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Clinical| Volume 37, ISSUE 6, P766-769, December 2022

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Fire in the Operating Room: Surgical Case Report From a Forced-Air Warming Device Equipment Fire

      ABSTRACT

      Surgical fires are critical life-threatening events that can result in patient morbidity and mortality. This case report describes an equipment fire originating from a forced-air warming device occurring during a shoulder arthroscopy operation and discusses how the surgical team responded to mitigate risks to the patient and staff. Rapid response by the anesthesia professional and the surgical team helped prevent the fire from negatively impacting patient and staff safety. The patient was discharged from the hospital without any complications. We recommend that surgical teams engage in a coordinated and continual cycle of fire prevention, including enhanced education and interprofessional team training.

      Keywords

      Surgical fires are critical life-threatening events that can result in patient morbidity and mortality. Although surgical fires rarely occur, their effects can be highly devastating to patients and healthcare workers.

      The Joint Commission. Sentinel Event Alert 29: Preventing surgical fires. The Joint Commission. Available at: https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-issue-29-preventing-surgical-fires/. Accessed December 5, 2021.

      A surgical fire can occur in any location with surgical capabilities, including large and small hospitals, ambulatory surgical centers, and physicians' offices.

      AORN. AORN Fire Safety Tool Kit. Association of periOperative Registered Nurses; 2021. Available at: https://test.aorn.org/guidelines/clinical-resources/tool-kits/fire-safety-tool-kit. Accessed December 5, 2021.

      The Emergency Care Research Institute (ERCI) estimates that approximately 90-100 surgical fires occur annually in the United States (US), resulting in 20 serious patient injuries and two to three patient deaths.

      The Joint Commission. Sentinel Event Alert 29: Preventing surgical fires. The Joint Commission. Available at: https://www.jointcommission.org/resources/patient-safety-topics/sentinel-event/sentinel-event-alert-newsletters/sentinel-event-alert-issue-29-preventing-surgical-fires/. Accessed December 5, 2021.

      ,
      • Bruley M
      • Arnold T
      • Finley E
      • Deutsch E
      • Treadwell J.
      Surgical fires: Decreasing incidence relies on continued prevention efforts.
      ,

      Institute for Safe Medication Practices. Surgical fires caused by skin preps and ointments: Rare but dangerous and preventable. Available at: https://www.ismp.org/resources/surgical-fires-caused-skin-preps-and-ointments-rare-dangerous-and-preventable. Accessed January 30, 2022.

      Adding to adverse patient outcomes are hospital costs associated with medical litigation, ranging from $82K to $518K per event.
      • Choudhry AJ
      • Haddad NN
      • Khasawneh MA
      • Cullinane DC
      • Zielinski MD.
      Surgical fires and operative burns: Lessons learned from a 33-year review of medical litigation.
      Patient safety groups classify surgical fires as a “never event” because they are unambiguous (ie, clearly identifiable and measurable), serious (ie, potential for death or significant disability), and largely preventable.
      • Jardaly A
      • Arguello A
      • Ponce BA
      • et al.
      Catching fire: Are operating room fires a concern in orthopedics?.
      ,

      AHRQ. Patient Safety Network. Agency for Healthcare Research and Quality. Available at: https://psnet.ahrq.gov/primer/never-events. Accessed December 5, 2021.

      Since the Joint Commission issued a surgical fire Sentinel Event Alert in 2003, patient risk of surgical fires has decreased by 71%.
      • Bruley M
      • Arnold T
      • Finley E
      • Deutsch E
      • Treadwell J.
      Surgical fires: Decreasing incidence relies on continued prevention efforts.
      One reason for the decrease is the combined efforts to educate clinicians about operating room fire safety by specialty organizations and patient safety groups, including the American Society of PeriAnesthesia Nurses (ASPAN), Association of periOperative Nurses (AORN), American Association of Nurse Anesthesiology (AANA), and American Society of Anesthesiologists (ASA).
      Three components must be present to support a surgical fire; namely an oxidizer, fuel, and an ignition source. These three components represent the fire triad.

      AORN. AORN Fire Safety Tool Kit. Association of periOperative Registered Nurses; 2021. Available at: https://test.aorn.org/guidelines/clinical-resources/tool-kits/fire-safety-tool-kit. Accessed December 5, 2021.

      Surgical fires most commonly occur on the patient's face, scalp, neck, and chest.
      • Bruley M
      • Arnold T
      • Finley E
      • Deutsch E
      • Treadwell J.
      Surgical fires: Decreasing incidence relies on continued prevention efforts.
      Although the entire surgical team plays an essential role in fire prevention, each member influences the components of the fire triad differently. Oxygen and nitrous oxide, which anesthesia professionals predominantly administer, are the two most common oxidizers used in the operating room.
      • Jones TS
      • Black IH
      • Robinson TN
      • Jones EL.
      Operating room fires.
      The most prevalent fuel sources contributing to surgical fires are drapes, gowns, sponges, gauze, prep solutions, body hair, airway devices, and fiberoptic cables.
      • Kezze I
      • Zoremba N
      • Rossaint R
      • Rieg A
      • Coburn M
      • Schalte G.
      Risks and prevention of surgical fires: A systematic review.
      The perioperative nurse often impacts items in the fuel category, although nearly all materials become flammable when using elevated oxygen levels.

      AORN. AORN Fire Safety Tool Kit. Association of periOperative Registered Nurses; 2021. Available at: https://test.aorn.org/guidelines/clinical-resources/tool-kits/fire-safety-tool-kit. Accessed December 5, 2021.

      ,
      • Jones TS
      • Black IH
      • Robinson TN
      • Jones EL.
      Operating room fires.
      The most common ignition sources are electrocautery, lasers, and fiberoptic cables, and the vigilance of the surgeon often influences their impact.

      AORN. AORN Fire Safety Tool Kit. Association of periOperative Registered Nurses; 2021. Available at: https://test.aorn.org/guidelines/clinical-resources/tool-kits/fire-safety-tool-kit. Accessed December 5, 2021.

      ,
      • Jones TS
      • Black IH
      • Robinson TN
      • Jones EL.
      Operating room fires.
      Maintaining normothermia in surgical patients has many benefits, including reducing recovery time and decreasing the risk of surgical site infections.
      • Mehta SP.
      Burn injuries from warming devices in the operating room.
      Perioperative and perianesthesia nurses use forced-air warming to maintain patient normothermia across the perioperative continuum of care (ie, preoperative, intraoperative, and postoperative periods). Additionally, anesthesia professionals use forced-air warming devices to help maintain or restore normothermia intraoperatively in surgical patients. The forced-air system contains a warming unit and single-use disposable blankets. The forced-air warming device injects warm air through a connecting hose to a blanket containing a series of microperforations allowing air to escape and provide convective warming to the patient. Although forced-air warming devices are typically safe to use and provide many patient benefits, some patients have experienced thermal burns from the practice of “hosing,” when clinicians use forced-air warmers without the blanket attached.
      • Mehta SP.
      Burn injuries from warming devices in the operating room.
      Equipment fires are a rare occurrence in the operating room.

      AORN. AORN Fire Safety Tool Kit. Association of periOperative Registered Nurses; 2021. Available at: https://test.aorn.org/guidelines/clinical-resources/tool-kits/fire-safety-tool-kit. Accessed December 5, 2021.

      Previous researchers have excluded some equipment fires from statistical analysis, as many occur off the operative field.
      • Bruley M
      • Arnold T
      • Finley E
      • Deutsch E
      • Treadwell J.
      Surgical fires: Decreasing incidence relies on continued prevention efforts.
      Although not in direct contact with the patient, like electrocautery or lasers, equipment fires occurring off the operative field can negatively impact patient safety. Lalla & Koteswara
      • Lalla RK
      • Koteswara CM.
      Fire in the operating room due to equipment failure.
      reported an equipment fire originating from an anesthesia ventilator during mechanical ventilation. Although the fire originated off the operative field, the patient was directly connected to the anesthesia machine and ventilator via the breathing circuit and was at risk for harm. Thus, some fires that occur off the operative field can place patients and staff members at risk for injury. This report describes an equipment fire from a forced-air warming device that occurred during a shoulder arthroscopy case, and discusses how the surgical team responded to mitigate risks to patient and staff member safety.

      Case Discussion

      Note: Patient characteristics altered to maintain anonymity.

      Case Detail

      The setting for the case was a small 92-bed military treatment facility located in the western part of the United States. Surgeons from 8 specialties perform more than 6,000 annual cases in nine surgical suites in this setting. The surgical team members present for the operation were 2 orthopedic surgeons, one surgical technologist, one perioperative nurse, and one certified registered nurse anesthetist (CRNA).
      A 19-year old male patient with an American Society of Anesthesiologists (ASA) physical status classification level rating of ASA I underwent left shoulder arthroscopy. The surgical team conducted a TeamSTEPPS

      Agency for Healthcare Research and Quality (AHRQ). TeamSTEPPS: Strategies and tools to enhance performance and patient safety. Available at: https://www.ahrq.gov/teamstepps/instructor/index.html. Accessed December 01, 2021.

      brief before the surgical case to review the operative plan and discuss potential patient and case concerns.
      The patient received an ultrasound-guided interscalene brachial plexus block by the CRNA before entering the surgical suite and antibiotic prophylaxis per standard procedures. Once in the operating room, the CRNA placed the patient on standard anesthesia monitors and preoxygenated the patient. The perioperative nurse placed sequential compression devices on both patient lower extremities for venous thromboembolism prophylaxis. Intravenous (IV) induction of general anesthesia was achieved while maintaining hemodynamic stability. The CRNA placed an 8.0 mm endotracheal tube and confirmed its location with bilateral breath sounds and positive end-tidal carbon dioxide tracing. The CRNA maintained general anesthesia with 2% sevoflurane and an air /oxygen mix with FiO2 0.5. The patient was positioned and secured in the right lateral decubitus position with bean bag support with appropriate care to pad all pressure points. The patient bed was turned 90 degrees to facilitate optimal surgical visualization.
      The CRNA applied a lower-body forced-air warming blanket extending from the nipple line to the feet of the patient. The CRNA placed the forced-air warming unit between the anesthesia machine and the operative field. The device was turned on and set at 43.0°C and operated per the manufacturer's instructions. After an exam under anesthesia, the surgical team prepped the patient with iodine povacrylex and isopropyl alcohol solution, draped the operative arm, and placed the arm into a lateral traction device. The team performed a surgical time out prior to incision, and the surgery proceeded uneventfully.
      Approximately 30 minutes after incision, the CRNA detected the odor of burning electrical components and observed smoke and flames originating from the forced-air warming device base and traveling up the hose attachment towards the patient (Figure 1). The CRNA immediately notified the surgical team of the fire while simultaneously discontinuing oxygen delivery to the anesthesia circuit, using air only for the next twenty minutes (FiO2 0.21, O2 saturation >95%). The CRNA disconnected the power cord from the rear of the forced-air warming device, and the surgeon extinguished the fire by dumping a basin of sterile water onto the device and hose. The CRNA quickly disconnected the hose from the forced-air warming blanket and observed that the blanket was much warmer than expected. The CRNA removed the forced-air warming blanket from the patient, a sterile incise drape was applied to the surgical site, and the team removed the original sterile drapes to check for thermal damage. Operating room staff not involved in surgical cases arrived to provide support. The team removed the forced-air warming unit from the room and sent the device to medical maintenance for technical inspection.
      Figure 1
      Figure 1Forced-air warming equipment fire. A forced-air warming device caught fire during an orthopedic surgical case, with the fire originating at the equipment base and traveling towards the patient.
      After removing the drapes, the CRNA and surgeon carefully inspected the patient for thermal injuries, finding no damage. The patient's vital signs were stable. The patient had no pulmonary exposure to combustion products due to the closed anesthesia circuit. Although not in direct contact with the patient, the buckle on the surgical table strap was excessively warm. The surgeon and CRNA decided to continue surgery in the room, as the patient was under general anesthesia and the surgical case was in progress. Staff members were surveyed for minor exposure to noxious combustion products and reported no negative health effects.
      The team considered all sterile items in the surgical suite contaminated due to the presence of aerosolized smoke particles. The team opened sterile instruments and supplies while the patient was prepped and draped again. The CRNA avoided using a forced-air warming device for the rest of the case. The surgery proceeded without incident, and following extubation, the patient was transported to the post anesthesia care unit (PACU) in stable condition. The surgeon discussed the event with the patient. The CRNA and perioperative nurse completed a handoff report with PACU nurses informing them of the equipment fire and alerting them to observe the patient for any adverse effects. The patient was discharged after meeting standardized outpatient discharge criteria.

      Actions Post Surgical Case

      The surgical team performed all subsequent surgical cases in a neighboring surgical suite. The CRNA completed a patient safety report, and all team members participated in interviews conducted by the hospital safety department. After the surgery, perioperative leaders closed the surgical suite to determine if the fire originated from the device or from an electrical power quality problem. The hospital uses an isolated power system, although the system alarm in the isolation panel did not activate. The hospital facilities management department thoroughly tested the surgical suite for electrical problems and other safety functions, and subsequently cleared the operating room for use. The hospital planned a switch to a different brand of forced-air warming units before the electrical fire occurred. The electrical fire hastened this product switch, and all forced-air devices in the operating room were removed and replaced with new units.
      The surgical team conducted a review to discuss and analyze what went well, what needs improvement, and what solutions are available to mitigate future risk and improve care. Although the manufacturer was alerted to the faulty device, their technical team could not determine the root cause of the fire within the forced-air warming unit. The review found that the surgical team acted quickly in a calm and controlled manner to extinguish the fire and prevent harm to the patient and staff. All surgical team members knew their role and worked cohesively to aid the fire response. The immediate concern was to quickly extinguish the fire because flames were traveling up the hose attachment towards the patient and surgical team. The room had a CO2-based fire extinguisher mounted on the wall located just inside the patient room entry doors. Because using a fire extinguisher is considered the last resort in a surgical fire,

      ERCI. Surgical Fire Prevention. Emergency Care Research Institute Available at: https://www.ecri.org/solutions/accident-investigation-services/surgical-fire-prevention. Accessed December 5, 2021.

      the surgical team used a basin of sterile water to extinguish the fire. Clinicians should use CO2-based fire extinguishers with caution because the fine powder emitted can be challenging to remove from open wounds and can impair staff breathing and visibility.

      ERCI. Surgical Fire Prevention. Emergency Care Research Institute Available at: https://www.ecri.org/solutions/accident-investigation-services/surgical-fire-prevention. Accessed December 5, 2021.

      However, using a CO2-based fire extinguisher to extinguish the flames would have been a top choice for our situation, as it was an active mechanical fire.

      Fire Prevention and Training

      Fire safety is an iterative and continual process, and reducing the risk of surgical fires is the responsibility of the entire surgical team.

      AORN. AORN Fire Safety Tool Kit. Association of periOperative Registered Nurses; 2021. Available at: https://test.aorn.org/guidelines/clinical-resources/tool-kits/fire-safety-tool-kit. Accessed December 5, 2021.

      A coordinated approach is necessary for surgical fire prevention and response.
      • Apfelbaum JL
      • Caplan RA
      • Barker SJ
      • et al.
      Practice advisory for the prevention and management of operating room fires: An updated report by the American Society of Anesthesiologists Task Force on operating room fires.
      We recommend that leaders design fire prevention strategies based on freely available comprehensive toolkits from specialty organizations, including the ERCI,

      ERCI. Surgical Fire Prevention. Emergency Care Research Institute Available at: https://www.ecri.org/solutions/accident-investigation-services/surgical-fire-prevention. Accessed December 5, 2021.

      Anesthesia Patient Safety Foundation,

      The Anesthesia Patient Safety Foundation. Prevention and management of operating room fires video. Available at: https://www.apsf.org/videos/or-fire-safety-video/. Accessed January 30, 2022.

      and the AORN,

      AORN. AORN Fire Safety Tool Kit. Association of periOperative Registered Nurses; 2021. Available at: https://test.aorn.org/guidelines/clinical-resources/tool-kits/fire-safety-tool-kit. Accessed December 5, 2021.

      and combine them with realistic interprofessional high fidelity or virtual reality simulation training.
      • Truong H
      • Qi D
      • Ryason A
      • et al.
      Does your team know how to respond safely to an operating room fire? Outcomes of a virtual reality, AI-enhanced simulation training.
      Involvement of all team members is essential in fire prevention training to help build team cohesion and decrease role ambiguity across professional boundaries.
      • Bruley M
      • Arnold T
      • Finley E
      • Deutsch E
      • Treadwell J.
      Surgical fires: Decreasing incidence relies on continued prevention efforts.
      Additionally, effective surgical team communication
      • Stucky CH
      • De Jong MJ
      • Kabo FW.
      Military surgical team communication: Implications for safety.
      ,
      • Stucky CH
      • De Jong MJ
      • Kabo FW
      • Kasper CE.
      A network analysis of perioperative communication patterns.
      is necessary to identify and eliminate fire hazards and coordinate the fire strategy plan competently.
      • Bruley M
      • Arnold T
      • Finley E
      • Deutsch E
      • Treadwell J.
      Surgical fires: Decreasing incidence relies on continued prevention efforts.
      Completing the training in an interprofessional team setting helps increase surgical team familiarity, improves communication, and aids the development of shared mental models.
      • Stucky CH
      • De Jong MJ.
      Surgical team familiarity: An integrative review.
      Our case study is directly relevant for perioperative and perianesthesia nurses alike, as forced-air warming is often used to maintain patient normothermia across the perioperative continuum of care.

      Conclusion

      To our best knowledge, we are the first to present an orthopedic surgical patient case report concerning an equipment fire originating from a forced-air warming device and the immediate actions the surgical team took to ensure patient and staff safety. Rapid response by the anesthesia professional and the surgical team helped prevent the fire from negatively impacting patient or staff safety. We recommend that surgical teams engage in a coordinated and continual cycle of fire prevention to include enhanced education and interprofessional team training.

      Disclaimer

      The views expressed are solely those of the authors and do not reflect the official policy or position of the US Army, the Department of Defense, or the US Government.

      Acknowledgments

      The authors would like to thank Colonel William J. Brown, PhD, FAANP for his insightful suggestions and professional oversight of the manuscript.

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        • Treadwell J.
        Surgical fires: Decreasing incidence relies on continued prevention efforts.
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      6. ERCI. Surgical Fire Prevention. Emergency Care Research Institute Available at: https://www.ecri.org/solutions/accident-investigation-services/surgical-fire-prevention. Accessed December 5, 2021.

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