Surgery, Fire Free

Sep 1, 2005 12:00 PM, By Steve Ennis

For nearly the first two years of his life, Nathan Laporte could not be held by his mother, his family's lawyer told a jury in August during a hearing on a lawsuit against William Beaumont Hospital in Royal Oak, where Laporte was born.

Born prematurely, Laporte spent his first years receiving thousands of injections of steroids and pain-killers, reports one attorney, and the child has never recovered from a hospital fire that nearly killed him, he adds. His parents contend that a flash fire that exploded during a minor surgical procedure in 1997 damaged the baby's lungs. After the fire, he remained in the hospital for nearly two years.

The hospital admits a mistake was made with the fire, when a cautery device ignited some gauze and sparked the fire during a follow-up surgical procedure to put a nutrition tube into the baby's neck.

Laporte's story illustrates just one of the many hazards in surgical units that are associated with the use of high-frequency, electrically powered equipment. Some of these potential hazards include interference with implanted equipment; accidental contact with a practitioner or the patient, resulting in burns or electrical shock; and explosions or fires. While this article focuses on explosion or fire risks related to electrical surgical units (ESUs), many of the recommended safety precautions will apply to other potential facilities.

While the number of fires that occur in the United States each year in a surgical setting is relatively low, the risk merits the inclusion of surgical fire reduction into the Joint Commission on Accreditation of Healthcare Organizations' (JCAHO) national patient safety goals.

The reality is that the presence of a heat source (ESU) combined with intensified oxygen concentrations and the likely presence of flammable vapors (skin preparation solutions and metabolic gases) in direct proximity to an incapacitated patient present a particularly significant level of potential risk. Surgical fires that occur near the patient's face often also involve the airway itself. In seconds, a life-threatening situation can arise with little or no time to react. For these reasons, efforts towards fire prevention must receive primary consideration.

Recommended surgical suite electrical safety program features

It is recommended that every surgical suite have an Electrical Safety Program to prevent life-threatening situations. When developing a program to promote the safe use of electrosurgical units, the following strategies are recommended:

• Evaluate equipment purchases carefully and completely. Select equipment based on compatibility with specific organizational needs. Involve representatives of the medical staff, nursing staff and materials management, biomedical and engineering services in this process. Ensure that the equipment to be purchased will function effectively in the clinical setting and can be fully serviceable.

• Operate electrosurgical units in accordance with manufacturer specifications. Obtain a complete set of operating manuals for each type of device and attach the manufacturer's operating instructions to each unit.

• Require that a factory-authorized representative provide advance training to clinical and biomedical service personnel prior to placing any new equipment into service. Ensure that such training extends to part-time and/or “off-shift” staff members. Maintain detailed records of such training sessions. Within this advance training, establish operational guidelines for the use of each type of device. The operational guidelines should include the pertinent clinical applications and procedures for the device; a preventive maintenance schedule; cleaning and inspection schedule and procedure; training and certification requirements; and emergency response procedures.

• Train all personnel in accordance with the operating guidelines. This includes all medical staff involved with operations using electrosurgical units. Staff who clean the devices also need to know how to identify if a device is intact and operational.

• Develop a preoperative “device check-out” procedure (and list). Verify that key precautionary settings or actions are in compliance with established guidelines. Include documentation concerning satisfactory completion of that “check-out” process in each patient's medical record.

• Select and install appropriate emergency response equipment in each surgical area. This should include one or more fire extinguishers of a suitable type in each operating room. These extinguishers must be installed so the staff have unobstructed access during an emergency.

Selecting the proper fire extinguisher

When selecting a fire extinguisher, consideration must be given to the effect each form of extinguisher discharge will have on controlling the fire, the patient and the operating environment. For example, dry chemical extinguishers are effective, but produce a large amount of residue that could contaminate the entire surgical suite. Carbon dioxide and other clean agent extinguishers do not produce a residue, but can cause thermal shock, static discharge and respiratory complications. They also have little or no rating to extinguish Class A fires (ordinary combustibles).

A new, water mist extinguisher shows promise for use in this environment. This extinguisher possesses a Class A and Class C (2A:C) rating making it suitable for use on ordinary combustibles and fires involving energized electrical equipment. The fine spray from the unique misting nozzle provides safety from electrical shock, enhances cooling and soaking characteristics of the agent and reduces scattering of the burning materials. The distilled water agent is non-toxic, leaves no powder residue and is not a threat to respiration. The unit also is easy to clean as it is covered with antiseptic white paint finish.

During several test fires simulating surgical conditions with enriched oxygen concentrations, the water mist extinguisher, manufactured by Amerex Corp., demonstrated a rapid flame knock down with a soaking action that prevented re-ignition.

Prevention

Staff — including operating licensed independent practitioners and anesthesia providers — should be educated on how to control heat sources and manage fuels. Also, guidelines should be established to minimize oxygen concentration under drapes.

The level of oxygen concentration is often a factor in surgical fires. The risk of fire is significantly increased when greater-than-normal concentrations of oxygen are used. According to ECRI, an independent nonprofit Health Service Research Organization, using room air instead of pure oxygen “could prevent most surgical fires.”

Surgeons and anesthesia providers should be especially aware of these increased risks. If “100 percent oxygen” is not truly clinically indicated, is it worth the added patient safety risk? Members of the medical staff, or operating room committees may wish to review “oxygen use” practices in order to develop clinical guidelines for when intensified oxygen concentration may or may not be appropriate.

Standards and guidelines

The Association of periOperative Registered Nurses (AORN) issued its Recommended Practices for Electrosurgery in 1998 and retains them in their 2004 standards. The current “NFPA 99: Standard for Health Care Facilities” contains an annex entitled, “The Safe Use of High-Frequency Electricity in Health Care Facilities.” It is noted therein, however, that the “annex is not a part of the requirements of this NFPA document, but is included for informational purposes only.”

Although they are no official “standards,” the recommendations outlined in this NFPA document provide an excellent resource for developing an effective Electrosurgical Fire Safety Program. The laser safety standards also provide prudent safety guidelines for inclusion in a surgical department's fire safety program.

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ABOUT THE AUTHOR

Steve Ennis, CHSP, CFPS, is president of SME Consulting Inc. He provides educational programs and consultative services in the areas of life safety, emergency management and Environment of Care to healthcare organizations.

THE WATER MIST EXTINGUISHER

Amerex Corp., Trussville, Ala., is a manufacturer of hand-portable and wheeled extinguishers for commercial and industrial applications. The company recently unveiled its Water Mist Fire Extinguisher that effectively extinguishes Class A fires, where a Class C (live electrical equipment) hazard exists — while not putting patients' and staff members' health at risk.

“Each year, we hear numerous stories about hospital fires and the complications of using a dry chemical or clean agent fire extinguisher in those situations due to the resulting effect of cardiac and respiratory complications,” says Bill Beyer, Amerex president and general manager.

The Amerex Water Mist Fire Extinguisher is weather and corrosion resistant and uses a water-based, nontoxic firefighting agent that does not pose respiratory or ventilation concerns to health care patients. The Water Mist Extinguisher uses a fine spray of de-ionized water, which leaves no residue, is non-toxic, and will not result in contamination.

Approved by Underwriter's Laboratories, the water mist extinguisher is available in both 6 and 9 liter units and can discharge a distance of 10 to 12 feet. It also is made of all non-magnetic construction and tested by an independent lab to be safe in a Tesla-3 MRI environment.

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