Surgical preps: New fire worries affect OR

Maintain strict protocols, safety experts say

Just as the Center for Medicaid & Medicare Services (CMS) granted hospitals new latitude to place alcohol-based hand rub containers in hallways, new fire concerns emerged that could restrict the use of alcohol-based surgical preparations in the operating room.

Infection control advocates and safety experts scrambled to respond to a ruling by a regional CMS officer that prohibits the preparations containing alcohol when cautery, electrosurgery, or laser devices are in use. The ruling came after a device sparked a surgical fire and burned a patient in Nebraska.

Alcohol has been a mainstay of antiseptic procedures, and infection control professionals expressed concern that its removal from operating rooms could lead to an increase in surgical site infections.

A National Fire Protection Association (NFPA) committee will meet in July to consider issuing clarification on the issue as a Tentative Interim Amendment (TIA) to the fire code.

CMS also is working with the NFPA and the American Society for Healthcare Engineering (ASHE) of the American Hospital Association to allow the use of alcohol-based surgical preparation solutions if there is a time-out to allow the substance to dry.

It’s a matter of balancing risks, explains Susan McLaughlin, MBA, CHSP, MT(ASCP)SC, president of SBM Consulting in Barrington, IL, and a codes and standards consultant to ASHE.

“Of course, we have the risk of surgical-site fires, and unfortunately there have been some,” she adds. “But . . . we’re trying to reduce the number of hospital acquired infections. It truly becomes an education process that we have to undertake in the health care industry, to be able to use the materials that we need to use to provide the patient care, and use them safely.”

Infection control professionals expressed alarm that restrictions on the use of alcohol could have serious repercussions. “We don’t know the unintended consequences, which could well be an increase in surgical-site infections,” says Judene Bartley, MS, MPH, CIC, vice president of Epidemiology Consulting Services in Beverly Hills, MI, and a member of the public policy committee of the Association of Professionals in Infection Control and Epidemiology.

In fact, the fire code doesn’t prohibit the use of alcohol-based products in the operating room, ASHE asserts in an advisory ( “In fact, NFPA 99 [the fire code used by CMS] specifically addresses germicidal solutions in surgery and provides conditions for their safe use.”

You can use the alcohol-based preparations safely with cautery or lasers if you follow a strict protocol, according to the TIA proposed by ASHE.

Operating room personnel should make sure the solutions do not pool under the patient’s drapes and should implement a time-out before starting a surgical procedure to make sure the solution has dried completely, ASHE advises.

“[Hospitals] should risk-assess their process and educate the surgical team about the issues and the precautions to be taken,” McLaughlin says.

The Nebraska case dramatically highlights the fire hazard in an operating room. An 86-year-old woman was undergoing a biopsy when the linens supporting her head caught fire. She received severe burns to her head, neck, and shoulders and died of pneumonia a month later, according to news reports.

There always will be a risk of fire in the OR, as long as heat-producing devices are used in the procedures, Bartley notes. But the discussions can place a sharp focus on preventive measures, she says.

“We can use the opportunity to take another look at what our processes are and how they can be better,” Bartley adds.

Meanwhile, CMS officially has allowed the placement of containers of alcohol-based hand rubs in hospital hallways. As of May 24, CMS is adopting the amendment to the NFPA Life Safety Code that allows the dispensers.

The amendment dictates the size, spacing, and placement of the containers. For more information, go to