Editorial Fires in the Operating Room: Prepare and Prevent Michael W. Stewart, MD - Jacksonville, Florida George B. Bartley, MD - Rochester, Minnesota According to the Institute of Medicine, 2.9% to 3.7% of hospitalized patients are subjected to medical errors, and 8.8% to 13.7% of these patients experience fatal consequences.1 Each year in the United States, medical errors result in 44 000 to 98 000 deaths and significantly more injuries.1 The U.S. News & World Report acknowledged the increasing importance of safety in the delivery of health care by doubling its weighting in the evaluation of overall hospital quality.2 The growing need to prevent wrong-site, patient, or procedure surgery has led to a change in operating room culture.

How Did We Get Here?

to these 3 components, with different members of the surgical team bearing primary responsibility for controlling each: fuel ¼ circulating nurse; oxidizing agent ¼ anesthesiologist; ignition device ¼ surgeon. Endotracheal tube fires affect people on a visceral level and receive considerable attention by regulators and the media. But what about other fires? The American Society of Anesthesiologists Closed Claims Database listed 103 fires between 1985 and 2009.7 Most of these involved open oxygen delivery for head, neck, and upper chest procedures, and 90% of the fires were started by electrocautery. The Pennsylvania Patient Safety Authority analyzed 65 fires and found that 58% of them were started by electrocautery, 38% were started by fiber optics, and 3% were started by laser.8 An increasing proportion of these cases involve monitored local anesthesia, because the increasing use of propofol during the performance of a regional block encourages physicians to use more supplemental oxygen to offset the anticipated respiratory depression.

The mandated timeout before each surgical procedure is designed to reduce the risk of wrong-site surgery, but many of us may not realize that operating room fires occur as frequently. The Emergency Care Research Institute (ECRI) estimates that patients are harmed by 20% of the 550 to 650 operating room fires that are reported each year and, Why Should This Concern therefore, ranked fires as number 3 on their list of technolOphthalmologists? ogy-related hazards in the hospital.3 Both the U.S. Food and Drug Administration4 and the Joint Commission of Health Fire risk is expressed on a 3-point scale with 1 point Care Administration5 have publicly emphasized the importance of fire prevention. The Centers for Medicare and assigned for each of the following: surgery above the xiMedicaid Services temporarily suspended surgeries at one phoid process, delivery of supplemental oxygen, and use of institution after 6 fires (3 of an ignition source. A high-risk prowhich involved patients) Ophthalmic surgeries ... are classified cedure (3 points) is one in which an occurred within 1 year.6 Operignition source is used near a fuel as high risk for fires. ating room fires, together with source in an oxygen-rich environretained surgical sponges and wrong-site surgery, are now ment. Therefore, ophthalmic surgeries are frequently classified as “never” events by the Centers for Medicare and assigned 3 points and classified as high risk for fires. Medicaid Services. During recent hospital inspections, the The fire risk assessment system classifies head and neck Joint Commission has expected that fire assessment be surgeries as high risk, and this is reflected by the relatively included in the preoperative timeout. Consequently, fire risk high number of publications in the otolaryngology and assessment has recently become a standard component of plastic surgery literature. Reports of fires in the ophthalmic the preoperative timeout in some medical centers.5 literature are rare, but oculoplastic surgery, with its To initiate and sustain an operating room fire, 3 comfrequent use of open oxygen delivery and electrocautery, ponents are required: fuel (tracheal tubes, drapes, gauze, probably poses the highest risk among ophthalmic sponges, solutions containing alcohol or other volatile surgeries. compounds, patient’s hair, gloves, oxygen masks, nasal One of us referred to a surgical fire during an oculoplastic cannula, dressings, ointments, gowns, gastrointestinal gases, surgery procedure as “my most frightening” case,9 which in hindsight was attributed to the accumulation of oxygen due blankets, suction catheters, fiberoptic endoscopes, fiberoptic to tight draping over the nasal cannula. In a Letter to the cable coverings, and packaging materials); an oxidizing Editor, Huddleston et al10 noted no incidence of “oxygen agent (oxygen or nitrous oxide); and an ignition source rich environments” during oculoplastic surgeries when open (electrosurgical or electrocautery devices, lasers, heated drapes were used with nasal cannulaeadministered oxygen. probes, drills and burrs, argon beam coagulators, fiberoptic However, masks were frequently associated with high light cables, and defibrillator paddles). The fire risk triangles oxygen concentrations. now being posted in many operating rooms draw attention Ó 2015 by the American Academy of Ophthalmology Published by Elsevier Inc.

http://dx.doi.org/10.1016/j.ophtha.2014.08.049 ISSN 0161-6420/14

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Ophthalmology Volume 122, Number 3, March 2015 Vitreoretinal operations are classified as high risk because fiberoptic light pipes for endoillumination and bipolar cautery for hemostasis are routinely used. Although temperatures generated by small-gauge fiberoptic illuminators are generally low, fires have been described when highintensity “chandelier” light sources have come into contact with surgical drapes. When factoring in their lower frequency of use, some experts believe that laser may constitute a greater fire threat than electrocautery. The 2013 update of the “Practice Advisory for the Prevention and Management of Operating Room Fires: An Updated Report by the American Society of Anesthesiologists Task Force on Operating Room Fires” characterizes cataract surgery as a high-risk procedure.11 Supplemental oxygen is frequently administered to patients under sterile drapes, but cataract surgeons working through clear cornea incisions do not routinely use an ignition source; phacoemulsification is not characterized as such. Therefore, cataract surgery should receive a risk score of 2 (low risk).

What Should Ophthalmologists Do? Surgeons should embrace the team approach to safety and take a proactive approach to fire prevention. Consistent with the new advisory, surgeons should periodically hold fire drills with the surgical team. Fire drills can address issues such as when and how to evacuate the operative suite, and determining whether equipment or cords obstruct the escape route between the patient and the door. Fire risks associated with each procedure should be discussed by the operating room team with emphasis on prevention and management. Fire risk identification should be routinely incorporated into the surgical timeout, thus promoting a change in operating room culture to prevent “never” events, as has been done regarding retained surgical instruments and wrong-site surgery. Most patients undergoing ophthalmic surgery under topical or regional monitored anesthesia receive supplemental oxygen while under sterile surgical drapes. This may entrap oxygen and lead to elevated concentrations. At the core of the new guidelines released by the ECRI and the Anesthesia Patient Safety Foundation is the discontinuation of traditional open 100% oxygen delivery for procedures above the xiphoid. Only medical air, a nitrogen (78%) and oxygen (21%) mixture that is locally manufactured or pulled in from the environment, should be used for open delivery to the face. Sedated, spontaneously breathing patients who can maintain normal oxygen saturations on room air should not be given supplemental oxygen. If supplemental oxygen is warranted, however, concentrations should be kept at less than 30%. If additional oxygen is needed, the airway should be secured with a laryngeal mask or endotracheal tube to prevent oxygen accumulation. When oxygen is administered at low-flow rates (2 l/min) via nasal cannula, concentrations exceed 23% only within a few centimeters of the cannula. Because oxygen concentrations increase with higher flow ratesdtrapped oxygen concentrations can exceed 50% with flow rates of 6 l/mindelectrocautery should be kept at least

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10 cm from nasal cannulas when the flow rate equals or exceeds 4 l/min. To minimize the risk of starting a fire, surgeons should preferentially use bipolar over monopolar electrocautery devices, always visualize the tip during activation, and store the device in a safety holster when not in use. The use of bipolar cautery to achieve hemostasis should prompt communication between the surgeon and the anesthesia provider. When using an open delivery system such as nasal cannula, the Task Force agrees that the surgeon should notify the anesthesia personnel before activating an ignition source. This allows the anesthetist to stop or decrease the flow of supplemental oxygen to a safer level before the surgeon uses the ignition source. Fires associated with fiberoptic cables may start for 2 reasons. Burns may occur when the distal end of the cable is placed on the drape. Therefore, fiberoptics should be turned off whenever not in use. Fires also may start from cableinstrument connections. These areas should be kept free of flammable materials, and mismatches in connections should be prevented. The ECRI estimates that 10% of operating room fires are ignited by a laser. Lasers should be activated only when the aiming beam can be visualized, and they should be placed on standby when not in use. All members of the surgical team must be familiar with the appropriate response to operating room fires. The usual fire-control acronym RACE (rescue, alarm, confine, and extinguish) does not apply to the operating room. Operating room fires may involve the patient or the operating room environment. Any fire involving the patient must be immediately extinguished or the burning material must be removed. While a member of the surgical team addresses the fire, another should immediately turn off the oxygen source. The surgical suite should be evacuated if the fire cannot be immediately extinguished. Because the surgeon is usually the first to notice a fire, immediate attempts to extinguish it with saline should be made. Soaked towels draped across the surgeon’s arms can be used to smother the fire with a sweeping motion away from the patient; patting the fire encourages spread. Operating rooms are generally equipped with fire extinguishers containing CO2 or ammonium phosphate. Ammonium phosphate is mildly corrosive, so a CO2 extinguisher is preferred if the fire directly involves the patient. Fortunately, fires are unusual in the ophthalmic surgery suite, and with appropriate planning and meticulous attention to surgical details, they may indeed be “never” events. References 1. Kohn LT, Corrigan JM, Donaldson MS, et al. To Err Is Human: Building a Safer Health System. Washington, DC: National Academies Press; 2000. 2. Methodology: U.S. News & World Report Best Hospitals 2014-2015. Page 5. Available at: http://www.usnews.com/pubfiles/BH_2014_Methodology_Report_Final_Jul14.pdf. Accessed August 18, 2014. 3. 2010 Top Ten Technology Hazards. Available at: https://www. ecri.org/Documents/Top_10_Health_Technology_Hazards.pdf. Accessed August 13, 2014.

Editorial 4. Resources and tools for preventing surgical fires. March 2013. Available at: http://www.fda.gov/drugs/drugsafety/safeuseiniti ative/preventingsurgicalfires/default.htm. Accessed August 13, 2014. 5. Clarifications and expectations: preventing surgical fires. Making fire safety a top priority in the OR. Jt Comm Perspect 2013;33:8–11. 6. “Preventing surgical fires,” Sentinel Event Alert 29 (June 24, 2003). Available at: http://www.jointcommission.org/senti nel_event_alert_issue_29_preventing_surgical_fires/. Accessed August 13, 2014. 7. Mehta SP, Bhananker SM, Posner KL, et al. Operating room fires. Anesthesiology 2013;118:1133–9.

8. Clarke JR, Bruley ME. Surgical fires: trends associated with prevention efforts. Pennsylvania Patient Safety Authority Safety Advisory 2012;9:130–4. 9. Bartley GB. Learning from our (my) mistakes. Arch Ophthalmol 2012;130:240–2. 10. Huddleston S, Hamadani S, Phillips ME, Fleming JC. Fire risk in ophthalmic plastic surgery. Ophthalmology 2013;120: 1309. 11. Practice advisory for the prevention and management of operating room fires: an updated report by the American Society of Anesthesiologists Task Force on Operating Room Fires. Anesthesiology 2013;118: 271–90.

Footnotes and Financial Disclosures Financial Disclosure(s): Supported in part by Research to Prevent Blindness, New York, NY through an unrestricted grant to the Department of Ophthalmology, Mayo Clinic. The author(s) have no proprietary or commercial interest in any materials discussed in this article.

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Fires in the operating room: prepare and prevent.

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