ORMVol20No9staffSurvey

ires in the operating room are a risk that requires prevention, vigilance, and

quick action to prevent patient injury. To heighten awareness, the Christiana

Care Health System (CCHS) in Newark, Del, has added a Surgical Fire Risk

Assessment Score to its Patient Identification and Surgical Site documentation form.

“What brought this issue to our attention were 2 surgical fires. One occurred in

the electrophysiology lab and the other in the OR with a patient having a carotid

endarterectomy. Both cases involved a high concentration of oxygen, surgery above

the xiphoid, and a heat source,” Judith Townsley, RN, MSN, CPAN, director of clin-

ical operations for perioperative services, told

OR Manager.

The chairman of the anesthesiology department, Kenneth Silverstein, MD, devel-

oped the fire risk assessment score after the fires were investigated by ECRI

(www.ecri.org), a nonprofit organization that researches health services and tech-

nology, and Russell Phillips & Associates (www.phillipsllc.com), consultants in fire,

code compliance, and emergency management.

Assigning a fire risk score

The fire risk assessment is performed by the entire surgical team (anesthesia

provider, surgeon, and nurse) before the incision is made and is documented by the cir-

culating nurse, notes Denise Dennison, RN, BSN, CNOR, staff development specialist.

(See assessment guide, page 20.)

The assessment requires the surgical team to identify the 3 key elements that are

necessary for a fire to start—the fire triangle:

• heat

• fuel

• oxygen.

In the OR, 3 key risks are:

• surgical site or incision above the xiphoid

• open oxygen source (ie, patient receiving supplemental oxygen via face mask or

nasal cannula)

•

available ignition source (ie, electr

osur

gery unit, laser, or fiberoptic light source).

In the assessment, each of these risks is given a score of 1. The scor

es are tabulat

ed to determine a total fir

e risk score.

Score 3 = High risk. All 3 components of the fire triangle are present.

Score 2 = Low risk with potential to convert to high risk. This score is given

when the procedure is in the thoracic cavity, the ignition source is remote from an

open oxygen sour

ce, the ignition sour

ce is close to a closed oxygen source, or no sup-

plemental oxygen is used.

Score 1 = Low risk. Only supplemental oxygen is being used.

Each risk score has a fire protocol assigned to maximize patient safety (sidebar).

The documentation form allows the circulating nurse to indicate that the high-risk

protocol was initiated. It also allows for documentation that sufficient time was

allowed for fumes to dissipate when an alcohol-based prep solution is used.

Communication heightens awar

eness

Since adding the fire risk assessment to the OR documentation, communication

among the surgical team members as well as identification of the fir

e risk triangle have

vastly improved, notes Dennison.

“The secret to success of this process is that this formal communication and docu-

mentation make everyone involved aware of the potential risk of a fire,” says

Townsley.

OR Manager

Vol. 22 No. 1

January 2006

Scoring fire risk for

surgical patients

Patient safety

Just recently, Mary Cay Curran, RN, perioperative clinical process coordinator,

says she witnessed a discussion between a nurse and surgeon about the fire risk for

a patient under

going an arteriovenous fistula procedur

e. The sur

geon challenged

the nurse’s lower fire risk score because of the way the patient’s arm was positioned

and the fact that the graft was being done in the upper part of the arm. Both agreed

the fire risk was a 3, and the nurse immediately prepared the OR for the higher risk.

Curran has also witnessed nurses and sur

geons telling the anesthesiologist they

are going to use the ESU, which prompts the anesthesiologist to turn the 100% oxy-

gen down for a patient with a high-risk score.

“Enhancing communication between providers has strengthened our focus on

providing clinical excellence for our patients,” says Townsley.

—Judith M. Mathias, RN, MA

An ECRI fire prevention poster can be downloaded from the OR Manager Toolbox at

www.ormanager.com.

References

Bruley M E. Surgical fir

es: Perioperative communication is essential to pr

event this

rare but devastating complication.

Qual Saf Health Car

December 2004;13:467-471.

Meltzer H S, Granville R, Aryan H E, et al Gel-based surgical preparation resulting in

an operating room fir

e during a neur

osurgical procedure: Case report.

Neur

osur

April 2005;102:347-349.

OR Manager

Vol. 22 No. 1

January 2006

Surgical site fire risk assessment guide

lcohol-based prep solution had sufficient time for fumes to dissipate. Verified by:

o Y

o N

(Circulating RN signature)

(Circle appropriate option) Y N Print name

*Surgical site or incision above the xiphoid 1 0 __________________________________

*Open oxygen source (patient receiving supplemental oxygen o High Risk Fire Protocol initiated

via any variety of face mask or nasal cannula) 1 0

*Available ignition source (ie, electrosurgery unit, laser,

fiberoptic light source) 1 0

Total score

Scoring:

3 = High risk

2 = Low risk w/potential to convert to high risk

1 = Low risk

Complete this section if risk score increases to 3 during procedure

o High Risk Fire Protocol Initiated Signature/title ___________________ Print name _____________________ Time ________

Note: This is a section of a form entitled Identification of Patient, Procedure and Surgical Side/Sites, and Fire Risk Assessment.

Source: Christiana Care, Newark, Del.

Paugh D H, White K W. Fire in the operating room during tracheotomy: Acase report.

AANA J. April 2005;73:97-100.

Fire risk protocols

Score 3 = High risk

he circulating nurse and anesthesia provider take these precautions.

Circulating nurse

• Verifies fire triangle, including verbal confirmation of the oxygen percentage

• Ensures appropriate draping techniques to minimize oxygen concentration

under the drapes (ie, tenting, incise drape)

• Minimizes ESU setting

• Assesses that enough time has been allowed for fumes of alcohol-based prep

solutions to dissipate (minimum of 3 min)

• Encourages use of wet sponges

• Ensures a basin of sterile saline and bulb syringe are available for fire suppres-

sion.

Anesthesia provider

• Ensures that a syringe full of saline is in reach for procedures conducted within

the oral cavity

• Documents oxygen concentrations and flows

• Uses the MAC circuit for oxygen administration initially at FiO

of .30 using

fresh gas flows of at least 12 L/min.

Score 2 = Low risk with potential to convert to high risk

Standard fire safety precautions are followed with the potential to convert to

high-risk precautions if necessary.

Standard precautions are to:

• observe alcohol-based pr

ep drying times (minimum of 3 min)

• protect heat sources (eg, using the ESU pencil holster)

•

use standard draping pr

ocedure.

Scor

e 1 = Low risk

Standard fire safety precautions are followed.

OR Manager

Vol. 22 No. 1

January 2006