Choice of tool can lower risk of airway fires

About 650 surgical fires are reported in U.S. hospitals each year, according to the nonprofit ECRI Institute in Plymouth Meeting, PA, and there are another three to four times as many near-misses. Fires during surgery can be extremely serious, causing significant injuries and death to both patients and clinicians.

Risk managers can reduce the risk of surgical fires by encouraging safe practices, including the careful choice of instrumentation that is less likely to contribute to a fire, suggests Soham Roy, MD, associate professor at the University of Texas Medical School at Houston in the Department of Otorhinolaryngology — Head and Neck Surgery. He also is director of pediatric otolaryngology — Head and Neck Surgery at Children's Memorial Hermann Hospital in Houston.

The Joint Commission has recognized the threat of surgical fires, releasing a Sentinel Event Alert in 2003 that outlined strategies to prevent surgical fires.1 In that Alert, The Joint Commission noted that electrosurgical equipment sparks the most fires (68%), followed by lasers (13%). The airway is the most common location of fire (34%), followed by face and head (28%), and elsewhere inside or outside the patient (38%); an oxygen-enriched atmosphere contributes to 78% of all cases.

Roy has studied the issue extensively and says the risk of surgical fires may be worse than the statistics indicate.

"A lot of people fail to understand just how serious this problem is. Surgical fires are probably one of the most underreported phenomena in the operating room," Roy says. "Surgical fires are considered a never event, and people think this is an isolated incident that happens once a year around the country, and it's never going to happen to you."

Fires occur with surprising regularity in some specialties. Roy and a colleague recently surveyed members of the American Academy of Otolaryn- gology — Head and Neck Surgery on their experience with surgical fires and found that 25% of respondents had personally witnessed at least one fire in the operating room. Interestingly, 10 people reported being involved with two fires, and two surgeons reported five fires apiece.

"It's more common than you think, but it's rarely discussed," Roy says. "People think of it as a once-in-a-lifetime event, but it can happen a lot more than once in a lifetime."

Roy's research suggests that the risk can be significantly reduced by choosing surgical tools less likely to start a fire. He conducted a study that demonstrated the risk factors of various surgical modalities, including electrocautery (Bovie), CO2 laser, and Coblation (bipolar radiofrequency ablation) over the past two years.2 In his research, Roy and his colleagues examined the risk of fires and burns during endoscopic surgeries with halogen light sources, electrosurgery, and created mechanical chicken models to study fire risk in oropharyngeal and airway surgeries. The research determined that the Coblation eliminated the risk of surgical fire, as it produces less thermal energy dissipation with lower surrounding temperatures in the tissues, which eliminates the ignition source necessary to spark a fire. Even in a 100% oxygen-enriched environment, the risk of surgical fire was eliminated in Roy's model using Coblation, he says.

Roy explains that head and neck procedures are at the highest risk of surgical fire, due to the presence of exposed supplemental oxygen around flammable materials. Fires have been reported during tracheostomy, adenotonsillectomy and skin surgery of the head and neck.

No matter where they occur, surgical fires require a "classic triad" of elements to occur: an ignition source, fuel, and an oxidizer. Ignition sources often are electrosurgical units, lasers, and light cords; and endotracheal tubes, operating room drapes or towels, sponges and alcohol preparation solutions can provide the fuel. The oxidizing agent can be a gas commonly used in surgery, such as oxygen or nitrous oxide.

The role of oxygen and nitrous oxide are important factors to consider. Roy recommends that the anesthesiologist collaborate with all surgical team members throughout the procedure to minimize the presence of an oxidizer-enriched atmosphere in proximity to an ignition source. Keeping the fraction of inspired oxygen (FiO2) below 50% may eliminate the risk of fire ignition, he says.

Surgical fires can be small and quickly controlled, but they also can be fatal. Janice McCall, a 65-year-old woman from Energy, IL, died Sept. 8, 2009, at Vanderbilt University Medical Center in Nashville, TN, six days after being burned on the operating table at Heartland Regional Medical Center in Marion, IL, according to her family attorney, Robert Howerton, JD, of the law firm Howerton Dorris in Marion, IL.

The Tennessee state medical examiner's office said McCall died from complications of thermal burns and classified her death as accidental. Heartland released a statement confirming that ''there was an accidental flash fire in one of the hospital's operating rooms," which was immediately extinguished but injured the patient.

"Awareness is the key to prevention. Once you convince people that this is a real risk, there are steps to take and ways to greatly reduce that risk," Roy says.

Roy urges risk managers to employ policies and procedures that can reduce the risk of fire. Before each surgical case, he says the OR team should consider whether the case is at high risk for surgical fires — determined by the procedure, materials, and gasses in use, and the instrumentation. If those factors suggest a high risk, the team should decide on a plan for preventing and managing a fire. This could all be discussed during the timeout before surgery, he suggests.

Communication between nursing staff, anesthesiologist, and surgeon is critical, Roy says.

"Fires tend to occur when there is miscommunication or a lack of communication [among] surgeons, anesthesiologists, and operating room staff," he says. "It is incumbent that everyone, not just the surgeon, realize there is a risk of fire and that the entire team communicates openly about how they're going to prevent it from happening."

References

1. The Joint Commission. Preventing Surgical Fires. Sentinel Event Alert; Issue 29, June 24, 2003.

2. Roy S, Smith LP. "Device-Related Risk of Airway Fire in Oropharyngeal Surgery." Abstracts of the AAO-HNS Annual Meeting, 2008; American Journal of Otolaryngology.

Sources

For more information on preventing surgical fires, contact:

• Robert Howerton, Partner, Howerton Dorris & Stone, Marion, IL. Telephone: (618) 993-2616. E-mail: rhunter@neondsl.com.

• Soham Roy, MD, Director of Pediatric Otolaryngo-logy — Head and Neck Surgery, Children's Memo- rial Hermann Hospital, Houston. Telephone: (713) 704-5437.