Case Title: Fire in Labor and Delivery: Simulation Case Scenario.
Simulation Developers: OB/GYN Department Chairman and Maternal Fetal Medicine Director, Anesthesia Attending, Perinatal Nurse Educator, OB/GYN Simulation Director, Hospital Safety Director, Labor and Delivery Nurse Manager.
Dates of Development: August to November 2009.
Target Audience: All OB/GYN faculty, all OB/GYN residents, all Labor and Delivery nursing staff, all Anesthesia residents and attendings, medical students on Anesthesia or OB/GYN rotations.
Surgical fires are a rare incident in today's operating rooms (ORs). Since 1995, a total of 100 surgical fires have been reported to the Joint Commission as sentinel events.1 These fires occur in various locations throughout the hospital setting. Emergency Care Research Institute, an independent nonprofit health services research agency, extrapolates that there are between 550 and 650 surgical fires annually, based on data published by the Pennsylvania Patient Safety Authority in 2007.2,3 In the 2008 report, the Pennsylvania Patient Safety Authority indicates that one in every 88,000 procedures may involve a surgical fire. Forty-four reports involving surgical fires and 274 reports of perioperative burns were received by the Pennsylvania Patient Safety Authority from 2006 through 2008. The reports of fires and burns are not mutually exclusive; some involve both a fire and burns to the patient. Sixty-one percent of these reports identify an electrosurgical unit or other device used to cut or fuse tissue as being implicated in the fire or burn.3
Although surgical fires are rare, the consequences can be tragic for both the patient and the healthcare workers involved in the case. Because virtually all surgical fires are preventable, it is important to identify hazards and to effect a plan to manage a fire expeditiously to improve patient outcomes. The number one recommendation for preventing surgical fires is spending time on fire prevention, including conducting staff training sessions and fire drills with the OR staff.2
There have been other published reports of surgical fires, as well as fire drills and fire safety and prevention education materials in other surgical subspecialties and in the anesthesia literature.4–6 However, there is limited information about the prevention of fires in an obstetrical setting. Fires in the obstetrical setting pose unique challenges because of having two patients, mother and baby. As such, obstetrical emergencies require timely action to reduce both maternal and neonatal morbidity and mortality.
Because this is a rare event, it is an ideal case scenario for a simulation drill. We describe the actual scenario that we used as well as the planning that was required before the day of the drill. We also discuss the strengths and weaknesses of the team's performance during the drill and the recommendations for our institution that were brought about through the process of planning, performing, and debriefing this simulation. We used the Duke University simulation development template7 to describe the planning and the drill.
Accreditation Council for Graduate Medical Education general competencies are as follows:
- Medical knowledge
- Patient care
- Practice-based learning and improvement
- Interpersonal and communication skills
- Systems-based practice.
Simulation Learning Objectives
- Observe the response of an OR team during an unannounced simulated scenario of a patient fire in the labor and delivery OR setting (points 2–6).
- Educate faculty, residents, and labor and delivery staff about the importance of OR fire awareness (points 2–4, 6).
- Identify OR hazards for surgical fires (points 1, 3, 6).
- Develop prevention strategies for surgical fires (points 1, 3, 6).
- Identify potential issues unique to a labor and delivery fire (points 2–4, 6).
- What steps can be taken to prevent surgical fires?
- Was the delegation of tasks appropriate for those involved?
- Where is the closest fire alarm and extinguisher to the OR?
- Where is the medical gas panel located in the surgical suite?
Guided Study Questions
- What are the basic elements of “the fire triangle”?
- What are the types of fires that can occur in the OR and how can they be extinguished?
- What are potential postoperative complications that can occur after a surgical fire?
In our simulation, observers chosen before the drill were asked to record strengths and weaknesses of the team's performance during the scenario as well as record the time of each stage of the simulation. This group included an upper-level OB/GYN resident and anesthesia resident, the perinatal nurse educator, a nursing staff team leader, and the hospital safety director. Based on the observations noted, an assessment tool (Table 1) has been created for future drills, which includes a checklist for the observers to evaluate the learner's actions as described in the simulation grid (Table 2).
- Intraoperative vital sign display
Portable vital sign monitoring equipment
- · Noninvasive blood pressure cuff
- · Pulse oximeter
- · 5-lead EKG
- · Temperature probe
- · Capnograph
Other Equipments Required
- Patient simulator
Airway supplies and equipment
- · We used the NOELLE obstetric simulator by Gaumard
- · Laryngoscope
- · Endotracheal tube
- · Stethoscope
- · Silk or paper tape
- · Anesthesia machine
- · Simple face mask
- · Ambu bag
- · Oxygen tank and tubing
- · Propofol, succinylcholine, and fentanyl
- · Ephedrine and Neo-Synephrine
Cesarean section instrument tray
- · Four 1-L bags of lactated ringers or normal saline
- · Anesthesiologist
- · Surgeons
- · OR technicians and nurse
- · Pediatric team
- · Additional support staff
The simulation developers corresponded via email for approximately 10 weeks before the drill. A formal planning meeting was held 3 weeks before the drill, which involved all simulation developers to finalize the details.
- Setup: 30 minutes
- Simulation: 15 minutes
- Debrief: 15 minutes
Case Stem to be Read to Participants
Noelle is a 32-year-old woman, gravida 3, para 2, at 38 weeks' gestational age, who presents to triage complaining of vaginal bleeding and painful uterine contractions. On initial evaluation, she is noted to have significant vaginal bleeding. Fetal monitoring reveals baseline of 140 bpm, minimal variability, and recurrent late decelerations. Tocometry reveals contractions every 2 minutes. Abruptio placenta is suspected, and a stat cesarean section is called for repetitive late decelerations and overall nonreassuring fetal heart tracing. Nursing staff and anesthesia personnel are notified.
Her medical and surgical history are negative, and she does not have any allergies to medications. Her pregnancy has been uncomplicated.
Information for Facilitator/Simulator Operator Only
This scenario was developed to observe the response of the medical team to an unannounced surgical fire in the labor and delivery OR. Fire safety in the OR is a topic more commonly addressed by anesthesiologists and general surgeons. However, this topic can also be applied to obstetrics, as such emergencies require immediate and coordinated efforts to protect the patient, the newborn, and the personnel in the OR.
The patient is an otherwise healthy 32-year-old woman, presenting with abruptio placenta and nonreassuring fetal status. A stat cesarean section is announced. The ensuing scenario of a surgical fire highlights the necessary interventions for patient and personnel safety.
In 2003, the Joint Commission on Accreditation of Healthcare Organizations issued a Sentinel Event Alert regarding the prevention of surgical fires.1 The fire triangle of heat, fuel, and an oxidizer are necessary elements for ignition of a fire, and these basic elements are prevalent within a surgical suite. The most common source of heat and ignition is the electrosurgery or electrocautery unit, but other sources may include fiberoptic light cables and lasers. Fuel sources are anything that can burn, including drapes, gowns, linens, and sponges. Oxidizers are gases that support combustion, and the oxygen-enriched environment of the OR needs to be treated with special caution. With increased oxygen concentration, a fire is easier to ignite, fuels burn faster, and the fire is more difficult to extinguish.1,2,4,5,8
Alcohol-based surgical preps are volatile, and any residual alcohol, pooled on or below the patient or soaked into linens, will vaporize. In the closed space below the surgical drape, these alcohol vapors, and an increased oxygen concentration can be an extremely flammable mixture.5,8 In our institution, the skin prep for a stat cesarean section is 99% isopropyl alcohol that is liberally applied to the patient's abdomen. A “pat and peel” quick dry with a sterile towel is then performed before applying the drape. While an adhesive drape reduces the amount of vapor collection and leakage at the surgical site,9 the adhesiveness of the drape may not be reliable if the surgical field is incompletely dried (which even further escalates the risk of a surgical fire). A reservoir-type applicator for surgical prep typically has less overflow than the gauze prep; however, adequate drying time per the manufacturer is typically several minutes8—minutes that may be critical in the obstetrical setting to circumvent poor neonatal outcomes.
Preparation is the key to prevention. According to the Position Statement on Fire Prevention from the Association of periOperative Registered Nurses, specific fire risk reduction strategies include the following: participation in a fire drill; use of fire-fighting equipment; knowledge of the location and operation of the medical gas panel; awareness of the ventilation and electrical system locations and operation, including knowing the personnel authorized to shut them off; and initiation of a fire alarm or “Code Red.”10
In the following scenario, a stat cesarean section is complicated with a surgical fire. The fire is ignited by the electrocautery device, and the surgical drapes are the fuel sources. The fire cannot be contained, and the patient and newborn must be moved to a safe location. This scenario highlights the unique challenges of a surgical fire in the labor and delivery OR.
In an effort to create a realistic scenario, our simulation was performed in an actual labor and delivery OR and not in the simulation laboratory. This allowed us to observe the response of the surgical team and highlight areas for improvement. Because of the concern for the safety of the participants and potential for contamination of the OR, an actual fire could not be ignited. As with many simulations, participants must suspend the constraints of reality and accept some imaginative license. In our simulation, the participants were notified of the fire by a laminated placard that was placed on the patient after the use of the electrocautery device. The participants then communicated with the operator of the simulation to determine the extent of the flames and lack of containment of the fire after attempting extinguishment. As in any simulation, unexpected outcomes may ensue. For example, in our simulation, the OB residents properly used lactated ringers in an attempt to put out the fire; however, they did not immediately remove the surgical drape. The operator kept repeating “The patient is still on fire,” until the drape was removed. In addition, the developers of the simulation had expected that the electrocautery device would be used and the subsequent fire would be ignited before the delivery of the infant, as that would further complicate the transport of the patient, with the need for the pediatric team and all their necessary supplies. However, the OB residents were undisturbed by the operator stating that there was a bleeding vessel after the initial incision, and it was not until after the delivery of the baby that the surgeons turned their attention to “the bleeding vessel.” At this time, the operator urged the surgeons to control the bleeding, as it was obstructing the field of view. Should the surgeons not use the electrocautery device for the “bleeding vessel,” the operator may encourage the surgeons to use electrocautery for some continued oozing that obstructs the field of view. Although an unannounced simulation is inherently unscripted, it is the role of the operator to redirect the participants should the need arise.
After the simulation, a multidisciplinary debrief session can identify strengths and weaknesses of the response to the fire drill. In our institution, we use the TeamSTEPPS approach and the Team Performance Observation Tool11 to debrief all our simulations. TeamSTEPPS is a program developed by the Department of Defense Patient Safety Program in collaboration with the Agency for Healthcare Research and Quality. This program creates a “culture of safety” that can be individualized for the needs of the team. The Team Performance Observation Tool is a standardized model for conducting a debrief session to evaluate the performance of the team.11 The tool evaluates evidence-based communication techniques and is also useful for evaluating scenario-specific opportunities for improvement by standardizing the debrief.
Patient Data Background and Baseline State
The patient is a healthy 32-year-old woman at 38 weeks' gestational age who requires an emergency cesarean delivery for abruptio placenta and nonreassuring fetal status.
Review of Systems
- Central nervous system: awake and alert, crying out in pain from contractions.
- Cardiovascular: NA
- Pulmonary: NA
- Renal/hepatic: NA
- Endocrine: NA
- Hematology/Coagulation: NA
- Medical history: none
- Surgical history: none
- Medications: prenatal vitamins
- Allergies: NKDA
- Obstetric history: two full-term, spontaneous vaginal deliveries without complications
- Gynecologic history: menarche age 12 years, menses q 28 days, lasting 4 days. No history of abnormal Pap smears. No history of sexually transmitted infections.
- Social history: denies tobacco, alcohol, and illicit drugs. Married, works as a teacher, lives at home with husband and children.
- Family history: none
- Blood pressure: 110/60 mm Hg; pulse: 96 bpm; respiration: 18; temperature: 98.6° C; and O2: 98%
- Weight: 180 lbs and height: 5′ 6″
- General: appears in acute distress
- Airway: Class 2
- Cardiovascular: regular rate and rhythm, no murmurs
- Lungs: clear to auscultation bilaterally without wheezes
- Abdomen: gravid, tender to palpation
- Extremities: nontender calves, no edema
- Sterile speculum examination: moderate amount of blood in vault, cervical os appears 2 cm with active bleeding from os
- Beside ultrasound: fundal placenta; biophysical profile 2/10 (+2 for AFI)
- Blood type: O+
- Hb: 9 g/dL
- Hct: 28%
- Platelets: 180,000
- WBC: 9000
- HIV: negative
- Rubella: immune
- RPR: nonreactive
In our simulation, the participants and the observers had a thorough debriefing. This session highlighted the strengths and weaknesses of the team's performance during drill, and from this discussion, we developed a series of recommendations for our institution to better improve the preparedness for a fire emergency. The observers reported the following strengths: clear communication and organized teamwork; appropriate delegation and task assistance; prompt identification of the fire and notification of a Code Red; immediate discontinuation of inhalation agents, ventilation with Ambu bag, and rapid effort to discontinue the oxygen supply in the OR hallway; appropriate attempt to extinguish the fire; and proper staffing at the labor and delivery entrance for the Code Red (and automatic disarming of the locked entryway). The weaknesses that were noted included the following: staff unfamiliar with location of fire extinguishers and sprinkler zones in the OR area; no portable vital sign monitor immediately available; patient not transported to the ideal safe area; and no plan was developed to move patient to the main OR. The recommendations for our hospital include the following: (1) a portable vital sign monitor should be available in the OR at all times; (2) a fire pull should be added in the labor and delivery OR hallway; (3) fire extinguishers in the OR hallway should be more clearly identified; (4) a plan should be devised in case of the need to transport a patient to the main OR; (5) staff should be educated on the sprinklers and fire safe zones in labor and delivery; (6) fire safety should be assimilated into everyday OR routine; and (7) future fire drills should be conducted.
Observers of the simulation were also asked to record the time of critical events. Of note, only two observers maintained awareness of the timing, whereas the other observers reported that they were so engrossed by the simulation that they were unable to remember to record the times. We have created an assessment tool to aid in the collection of this objective data. This information can then be used to compare future drills and discern improvement in the response of the team. Although our simulation was not videotaped, we recommend that future simulations be recorded to allow the opportunity to reevaluate the actions of the team members. This simulation was extremely valuable to our institution, as it is a novel approach to improve fire safety and awareness in labor and delivery.
The authors thank Laura Kerr, RN (Labor and Delivery Nurse Manager), Steve Patteson, MD (Anesthesia Attending), Jeffrey Pigg (Safety Coordinator), and Beth Weitz, NP (Perinatal Nurse Educator) for their contribution to the planning and coordination of the drill.