Scoring patients for fire risk adds to safety

In Brief

Assessing fire risk before procedures

IN RECENT YEARS, healthcare professionals have turned their attention to reducing the risk of fires in the OR. From 2005 to 2009, a Joint Commission National Patient Safety Goal (11) was to reduce the risk of surgical fires.¹ Although fire safety usually focuses on surgical patients, the risk is similar for patients undergoing procedures outside the OR.

At Christiana Care Health System in Wilmington, Del., we've made reducing the risk of fire both within the OR and during bedside procedures a top priority. This article describes our innovative approach to scoring fire risk before procedures and explains how to lessen the possibility of fire based on the level of risk involved. First, let's take a look at the factors that contribute to fire risk.

Dangerous triangle

Fires occur when the three components of the fire triangle—fuel, an ignition source, and oxygen—come together. (See The fire triangle.) In the OR, each of these components is typically controlled by a different member of the OR team. Mainly the surgeons control the heat sources, such as electrosurgical units, lasers, and fiberoptic light cables. The anesthesia providers are responsible for the anesthetic gases and supplemental oxygen that contribute to an oxygen-enriched atmosphere in the OR. Nurses are involved with potential fuel sources, including gowns, drapes, sponges, lap pads, prep solutions, and even the patient's clothing, hair, and skin.²

Each component of the fire triangle may be present at the bedside as well. A patient who receives supplemental oxygen during a bedside procedure is just as much at risk from fire as a surgical patient, if an ignition source is also present.³

Many bedside procedures, such as electrical cardioversion, percutaneous tracheostomy, and wound debridement, involve equipment that can provide an ignition source. These procedures are often performed in the postanesthesia care unit, surgical ICU, ED, and medical-surgical units.

Figure: The fire triangle

Lighting a fire for safety

We began our fire safety initiative by assembling a multidisciplinary team that included members from the surgery, anesthesiology, and nursing departments, as well as performance improvement and clinical engineering personnel.

Our team collaborated with expert consultants to conduct a thorough assessment of our facility and processes already in place. After combining this facility assessment with a detailed literature search and professional networking, we developed fire risk reduction strategies.

Some recommendations involved physical factors, such as smoke barriers, fire doors, and the location and functioning of fire extinguishers. Other recommendations focused on procedural factors, such as our code red activation system, and strategies to increase the awareness for the potential for fire.

Creating a tool

The chair of the department of anesthesiology, Dr. Kenneth Silverstein, developed a simple fire risk assessment tool to assess the risk of fire and foster communication among caregivers.⁴ The Silverstein Fire Risk Assessment Score assigns one point for each of three risk factors:

• procedural site above the xiphoid process
• an open oxygen source (that is, is the patient receiving supplemental oxygen via any variety of face mask or nasal cannula?)
• presence of an ignition source, such as electrosurgery unit, laser, or fiberoptic light source.

Specific protocols are mandated for each score. (See Minimizing fire risk.)

Time for a "time-out"

To ensure that the assessment is performed for every procedure, both in the OR and at the bedside, we incorporated the fire risk score as one of the components of our universal protocol "time-out." This verbalization of the fire risk score increases awareness of the potential for fire, enhances communication among team members, and makes staff active participants in fire prevention.

After announcing the fire risk score, we document it as part of our time-out. When the risk of fire during a procedure has been identified and the elements that may contribute to fire are controlled appropriately, the likelihood of fire decreases.

Take precautions

Be aware that fire is a risk at the bedside as well as in the OR, and take appropriate precautions. If an ignition source is used, communicating with the other caregivers and minimizing the patient's oxygen flow are vital.

The increased use of alcohol-based antiseptics for both skin prep and hand hygiene may further increase the potential for fire.³ Make sure that prep solutions have had time to dry and haven't pooled.

For procedures taking place in or around an airway (for example, tracheostomies), always use wet sponges rather than dry and make sure water or saline is available for fire suppression.⁵

Because electrocautery is seldom used for most bedside procedures, the bedside fire risk is rarely rated 3. Even so, avoid complacency and don't assume that lack of cautery means no risk. Continuing vigilance and education are vital. Education should include all members of the procedural team: nurses, surgical technologists, anesthesia care providers, and surgeons. It should include information on the potential risk of fires during procedures, the fire triangle, fire risk reduction strategies, and the appropriate response should a fire occur.⁶

Passing the torch for safety

Our standardized fire safety protocols and education program ensure that staff members are better prepared to initiate the risk reduction strategies and provide a safer environment for our patients. For more information, please visit our website at http://www.christianacare.org.

Minimizing fire risk

Fire risk 1: Low risk

• Follow standard fire safety precautions, which include:
• Let prep solutions dry for at least 3 minutes.
• Protect heat sources (for instance, keep the active electrode tip of the electrosurgical unit in a holster when not in use).
• Use a standard draping procedure.

Fire risk 2: Low risk with potential to convert to high risk

• Follow standard fire safety precautions (as above), but be prepared to convert to high-risk precautions if necessary.

Fire risk 3: High risk

• Follow standard fire safety precautions (as above).
• Use high-flow/low FiO₂ (≤0.30 if possible).
• When electrocautery is used with an open oxygen delivery system, stop supplemental oxygen at least 1 minute before and while using cautery.
• Use wet sponges.
• Have sterile water or saline available for fire suppression.
• Keep a syringe full of saline available for procedures in the oral cavity.
• Use the lowest electrocautery setting possible.