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

2. Overview and Goal
Every perioperative team member should participate in perioperative fire safety prevention strategies and be able to take action if a fire occurs.
The goal of this learning activity is to educate perioperative team members about the recommended actions for extinguishing a fire and protecting patients and personnel.

3. Objectives
After completing this continuing nursing education activity, the participant will be able to:
Identify types of fires.
Discuss the steps to extinguish a fire in perioperative areas.
Describe how to smother a fire.
Identify evacuation routes.
The objectives for this segment are :
Identify types of fires.
Discuss the steps to extinguish a fire in perioperative areas.
Describe how to smother a fire.
Identify evacuation routes.

4. Fire reports by procedure High risk procedures
Fire facts
Locations
Patient injuries
Fire reports by procedure
High risk procedures
Fire safety is a team effort
The next six slides are a review of the fire facts and are included in each of the three slide decks. This information is provided as a review of important fire safety information at the beginning of each slide deck set in this tool kit. If you are presenting all three of the slides decks at the same time, you can choose to move through these slides more quickly.

5. Fire Facts 200-240 per year in the U.S.
Estimated frequency of OR fires
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 fires per year in the OR is down from the previous estimate of 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).

6. 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.

7. 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 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.

8. 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.

9. 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.

10. 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.

11. Types of Fires ON the patient IN the patient
Includes airway fires
ON or IN a piece of equipment
Even though all of the appropriate preventative measures have been taken, a fire may still occur. Therefore, perioperative team members must know how to fight a fire.
There are three different types of fires. The methods usually used for extinguishing vary with the location, but various methods can be used on a fire independent of the location.
A fire on the patient is described as one that is on the surface of the skin, drapes, or the patient’s hair.
A fire in the patient is defined as a fire that occurs within a patient’s body cavity. Examples would include a fire in the airway involving an endotracheal tube, or a fire involving the intestinal tract because the gases within the bowel were ignited when the surgeon opened the bowel with an electrosurgical active electrode.
The third type of fire involves equipment; it does not directly involve the patient.

12. Fighting Fires On a Patient
Announce the fire
Attempt to extinguish with water or saline
Remove burning materials from patient
Extinguish on floor
Turn off oxygen source
Obtain a fire extinguisher as last response
Save all involved materials
These are the actions that should be taken when fighting a small fire on the patient. The actions are not numbered because the order may vary depending on the type and location of the fire and the actions may be taken simultaneously by different team members. However, when a fire does occur, the first thing that the person discovering the fire must do is to announce it to the rest of the team.
The next most important action is to extinguish the fire as soon as possible to decrease potential injury to the patient. This is easily accomplished by throwing (pouring) saline or water on the fire or by patting the fire out with a gloved hand or a wet towel depending on how large the fire is and how quickly it is spreading.
If the fire is on the drapes or involves another item that can be removed from the patient, remove the burning item as soon as possible. If not previously extinguished, the fire can then be extinguished on the floor where it will not harm the patient.
No matter where the fire is located, the person controlling the oxygen source to the patient should discontinue the flow as soon as possible and switch to room air.
Obtaining the fire extinguisher may be the last response because the fire may be easily extinguished without an extinguisher and valuable time may be lost, potentially resulting in greater injury to the patient.
After the fire has been extinguished, it is very important to save all of the materials involved in the fire so the fire department, risk management department, and others will have the materials necessary to do a complete investigation and determine the cause of the fire.

13. Fighting Fires Involving an Endotracheal Tube
Announce the fire.
Collaborate and assist the anesthesia professional with:
disconnecting and removing the breathing circuit
turning off the flow of oxygen
pouring saline or water into the airway
removing the endotracheal tube and any segments of the burned tube
examining the airway
re-establishing the airway
The first step in fighting a fire remains the same when fighting a fire involving an endotracheal tube. Communicate to all team members the presence of the fire. The team must communicate with the anesthesia professional regarding actions necessary to extinguish the airway fire. The actions to fight an airway fire include disconnecting and removing the breathing circuit, turning off the flow of oxygen at the anesthesia machine, and if necessary, pouring saline or water into the airway.
Once the fire is extinguished, you should provide assistance to the anesthesia professional. Actions include removing the ET tube and any segments of the burned tube that remain in the airway, examining the airway, and re-establishing the airway.

14. Fighting Fires On or In a Patient
Assess the surgical field for a secondary fire on the underlying drapes or towels
Assess the patient for injury
Report injuries to the physician
Document assessment
Activate alarms if necessary
Notify appropriate chain of command
After the initial fire on or in the patient has been extinguished or the burning material has been removed from the patient, the team should assess the surgical field for a secondary fire on the underlying drapes or towels. At this same time, the patient should be assessed for injuries. Report any injuries to the physician and document the findings. Depending on the facility policy and procedures, the fire alarm should be activated. Activation in this situation may be defined as notifying the appropriate person in the chain of command and allowing him or her make the decision about bringing in others, such as whether to call the fire department since the fire has already been extinguished.

15. Fighting Fires On or In Equipment
Communicate the presence of the fire to team members
Disconnect equipment from its electrical source
Shut off electricity to the piece of equipment at the electrical panel
Shut off gases to equipment, if applicable.
Assess the size of the fire and determine if equipment can be removed safely or if evacuation is needed
Extinguish the fire with a fire extinguisher, if appropriate
Activate alarms if necessary
Notify the appropriate personnel
The first step in this type of a fire also is to communicate to all team members that a fire has started. You will notice that many of the steps for this type of fire match the others including communication, extinguishing the fire by the best method, activating alarms and notifying the chain of command; and like other fire situations, various people are accomplishing these steps simultaneously. Any one of the steps may be enough to extinguish the fire, but they all should be completed with the exception of discontinuing the electrical supply. The involved piece of equipment should be disconnected from the electrical source but only if this can be accomplished safely. The current at the electrical supply (the fuse box or electrical panel) will only need to be shut off if you are unable to remove the plug from the outlet. When the electricity is disconnected at the panel, other monitors and equipment may also lose electrical power. The assessment of the size of the fire needs to be made rapidly because the room may fill with smoke. This may lead to the smoke detectors being activated, resulting in the air circulation system shutting down. If you are using an extinguisher on the fire, try to stand between the patient and the fire so the majority of the extinguishing agent will be discharged away from the patient, which may help to decrease the contamination on the patient.

16. How to Extinguish a Fire Using Solution
Use a nonflammable liquid such as saline or water
Aim at the base of the fire
Remember: drapes may be impermeable
One way to extinguish a fire is to pour a nonflammable liquid on it. When extinguishing a fire using a solution, aim the liquid at the base of the fire and be sure to cover it completely. Remember, many of the drapes are waterproof, and if the fire is burning under the drapes, throwing or pouring water on the drapes will have no benefit. Impermeable drapes must be removed to effectively fight the fire.

17. How to Smother a Fire DO NOT PAT
Hold towel between fire and patient airway
Drop the end of towel closest to the head
Drop the other end of towel over the fire
Sweep hand over towel from head toward feet
Raise the towel
Keep your body away from fire
DO NOT PAT
In addition to or instead of extinguishing a fire using a solution, the fire may be smothered. Grab a towel. Drop the end of the towel between the fire and the patient’s airway keeping the towel between you and the fire. Lean into the patient and place your arm at the dropped end of the towel. Drop other end of the towel over the fire. Sweep with your free hand over the towel to extinguish the fire. When the fire is extinguished, raise the towel to decrease the heat. Keep your body, especially your face, as far away from the fire as possible for your safety. Do not pat the fire because this will fan the flames and it will continue to grow.

18. in Other Parts of the Building
How to Handle a Fire
in Other Parts of the Building
Charge nurse should notify team members when procedures are in progress
Do not start elective cases
All personnel should prepare to evacuate
If there is a fire in another part of the building that is beyond the fire doors of the perioperative area, the person in charge should notify all team members in the rooms in which a surgical procedure is in process. Any elective procedures that have not been started should be held until the unit is notified that the fire has been extinguished. All personnel should begin to take steps to evacuate their rooms. These steps may include confirming that there is an oxygen tank on every transport vehicle (eg gurney, stretcher, OR bed). The oxygen tank may need to be attached to the head of the OR bed if the patient could not be moved to another transport vehicle. Consider the safest method to close the surgical incision if the surgery is only partially completed. Team members should consider a safe location where they may be able to continue the surgery if necessary; ideally, it will be on the same floor of the facility. Team members should also consider the safest method to evacuate the patient if necessary.

19. Fire Blankets Not for Patient Fires!
Fire Blankets are Not Recommended!
Fire may be sustained by O2 delivered to the patient
Using a fire blanket
May trap fire next to or under the patient
May displace instruments
Blanket may burn in oxygen-enriched atmospheres
Fire blankets, which are intended to smother a fire, are not recommended for fires on patients because the fire could be sustained by oxygen delivered to the patient, preventing the blanket from being effective. A blanket may also trap the fire next to and under the patient, which may cause further injury. The patient may also be injured because the instruments may be displaced when a fire blanket is placed on the patient. Fire blankets, like many other items mentioned in the list of fuels, will burn if used in oxygen-enriched atmospheres.

20. NFPA Fire Classification*
Class A: wood, paper, cloth, and most plastics (eg, combustible materials) Class B: flammable liquids or grease Class C: energized electrical equipment Combination: ABC, AC
The National Fire Protection Association (NFPA) classifies fires based upon the materials that are burning. This classification is the basis for the classification of fire extinguishers. A descriptor such as A, B, C, or a combination of these letters is found on fire extinguishers, and this corresponds to the type of fire for which the extinguisher should be used. A Class A fire extinguisher would be used on a fire having wood, paper, or cloth as the fuel. The Class A fire extinguisher may be filled with water under pressure. This type of extinguisher works by decreasing the heat, which is the ignition element of the fire triangle. A carbon dioxide extinguisher is effective because it removes the oxygen required for the item to burn and eliminates the heat because it has a very cold discharge. The carbon dioxide extinguisher is rated for Class B and C fires but will also extinguish a Class A fire. A dry chemical or a clean agent extinguisher may be rated for A-, B-, and C-type fires. These extinguishers are effective because they interrupt the chemical reaction of the fire triangle. Water-mist extinguishers may be rated for Class A and C fires. There are additional classifications of fire but they do not apply to a perioperative setting.
* NFPA = National Fire Protection Association

21. Recommended Fire Extinguisher
ECRI: Class A, B, C
NFPA: Class A, B, C, or AC
Check with the authority that has jurisdiction (eg, local fire marshal)
The ECRI Institute and the NFPA agree on the use of A-, B-, or C-type extinguishers in the perioperative setting. However, only the NFPA supports the use of a Class AC extinguisher, which is a water-mist extinguisher. When making decisions about fire extinguishers, be sure to involve the authority that has jurisdiction, in other words, the local fire marshal who governs the area where your facility is located. This person can tell you what the rules are for your facility, and these rules may differ between locations. AORN does not make a recommendation on fire extinguisher selection because of this variability.

22. Fire Extinguisher Use “PASS”
P Pull the pin A Aim nozzle at the base of the fire S Squeeze the handle S Sweep the stream over the base of the fire
If it is necessary to use a fire extinguisher, the first step is to obtain it from its storage location. When you are picking up the extinguisher, be aware that the extinguisher may be heavy. Many extinguishers weigh about 20 pounds. The extinguisher will have a handle that is locked by a pin. Take the handle of the extinguisher in one hand and pull the pin with the free hand. Do not compress the handle because this will result in the agent being dispersed from the end of the nozzle. Drop the pin and, using your free hand, grab the hose and aim the end of the nozzle at the base of the fire. Do not continue to grab the nozzle because it may become very cold. Stand approximately 8 to 10 feet from the base of the fire. Squeeze the handle to release the agent and sweep back and forth to “chase the fire away.” As the fire diminishes, move forward until the fire is extinguished or the extinguisher is empty. If the fire is not extinguished, evacuate the premises. Remember, fire extinguishers should not be your first line of defense. They are effective for extinguishing small fires.

23. Shutting Off Gases Find the valve location
Be familiar with valve operation
Determine when to shut off gases
Determine who can shut off gases
Each operating room has a gas shut-off valve. These are usually located in the hallway in close proximity to the OR. There is usually a different valve for each type of gas used in the room. Check your facility to determine exactly where these valves are located and how to operate them. The facility policy and procedure should dictate who can determine when the gases can be turned off. Frequently, it is the anesthesia professional in the room. The only time an RN circulator or other team member should turn off the gases is after he or she has received clearance from the anesthesia professional or other designated personnel.

24. Sprinklers and Smoke Detectors
activated by heat
must be unobstructed
Smoke detector
sounds alarm
If sprinklers are designed put out a fire, then why do we need other methods to extinguish a fire? Sprinklers are activated by heat and are frequently located in the ceiling or very high on the walls. They will activate when the temperature is high enough to cause the device to break, which is about 200 degrees Fahrenheit. All people should have left the room by the time the temperature gets this high. The sprinkler will send a spray of water out within so many feet of the sprinkler head. When sprinklers are installed, they are positioned to create an overlap pattern. For the sprinkler to work correctly, nothing can obstruct the flow of the water, which is why there are regulations regarding how high and how close to a sprinkler head supplies or equipment may be stored. Sprinklers are not equivalent to a smoke detector. A smoke detector, like the sprinkler head, is generally located high on the wall or on the ceiling. When the smoke detector is activated, an alarm sounds but no water or other extinguishing material is released.

25. Evacuation Types and Areas
Who determines when to evacuate
Lateral, horizontal, or vertical evacuation
Fire doors
Smoke compartments
Evacuation floor plan maps
Evacuation resulting from a fire originating in an operating room is very rarely required, but if evacuation becomes necessary, independent of where the fire originates, one person must determine the need to evacuate. This should be clearly designated in the facility policy and procedure and is generally someone who is in command of the fire situation, such as the department manager, director, or the administrator, and if available, the fire department representative. Team members in the OR are frequently the ones responsible for deciding to evacuate, and this decision may need to be made rapidly to decrease injury to the patient and or team members. If evacuation is necessary, it is usually accomplished by moving laterally on the same floor until you are behind a set of fire doors. Possible routes and the location of fire doors should be on a map located within your perioperative area. The fire door location should be designated on the maps of your unit, because all double-closing doors may not be fire doors. A door can be identified as a fire door by looking at the edge of the door for a label stating “fire door.” A vertical evacuation, which is occasionally necessary, is moving from one floor to a safe location on a different floor. Vertical evacuation may be up or down depending on the location of the fire and the building construction. The first evacuation is to a safe point beyond the current smoke compartment. A smoke compartment is created when the walls go from the floor to the ceiling with no open penetrations in them. Pipes may go through the wall, but they must be sealed so no smoke can follow the pathway through that wall. The wall must extend to the real ceiling and not just up to the false ceiling, which is what you see at approximately 8 feet off the floor. The facility engineering department can usually show you the smoke compartment and provide you with a map of your unit with the designated fire walls and or smoke compartment defined.

26. Evacuation Steps: Use “RACE”
R Rescue A Alarm C Confine E Evacuate
An easy way to remember the steps for evacuation is to use the acronym RACE. These steps should be completed in sequential order. In an OR fire, the first step, Rescue, should be to move the patient out of the room where the fire is burning. The patient may need to be transported on the operating room table. Staff members should not place themselves in severe danger, but this is a personal decision at the time. Then sound the Alarm at the pull station, usually located in the hallway. Sounding the alarm will alert any other rooms in the suite that there is a fire present in the OR. Next, Confine or Contain the fire; this means closing the door when you leave the OR in which the fire is present and any other doors that may be open. When the alarm is activated, the fire doors should close automatically, but if equipment is blocking the door, then move the equipment so the doors can close. This step also includes shutting off the gases and electricity to the involved room. The E stands for Evacuation, and that is evacuation of the entire operating room suite, not to be confused with evacuation of the room where the fire is burning; that evacuation was completed in the first step. The steps of RACE are carried out if the decision has been made that you are unable to extinguish the fire. (Note: that is why extinguish is not part of the RACE acronym.)

27. Summary In order to extinguish a fire you must
Know methods to extinguish a fire
Know how use an extinguisher
Know how to evacuate
In summary, to be able to extinguish a fire you must know methods to extinguish a fire, know how use an extinguisher, and know how to evacuate the OR and the surgical suite.

28. References
Guideline for a safe environment of care, part 1. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2015: 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): Clarke JR, Bruley ME. Surgical fires: trends associated with prevention efforts. Pennsylvania Patient Safety Advisory. 2012;9(2): Centers for Medicare & Medicaid Services. State Operations Manual. Appendix A—Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. Accessed January 28, National Fire Protection Association Technical Committee on Portable Fire Extinguishers. NFPA 10: Standard for Portable Fire Extinguishers. Quincy, MA: National Fire Protection Association; 2010.

29. The End