Surgical fires: A twist on the fire-and-alcohol problem

Surgical fires: A twist on the fire-and-alcohol problem

Some states may remove skin preps from OR

Even as the impasse over fire safety and alcohol handrubs nears resolution, another issue is putting infection control professionals and fire marshals at odds: surgical fires.

Surgical fires have prompted some state safety officials to ban use of alcohol-based skin preps (ABSPs) on patients in the operating room if cautery or lasers will be used. According to the Joint Commission on Accreditation of Healthcare Organizations, the fire triangle — heat, fuel, and oxygen — must be present for a fire to start. If the three elements come together in a hospital’s surgical suite, the results can be disastrous. Though they are considered rare occurrences in the health care environment, the JCAHO reported that there are approximately 100 surgical fires each year, resulting in up to 20 serious injuries and one or two patient deaths annually.¹ On the other hand, ABSPs help prevent surgical site infections, one of the most prevalent and costly nosocomial complications.

"The issue is how do we balance this risk so we don’t increase surgical site infections," says Judene Bartley, MS, CIC, a clinical consultant in Beverly Hills, MI, and a member of the Association for Professionals in Infection Control and Epidemiology. "Let’s address how we can improve this instead of just removing alcohol without thinking about unintended consequences."

Bartley is working on the issue with the American Society of Healthcare Engineering (ASHE), which recently issued an advisory in support of keeping ABSPs in the operating room. The message from Dale Woodin, ASHE deputy executive director, included key recommendations and explanatory points, summarized as follows:

ASHE Recommendations:

• Hospitals and other health care facilities should be allowed to continue utilizing alcohol surgical prep solutions to prepare patients for surgery by optimizing conditions to prevent surgical infections, provided that usage is consistent with the labeling and instructions of the product.
• Hospitals and other health care facilities utilizing alcohol surgical prep solutions should assess current procedures and develop protocols that ensure and document that the applied solution is thoroughly dry before introducing any source of ignition.

ASHE cites ECRI findings: ECRI (formerly the Emergency Care Research Institute), a nonprofit health services research agency, has published several articles on preventing, preparing for, and managing surgical fires. According to ECRI, the fuels in these fires are multiple and include the patient’s own hair (face, scalp, body) and GI tract gases.² Other combustibles include anesthesia components (endotracheal tubes, breathing circuits, airways, masks), prepping agents including alcohol, linens, dressings, various ointments, gloves, tubing, tourniquet cuffs, and other materials that may not be flammable in an environment that is not oxygen- or nitrous-oxide-enriched. Rather than prohibiting specific products to reduce the risk of fire, the ECRI guidance offers ways that the risk of surgical fires can be mitigated through effective management of each of the key patient care elements that could contribute to fires:

• Be aware that alcohol-based preps are flammable.
• Avoid pooling or wicking of flammable liquid preps.
• Allow flammable liquid preps to dry fully before draping; pooled or wicked liquid will take longer to dry than will prep on the skin alone.
• Use a properly applied incise drape, if possible, to help isolate head and neck incisions from O2-enriched atmospheres and from flammable vapors beneath the drapes. Proper application of an incise drape ensures that there are no gas communication channels from the under-drape space to the surgical site.

Alcohol the gold standard for skin disinfection: Alcohol is an important tool in the hospital operating room environment, proven to lower the risk of surgical-site infection. Although alcohol rapidly evaporates, damaged organisms continue to die after a single brief exposure. While all alcohols are bactericidal, higher-molecular-weight alcohols have more killing power. Both ethyl and isopropyl alcohols are in common clinical use, usually in concentrations of 70%-90%. The World Health Organization has designated alcohol as the gold standard against which all skin antiseptics should be judged.

There are other commonly used antiseptics — iodophors and chlorhexidine gluconate (CHG) — that have a residual cidal affect on skin flora (i.e., continuing kill action after the alcohol evaporates). They are available as aqueous solutions or tinctures (alcohol-based solutions). The added value of tinctures (at varying concentrations of alcohol) is the "instant" action of alcohols as noted above combined with the continuing residual activity of an iodophor or CHG. The combination improves cidal activity, faster drying of the solution on the skin, and a continuing cidal action of the antiseptic, whether an iodophor or CHG. Therefore it is essential to provide the full spectrum of options for skin antisepsis in order to optimize all factors that may prevent surgical site infection.

References

1. JCAHO. Sentinel Event Alert — Preventing Surgical Fires. June 24, 2003. www.jcaho.org.
2. ECRI. A clinician’s guide to surgical fires: how they occur, how to prevent them, how to put them out [guidance article]. Health Devices 2003; 32:5-24.