A surgical fire is something that happens to someone else, right? That's what we thought, too, until the unthinkable happened: 2 major OR fires 8 months apart. The first involved a 51-year-old woman undergoing a carotid endarterectomy. The second involved a 66-year-old man undergoing radiofrequency ablation and a pacemaker insertion. Although the patients and the procedures were vastly different, both cases had several factors in common:

• both were performed under monitored anesthesia care (MAC);
• both patients received supplemental oxygen through a face mask;
• in both cases, an alcohol-based prep solution was used; and
• the electrocautery used by the surgeon ignited both fires.

In response to these events, we made it our priority to develop a plan for reducing the risk of surgical fires. We developed a multidisciplinary team comprised of representatives from the departments of surgery, anesthesiology, nursing, performance improvement and clinical engineering.

What we learned
Operating room fires occur because the components of the fire triangle — oxygen, fuel and ignition source — exist in close proximity. Fuel for fires is found in draping material, sponges and lap pads, prep solutions, even the patient's clothing, hair and skin. Ignition sources include electrocautery devices, lasers and fiberoptic light cables. Anesthesia gases and supplemental oxygen create an oxygen-enriched atmosphere.

We learned that 75% of OR fires in the United States involve an oxygen-rich atmosphere. Electrocautery is the ignition source in 70% of cases, laser in 10% of cases and alternate heat sources such as cautery tools, surgical lights, burr sparks and defibrillators in 20% of cases.

What we did
Our goal is to ensure that each member of the surgical team maintains a level of awareness of the potential for fire in every case. The chair of our department of anesthesiology, Kenneth Silverstein, MD, developed a simple fire risk assessment tool that we use to foster communication among caregivers. This tool, which identifies high-risk situations when the most volatile elements of the fire triangle exist in close proximity, assigns 1 point for each risk factor:

• Is the surgical or incision site above the xiphoid?
• Does an open oxygen source exist as a result of the patient receiving supplemental oxygen via any variety of face mask or nasal cannula?
• Is an ignition source such as an electrosurgery unit, laser or fiberoptic light source present?

We add up the points, assign each patient a score, then follow specific protocols for each:

Fire Risk 1: Low Risk

• Follow standard fire safety precautions.
• Let prep dry for at least 3 minutes.
• Protect heat sources (using a cautery holder, for example).
• Employ standard draping procedures.

Fire Risk 2: Low Risk With Potential to Convert to High Risk

• Follow standard fire safety precautions with the potential to adopt high-risk precautions if necessary.
• Let prep dry for at least 3 minutes.
• Protect heat sources.
• Employ standard draping procedures.

Fire Risk 3: High Risk

• Observe prep drying time (minimum of 3 minutes).
• Employ occlusive draping to minimize oxygen buildup under drapes.
• Use high flow/low fraction of inspired oxygen (< or =0.30) if possible.

When electrocautery is used with an open oxygen delivery system:

• Stop supplemental oxygen at least 1 minute before and during cautery use.
• Use wet, rather than dry, sponges.
• Keep sterile water or saline solution available for fire suppression.
• Keep a syringe full of saline solution available for procedures performed in the oral cavity.
• Protect heat sources.
• Use the lowest possible electrocautery setting.

To ensure that we use the Silverstein Fire Risk Assessment Score before every case, we made determining a fire risk score a required component of the surgical time out. Announcing the score before the beginning of each case raises the awareness of potential fire risks, increases communication among the OR team and makes staff active participants in the prevention of fires.

Education is key
The next phase of our fire safety program involved creating a comprehensive fire safety education program. We wanted our staff to do more than merely learn about fire safety; we wanted them to assimilate fire risk reduction strategies into their daily routines. Additionally, we wanted to ensure staff would act immediately and appropriately if, despite all precautions, a fire still occurred in the OR.

Typically, different members of the surgical team control each of the fire triangle's components: Circulating nurses manage fuel sources, anesthesia providers administer oxygen and surgeons control ignition sources. Keep that in mind as you formulate your education plans; your teachings need to appeal not only to your nursing staff, but also to anesthesia providers, CRNAs, surgeons, residents and physician assistants.

The challenges of implementing our education plan were evident from the start. We are a multi-site, Level One trauma center. Our perioperative services department is one of the largest on the East Coast, performing more than 43,000 surgical procedures each year at 4 different sites, with more than 500 full-time employees, 230 surgeons and 120 anesthesia providers. Our education needed to be consistent across all departments, operating room sites and procedural areas, and include all staff and shifts, while minimizing disruption to our regular operating schedule. We chose a 3-pronged approach:

• Classroom learning. This phase involved the basic dissemination of information on fire-risk reduction strategies and the new fire-safety policies and protocols we planned on implementing. It included classroom teaching, in-services, signage and flyers placed throughout the hospital and Web-based educational opportunities.
• Fire drills. A well-rehearsed plan of action is key to ensuring that staff react appropriately to a fire emergency, so the importance of having a quick and effective fire response plan cannot be overstated. Our fire drills are conducted in the OR and include hands-on practice of several potential scenarios, including fire on a patient, fire in a patient's airway and evacuation of the patient. We provided each surgical team member with a detailed list of their roles, responsibilities and the actions they need to take in the event of a fire, and created a task checklist to ensure performance consistency and to document staff competency.
• CE. Finally, we created opportunities for annual and semi-annual continuing education.

Prevent defense
"Fire in the OR" is a phrase that will strike terror into the hearts of both patients and healthcare practitioners. Although this is a rare event, it's still occurring with regrettable frequency. The ECRI Institute reports the incidence of surgical fires in the United States at 550 to 650 each year, yet it admits that the true number is difficult to determine due to an absence of centralized reporting mechanisms.

The cost of surgical fires goes beyond financial. OR fires may have devastating physical effects, including serious injury, disfigurement and death, and staggering emotional impacts on both patients and staff. But when you identify the risk of fire in the operating room and control the elements of the fire triangle, you'll greatly decrease the likelihood of this avoidable tragedy.