A patient is having a carotid endarterectomy procedure and requires the delivery of supplemental oxygen at 50% to maintain a safe oxygen saturation. The RN circulator has prepped the patient’s skin at the surgical site with a solution of chlorhexidine gluconate with alcohol. The surgeon is planning to use an electrosurgical unit. The fire risk assessment for this procedure would be reported as an “ABCD,” and the recommended precautions should be taken for this patient. Example 2: A patient is having a total knee arthroplasty and requires the delivery of supplemental oxygen at 50%. Chlorhexidine gluconate with alcohol is applied as skin prep agent, and power equipment (drills and saws) and the electrosurgical unit will be used during the procedure. The fire risk assessment for this procedure would be reported an “ACDE.” Example 3: A patient is having a vaginal hysterectomy with spinal anesthesia. No supplemental oxygen is being delivered, iodophor paint is used as a skin prep agent, and the electrosurgical unit will be used. This fire risk assessment for this procedure would be reported and recorded as a “D.”  

Summary Steps for surgical fire prevention Know the components Ignition sources Oxidizers Fuels Communicate Fire risk assessment In summary, to be able to effectively prevent a fire, perioperative team members should be aware of the components of the fire triangle: ignition sources, oxidizers, and fuels and how they interact to create a fire. The second portion of fire prevention is communication. Communication includes completing a fire risk assessment.

References Guideline for a safe environment of care, part 1. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015:239-263. ECRI Institute. New clinical guide to surgical fire prevention. Patients can catch fire—here’s how to keep them safer. Health Devices. 2009;38(10):314-332. Clarke JR, Bruley ME. Surgical fires: trends associated with prevention efforts. Pennsylvania Patient Safety Advisory. 2012;9(2):130-135. Centers for Medicare & Medicaid Services. State Operations Manual. Appendix A—Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. http://cms.gov/manuals/Downloads/som107ap_a_hospitals.pdf. Accessed January 28, 2015.

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