Operating Room SafetyFires

Grand Rounds PresentationJune 18, 2009

John Chi, MD

Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870

UCLA Medical Center, 1990

UCLA Medical Center, 1990

• 26 year-old female struck by auto

• Blunt injuries to abdomen, chest

• Endotracheal intubation

• Emergency surgery

OR Fire

• Surgery completed

OR Fire

• Surgery completed

• Drapes ignited by cautery device

OR Fire

• Surgery completed

• Drapes ignited by cautery device

• Flames spread rapidly and engulf patient

OR Fire

• Surgery completed

• Drapes ignited by cautery device

• Flames spread rapidly and engulf patient

• Smoke forces OR staff to evacuate

OR Fire

• Surgery completed

• Drapes ignited by cautery device

• Flames spread rapidly and engulf patient

• Smoke forces OR staff to evacuate

• OR sprinkler system does not activate

OR Fire

• Surgery completed

• Drapes ignited by cautery device

• Flames spread rapidly and engulf patient

• Smoke forces OR staff to evacuate

• OR sprinkler system does not activate

• Fire Department arrives and controls fire

Outcome

• Patient expires in the fire

• Operating room staff treated for minor burns and smoke inhalation

Safety

“If you don't know what is going to happen, there is no way to stop it.”

OR Fires

• Introduction

• Causes

• Outcomes

• Prevention

Epidemiology

>30,000,000 surgeries per year

>2,000 reported hospital fires

30 reported OR fires

Source: American College of Surgeons,1997.

Locations of Fires

18

15

9

7

2

0 5 10 15 20

Equipment

Head & Neck

Airway

Torso

Perineum

Number of Fires

Source: Tyco Healthcare Valleylab 2006.

Locations of Fires

~ 65% of fires occur in the Head & Neck region because of the O2 rich environment

Source: ECRI. Devastation of patient fires. Health devices. 1992.

OR Fires

• Introduction

• Causes

• Outcomes

• Prevention

Requirements for Fire

Oxidizer + Fuel + Ignition = FIRE

Oxidizers

Oxidizers

• Oxygen

Oxidizers

• Oxygen– Oxygen is denser than air

1.308 g/L O2 > 1.251 g/L N2

Oxidizers

• Oxygen– Oxygen is denser than air

1.308 g/L O2 > 1.251 g/L N2

– Collects in low-lying areas

Oxidizers

• Oxygen– Oxygen is denser than air

1.308 g/L O2 > 1.251 g/L N2

– Collects in low-lying areas– Absorbed and retained by fabrics

Oxidizers

• Oxygen– Oxygen is denser than air

1.308 g/L O2 > 1.251 g/L N2

– Collects in low-lying areas– Absorbed and retained by fabrics

• Nitrous oxide

Oxidizers

• Oxygen– Oxygen is denser than air

1.308 g/L O2 > 1.251 g/L N2

– Collects in low-lying areas– Absorbed and retained by fabrics

• Nitrous oxide– Releases oxygen when heat is applied

OR Fuels

Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

OR Fuels

• Patient

Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

OR Fuels

• Patient

• Prepping agents

Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

OR Fuels

• Patient

• Prepping agents

• Ointments

Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

OR Fuels

• Patient

• Prepping agents

• Ointments

• Linens

Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

OR Fuels

• Patient

• Prepping agents

• Ointments

• Linens

• Equipment

Source: ECRI. Devastation of patient fires. Health devices. 1992;21:3-39.

OR Fuels - Patient

• Hair• Surgical cap• Gown• GI tract gases

OR Fuels – Prepping Agents

• Alcohol• Chlorhexidine• Acetone• Betadine

Betadine??

Betadine??

• Explodes in the presence of high oxygen or nitrous oxide concentrations at high temperatures

Source: Briscoe et al, 1976.

Betadine??

• Explodes in the presence of high oxygen or nitrous oxide concentrations at high temperatures

Source: Briscoe et al, 1976.

Betadine

Betadine

Flammability of the Product: May be combustible at high temperature.

Glycerin

Glycerin

Flammability of the Product: May be combustible at high temperature.

OR Fuels - Ointments

• Petrolatum• Benzoin• Paraffin• Aerosols

OR Fuels - Linens

• Drapes• Dressings, sponges• Surgical gowns,

masks, caps• Mattresses• Sheets, blankets• Egg crates

OR Fuels - Equipment

• Flexible endoscopes

• ECG wires

• Blood pressure cuff

• Tubing

• Gloves

• Anesthesia machine

Flammability Standards

• OR equipment

• OR supplies

• OR gowns, masks, caps

• Anesthetics

Source: Sommers JR. Flammability standards. SSM 1998;2:41-4.

Requirements for Fire

Oxidizer + Fuel + Ignition = FIRE

OR Fire Survey

Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

OR Fire Survey

8,523 questionnaires

Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

OR Fire Survey

8,523 questionnaires

349 respondents

Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

OR Fire Survey

8,523 questionnaires

349 respondents

88 respondents > 1 Fire

Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

OR Fire Survey

8,523 questionnaires

349 respondents

88 respondents > 1 Fire

10 respondents = 2 Fires

Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

OR Fire Survey

8,523 questionnaires

349 respondents

88 respondents > 1 Fire

10 respondents = 2 Fires

2 respondents = 5 Fires

Source: Smith LP, Roy S. Accepted at AAO-HNS Annual Meeting, Sept 2009.

Fire Scenarios

27% Endoscopic Airway Surgery

24% Oropharyngeal Electrocautery Surgery

23% Electrocautery Surgery under MAC

18% Tracheotomy

7% Endoscopic Light Cables

1% Anesthesia Machine

Endoscopic Airway Surgery

Endoscopic Airway Surgery

OXIDIZER: – Oxygen– Nitrous Oxide

Endoscopic Airway Surgery

OXIDIZER: – Oxygen– Nitrous Oxide

FUEL: – ET Tube, LASER ET Tube– Flexible Bronchoscope, Drapes

Endoscopic Airway Surgery

OXIDIZER: – Oxygen– Nitrous Oxide

FUEL: – ET Tube, LASER ET Tube– Flexible Bronchoscope, Drapes

IGNITION: – LASER - CO2 more often than KTP

Laser Ignition of Drapes

Source: Wolf et al, 2004.

Laser Ignition of Drapes

• Surgical drapes tested for time to ignition

Source: Wolf et al, 2004.

Laser Ignition of Drapes

• Surgical drapes tested for time to ignition

• CO2 laser 15 W, 2 mm spot x 30 sec

Source: Wolf et al, 2004.

Laser Ignition of Drapes

• Surgical drapes tested for time to ignition

• CO2 laser 15 W, 2 mm spot x 30 sec

21% O2 50% O2 95% O2

Source: Wolf et al, 2004.

Laser Ignition of Drapes

• Surgical drapes tested for time to ignition

• CO2 laser 15 W, 2 mm spot x 30 sec

21% O2 50% O2 95% O2

Primary ignition – drapes

Secondary ignition – drapes on filter paper

Source: Wolf et al, 2004.

Drapes Tested

• Nonwoven cellulose/polyester blend

• Polypropylene

• Reusable woven cotton/polyester blend

• Huck cotton towel drape adjunct

• Phenol polymer

Time to Primary Ignition 21%

Material Ignited / Tested TTI

Phenol polymer 0 / 10 N/A

Polypropylene 0 / 10 N/A

Huck towel 8 / 10 11.9 sec

Cotton-poly 10 / 10 4.0 sec

Cellulose-poly 10 / 10 2.7 sec

Time to Primary Ignition 50%

Material Ignited / Tested TTI

Phenol polymer 10 / 10 4.9 s

Polypropylene 9 / 10 0.14 s

Huck towel 10 / 10 2.3 s

Cotton-poly 10 / 10 1.1 s

Cellulose-poly 10 / 10 < 0.1 s

Time to Primary Ignition 95%

Material Ignited / Tested TTI

Phenol polymer 10 / 10 0.68 s

Polypropylene 10 / 10 0.18 s

Huck towel 10 / 10 < 0.1 s

Cotton-poly 10 / 10 0.65 s

Cellulose-poly 10 / 10 < 0.1 s

Time to Secondary Ignition 21%

Material Ignited / Tested TTI

Polypropylene & Filter Paper

10 / 10 4.7 s

Filter Paper alone

10 / 10 5.2 s

Filter paper was placed beneath the test material.

Laser Study Conclusions

• Time to ignition decreases with increasing O2 concentration

• Polypropylene assumes the ignition characteristics of materials it contacts

Oropharyngeal Electrocautery

Oropharyngeal Electrocautery

OXIDIZER: – Oxygen

Oropharyngeal Electrocautery

OXIDIZER: – Oxygen

FUEL: – ET Tube – Bovie Tip– Tonsil Sponge – Red Rubber Catheter

Oropharyngeal Electrocautery

OXIDIZER: – Oxygen

FUEL: – ET Tube – Bovie Tip– Tonsil Sponge – Red Rubber Catheter

IGNITION: – Monopolar Electrocautery

Fire risk: Monopolar v. Coblator

Source: Smith LP, Roy S, Laryngoscope, Accepted for publication.

Fire risk: Monopolar v. Coblator

• Monopolar – Coagulate: 15 W

• Coblator – Ablate: 9, 7, 3 – Coagulate: 5, 3

Source: Smith LP, Roy S, Laryngoscope, Accepted for publication.

Fire risk: Monopolar v. Coblator

• Degutted raw chicken

• 6.0 ET Tube

• 100% oxygen at 10 L/min

• 3 tonsil sponges

Source: Smith LP, Roy S, Laryngoscope, Accepted for publication.

OP Fire Study Setup

Monopolar Electrocautery

After 45–55 secs of Monopolar

After 45–55 secs of Monopolar

After the fire

Coblator Electrocautery

After 4 minutes of Coblator

After 4 minutes of Coblator

After 20 minutes of Coblator

After 20 minutes of Coblator

Back to Monopolar for 25 secs

Back to Monopolar for 25 secs

OP Fire Study Conclusions

• Monopolar Electrocautery (>15 W) poses a fire risk

• Coblator Electrocautery did not produce fires

Electrocautery Surgery (MAC)

Electrocautery Surgery (MAC)

OXIDIZER: – Oxygen

Electrocautery Surgery (MAC)

OXIDIZER: – Oxygen

FUEL: – Flash Fire – Drapes– EtOH Prep – Sponges

Electrocautery Surgery (MAC)

OXIDIZER: – Oxygen

FUEL: – Flash Fire – Drapes– EtOH Prep – Sponges

IGNITION: – Monopolar Electrocautery – LASER– Thermocautery– Oxidizer to ignition source <5cm

Arizona Medical Center,1998

Arizona Medical Center,1998

• 73 year-old male with SDH for bilateral burr holes

• Oxygen via face mask at 6 L/min

• Iodofor surgical prep – (0.7% iodine, 74% Isopropyl EtOH)

• Drapes: Towels, Paper surgical drapes

• Monopolar Electrocautery

OR Fire

OR Fire

• “Pop”

OR Fire

• “Pop”

• Smoke appears from beneath the drapes

OR Fire

• “Pop”

• Smoke appears from beneath the drapes

• Drapes quickly removed

OR Fire

• “Pop”

• Smoke appears from beneath the drapes

• Drapes quickly removed

• “Ball of flame” engulfs the patient’s head

OR Fire

• “Pop”

• Smoke appears from beneath the drapes

• Drapes quickly removed

• “Ball of flame” engulfs the patient’s head

• Oxygen mask on fire

OR Fire

• “Pop”

• Smoke appears from beneath the drapes

• Drapes quickly removed

• “Ball of flame” engulfs the patient’s head

• Oxygen mask on fire

• Fire smothered with drapes

OR Fire

• “Pop”

• Smoke appears from beneath the drapes

• Drapes quickly removed

• “Ball of flame” engulfs the patient’s head

• Oxygen mask on fire

• Fire smothered with drapes

• Oxygen flow turned off

Outcome

• Intubation

• 2nd degree burns of face, neck

• ICU x 2 months

• Pneumonia, Respiratory Failure

• Inpatient rehabilitation

Simulated OR Fire

Simulated OR Fire

• Life size manikin

• Oxygen supplied via face mask

• Positioned, prepped, and draped

• Monopolar electrocautery

Simulation Setup

Monopolar Electrocautery- POP

Smoke – POP + 5 seconds

Fire – POP + 13 seconds

Fire – POP + 24 seconds

Beneath the drapes

Beneath the drapes

Beneath the drapes

Beneath the drapes

Simulation Fire Requirements

Source: Barker SJ, Polson SJ, 2001.

Simulation Fire Requirements

• Supplemental oxygen

Source: Barker SJ, Polson SJ, 2001.

Simulation Fire Requirements

• Supplemental oxygen

• Closed space formed by drapes (Tenting)

Source: Barker SJ, Polson SJ, 2001.

Simulation Fire Requirements

• Supplemental oxygen

• Closed space formed by drapes (Tenting)

• Alcohol-based preparation solution– Manufacturer’s label drying time 2-3 minutes– Drying time > 5 minutes No fire

Source: Barker SJ, Polson SJ, 2001.

Oxygen Face Masks

Oxygen Face Masks

• Melt when exposed to open flame

Oxygen Face Masks

• Melt when exposed to open flame

• Do NOT burn without oxygen flow

Oxygen Face Masks

• Melt when exposed to open flame

• Do NOT burn without oxygen flow

• Ignite, burn with oxygen flow > 3 L/min

Tracheotomy

Tracheotomy

OXIDIZER: – Oxygen

Tracheotomy

OXIDIZER: – Oxygen

FUEL: – Flash Fire, ET Tube, Drape, Airway

Tracheotomy

OXIDIZER: – Oxygen

FUEL: – Flash Fire, ET Tube, Drape, Airway

IGNITION: – Monopolar electrocautery

• Electrocautery to enter trachea• Electrocautery after airway incision

Endoscopic Surgery

Endoscopic Surgery

OXIDIZER: – Oxygen

Endoscopic Surgery

OXIDIZER: – Oxygen

FUEL: – Drapes

• Cellulose-based: IGNITE• Polypropylene-based: MELT

Endoscopic Surgery

OXIDIZER: – Oxygen

FUEL: – Drapes

• Cellulose-based: IGNITE• Polypropylene-based: MELT

IGNITION: – Endoscopic Light Cable– Temperature > 200º Celcius

OR Fires

• Introduction

• Causes

• Outcomes

• Prevention

Outcomes

Analysis of Closed Claims

Source: Bhananker et al, 2006.

Analysis of Closed Claims

Analysis of the closed claims of 35 US professional liability insurance companies

Source: Bhananker et al, 2006.

Analysis of Closed Claims

Analysis of the closed claims of 35 US professional liability insurance companies

• 121 MAC-related claims reviewed

• 20 OR fires leading to burns

Source: Bhananker et al, 2006.

OR Fires

• 95% involved head, neck, face

OR Fires

• 95% involved head, neck, face

• 50% cited for substandard care

OR Fires

• 95% involved head, neck, face

• 50% cited for substandard care

• 89% resulted in payment to plaintiff– Median $71,375– Range $8,175 to $321,323

OR Fires

• Introduction

• Causes

• Outcomes

• Prevention

Prevention

Prevention

• Communication with OR Staff, Anesthesia

Prevention

• Communication with OR Staff, Anesthesia

• Assess the OR fire risk

Prevention

• Communication with OR Staff, Anesthesia

• Assess the OR fire risk

• Electrocautery – avoid Fuels + Oxidizers

Prevention

• Communication with OR Staff, Anesthesia

• Assess the OR fire risk

• Electrocautery – avoid Fuels + Oxidizers

• Minimize available O2

Prevention

• Communication with OR Staff, Anesthesia

• Assess the OR fire risk

• Electrocautery – avoid Fuels + Oxidizers

• Minimize available O2

• Prep Solutions – proceed with caution

Prevention

• Communication with OR Staff, Anesthesia

• Assess the OR fire risk

• Electrocautery – avoid Fuels + Oxidizers

• Minimize available O2

• Prep Solutions – proceed with caution

• Fire Safety Training

Summary

Summary

• OR fires are preventable

Summary

• OR fires are preventable

• Be aware of your surroundings

Summary

• OR fires are preventable

• Be aware of your surroundings

Oxidizer + Fuel + Ignition = FIRE

Thank You

• Lee Smith, MD

• James Kearney, MD

Otorhinolaryngology: Head and Neck Surgery at PENN Excellence in Patient Care, Education and Research since 1870