1. 2015 AORN Fire Safety Tool Kit
Fire: Team Responsibilities in the Perioperative Practice Setting
2015 AORN Fire Safety Tool Kit

2. Overview and Goal
All perioperative team members should know their role if and when a fire occurs in the perioperative setting.
The goal of this learning activity is to educate the perioperative team members about their roles if and when a fire occurs in the perioperative practice setting.

3. Objectives
After completing this continuing nursing education 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.
The objectives for this segment are :
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.

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 of the three 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
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. 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 responsibilities necessary 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 center that has a staff of 5 people.

12. 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 the facility size may also contribute to the familiarity of the 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 the fire department personnel to determine where the fire is located. In contrast, in a small rural facility, the fire department personnel may be very familiar with the layout of the building, because they have been there for various events, such as inspections.

13. 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 the 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 it 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.

14. 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 (RN circulator, surgeon, anesthesia professional, and scrub person) need the most extensive training in preventing and fighting fires. The responsibilities of each person will change depending on how many people are present.

15. 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 assisting with extinguishing the fire, but he or she may have other roles, such as notifying the administration team members. 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.

16. 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 fire
Assess 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 responsibilities 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 fire is really 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 accomplish 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 the scrub person
Assesses for secondary fire: surgeon or the scrub person
Assesses patient for injuries: surgeon or RN circulator

17. Responsibilities - All Fires
Notify appropriate personnel
Assign 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: 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 the surgeon.
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 your facility.

18. Responsibilities - Large Fire on the Patient
Perform responsibilities for All Fires
Activate alarm system
Turn off 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
Assist 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 policies. These responsibilities 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 accomplished by the RN circulator but only after collaborating 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 personnel may or may not be able to assist with this task.
Communicating with personnel from surrounding areas regarding the presence of a fire is another task. This may be accomplished by the RN circulator or delegated to personnel to sound the alarm and to bring assistance. The RN circulator can delegate this task.
If available, the charge RN or other supervisory personnel can delegate the responsibilities for 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 maybe even a secretary. The assigned traffic director assists the fire response team or fire department to the location.

19. Responsibilities - Large Fire on the Patient
Assist with decision to evacuate
Order evacuation of perioperative areas
Communicate with personnel in surrounding areas the need to evacuate
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

20. Responsibilities - Airway or ET Tube Fire
Perform 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 involving 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.

21. Responsibilities - Equipment Fire
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 fire.
Determine if equipment can be safely removed from the OR.
Determine if personnel should evacuate the OR.
Extinguish fire using extinguisher, if appropriate
Perform responsibilities for All Fires
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 on 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. Then, disconnect 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.

22. 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 procedure
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. They can assist not only in extinguishing the fire but can also assist in evacuation if necessary. Most important for the 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 (INSERT HERE THE TIME NEEDED FROM YOUR FACILITY) from 3 to 15 minutes to arrive.

23. Contacting the Fire Department
Authority with jurisdiction
May assist with perioperative education programs
Determine types of fire extinguishers
Determine location, storage, and amounts of alcohol-based hand scrubs
The term “authority with 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 with 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.

24. 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 role and the roles of all the other people in perioperative arena in case the person who usually fills that role is not present.

25. 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):

26. The End