‘All of a sud­den, there was fire’

Modern Healthcare - - NEWS - By Joe Carl­son and Sabriya Rice

It was a chaotic scene in the op­er­at­ing room just mo­ments be­fore a crit­i­cally ill pa­tient at FirstHealth Moore Re­gional Hospi­tal burst into flames. There was “lots of con­fu­sion,” a sur­gi­cal tech­ni­cian later told hospi­tal in­spec­tors.

The pa­tient who ar­rived at the emer­gency depart­ment in Pine­hurst, N.C., in June 2013 needed an im­me­di­ate tra­cheostomy. His grossly swollen tongue from an al­ler­gic re­ac­tion was pre­vent­ing him from breath­ing. A sur­geon was sum­moned from an­other op­er­at­ing room.

The sur­geon “was stand­ing there with knife in hand and he says, ‘Some­body prep the pa­tient,’” ac­cord­ing to a CMS re­port on the in­ci­dent. As blood gushed from the neck in­ci­sion, the sur­geon de­ployed an elec­tric cau­ter­iz­ing tool. It ig­nited the al­co­hol-based dis­in­fec­tant used at the in­ci­sion site, leav­ing the pa­tient with sec­ond-de­gree burns on his neck and shoul­ders.

Of­fi­cials at the 379-bed hospi­tal told in­spec­tors that fire-preven­tion poli­cies were in place. Yet that ini­tial scram­ble in the op­er­at­ing room, as de­scribed in the re­port, led to vi­o­la­tions of sev­eral well-es­tab­lished best prac­tices for safe-equip­ment use to pre­vent sur­gi­cal fires. They are in­cluded in the Pre­vent­ing Sur­gi­cal Fires Ini­tia­tive, which has been ag­gres­sively pushed by the Food and Drug Ad­min­is­tra­tion for the past three years.

The hospi­tal has since strength­ened its fire-safety rules, in­clud­ing ban­ning al­co­hol ster­il­iz­ers in most emer­gency pro­ce­dures. The sur­gi­cal team “re­sponded to the in­ci­dent ap­pro­pri­ately” and fin­ished the oper­a­tion af­ter putting out the fire, FirstHealth of the Caroli­nas CEO David Ki­larski said in a state­ment.

De­spite a slew of news ac­counts about pa­tients be­ing set on fire in op­er­at­ing rooms across the coun­try, adop­tion of pre­cau­tion­ary mea­sures has been slow, of­ten im­ple­mented only af­ter a hospi­tal ex­pe­ri­ences an ac­ci­dent. Ad­vo­cates say it’s not clear how many hos­pi­tals have in­sti­tuted the avail­able pro­to­cols, and no na­tional safety author­ity tracks the fre­quency of sur­gi­cal fires, which are thought to in­jure pa­tients in one of ev­ery three in­ci­dents. About 240 sur­gi­cal fires oc­cur ev­ery year, ac­cord­ing to rough es­ti­mates by the ECRI In­sti­tute, a not­for-profit or­ga­ni­za­tion that con­ducts re­search on pa­tient-safety is­sues. But fires may be un­der­re­ported be­cause of fear of lit­i­ga­tion or bad pub­lic­ity.

“Vir­tu­ally all sur­gi­cal fires are pre­ventable,” said Mark Bru­ley, vice pres­i­dent of ac­ci­dent and foren­sic in­ves­ti­ga­tion for ECRI, which has been track­ing op­er­at­ing-room fires for 30 years. He blames the per­sis­tence of the prob­lem on the slow mi­gra­tion of best prac­tices across the hospi­tal in­dus­try.

Five months af­ter the FirstHealth fire, dis­in­fec­tant man­u­fac­turer CareFu­sion warned doc­tors and hos­pi­tals to stop us­ing elec­tro­sur­gi­cal tools near some of its al­co­hol-based cleansers. Ex­perts warned that these tools should not be used around pu­ri­fied oxy­gen, which ig­nites quickly in con­cen­tra­tions above 35%. Sur­gi­cal teams should also drape ex­tra tow­els to pre­vent pool­ing of the flammable ma­te­ri­als, and fol­low FirstHealth’s own pol­icy to have sa­line wa­ter avail­able dur­ing pro­ce­dures with high fire risk.

Sev­eral of these pro­to­cols were vi­o­lated at FirstHealth, ac­cord­ing to in­spec­tion re­ports. A nurse not only ad­min­is­tered an al­co­hol-based skin cleanser, but the per­son ad­min­is­ter­ing the anes­the­sia be­gan the pa­tient with 100% oxy­gen. The elec­tro­cautery tool was used with­out wait­ing the rec­om­mended three min­utes for the al­co­hol to dry, state in­ves­ti­ga­tors were told.

“All of a sud­den, there was fire,” the anes­thetist told hospi­tal in­spec­tors who in­ves­ti­gated the fire. “Fire was go­ing up my arm, and I be­gan pat­ting out the fire on my­self.” Mean­while, the sur­geon pat­ted out the flames cov­er­ing the pa­tient’s neck and shoul­ders.

The steady in­ci­dence of sur­gi­cal­room fires alarms safety ex­perts and ad­vo­cates. “They should never hap­pen,” said Lisa McGif­fert, di­rec­tor of the Safe Pa­tient Project at the Con­sumers Union. The group sup­ports manda­tory reporting of se­vere pa­tient safety events.

In ad­di­tion to the FDA ini­tia­tive, sim­i­lar pub­lic-aware­ness cam­paigns have been launched by the Na­tional Qual­ity Fo­rum, the Joint Com­mis­sion, the Anes­the­sia Pa­tient Safety Foun­da­tion and by pa­tient ad­vo­cate Cather­ine Reuter, founder of sur­gi­cal­fire.org. While anec­do­tal ev­i­dence sug­gests the num­ber of sur­gi­cal fires has de­clined in re­cent years, it hasn’t stilled calls to ac­tion.

“The FDA has been com­mit­ted since

2010 to work­ing in col­lab­o­ra­tion with pub­lic and pri­vate or­ga­ni­za­tions to re­duce the oc­cur­rence of sur­gi­cal fires, pre­ventable events that can be dis­fig­ur­ing and even fa­tal for the pa­tients in­volved,” an FDA spokes­woman said. The agency is work­ing with a coali­tion of 28 groups to raise aware­ness.

Most sur­gi­cal fires in­volve the ig­ni­tion of con­cen­trated oxy­gen by elec­tro­sur­gi­cal tools used in up­per-body pro­ce­dures, where pa­tients re­ceive the highly flammable gas through face masks and nasal de­vices. But a grow­ing num­ber are linked to the ig­ni­tion of al­co­hol-based an­ti­sep­tics.

Last Novem­ber, the FDA al­lowed CareFu­sion, the maker of pop­u­lar al­co­hol-based an­ti­sep­tic Chlo­raPrep, to change the an­ti­sep­tic’s la­bel to warn that some ver­sions of the cleanser should not be used near elec­tro­surgery tools. The la­bels on other for­mu­la­tions now call for al­low­ing longer dry­ing times be­fore us­ing elec­tro­surgery tools.

Solid num­bers on the in­ci­dence of op­er­at­ing-room fires do not ex­ist. ECRI’s lat­est es­ti­mate of 240 op­er­at­ing-room fires each year be­tween 2004 to 2011 was re­vised down from ear­lier es­ti­mates of 650 fires a year be­tween 2004 to 2007.

While that sug­gests there has been im­prove­ment, stud­ies of anes­the­sia mal­prac­tice claims sug­gest there’s been a rise in in­ci­dents. “There is an in­her­ent prob­lem in pre­vent­ing rel­a­tively rare events,” said Dr. John Clarke, clin­i­cal di­rec­tor of the Penn­syl­va­nia Pa­tient Safety Author­ity. People think “it is not likely to hap­pen to you in par­tic­u­lar,” he said.

As one of the few states to ag­gres­sively push hos­pi­tals to adopt best safety prac­tices, Penn­syl­va­nia of­fi­cials say their pub­lic-aware­ness cam­paign is get­ting re­sults. “As these things be­come more known, people can ap­pre­ci­ate that this is an ideal op­por­tu­nity to learn from some­one else’s mis­take,” Clarke said.

The FDA and the Joint Com­mis­sion main­tain pub­lic re­ports of sur­gi­cal fires, but they are based on vol­un­tary pa­tient com­plaints that are not rep­re­sen­ta­tive of epi­demi­o­log­i­cal trends. Mod­ern Health­care iden­ti­fied a dozen such in­ci­dents in pub­lic hospi­tal-in­spec­tion re­ports.

In July 2012, for ex­am­ple, a sur­gi­cal team at 325-bed River­side Med­i­cal Cen­ter in Kanka­kee, Ill., burned a sur­gi­cal out­pa­tient’s face, hand and shoul­ders dur­ing a surgery to re­move a fore­head le­sion. In Fe­bru­ary 2012, a pa­tient at the 47-bed Fairview Lakes Med­i­cal Cen­ter in Wy­oming, Minn., who was re­ceiv­ing a pace­maker, was burned on the head, neck and hand af­ter an elec­tro­sur­gi­cal tool ig­nited oxy­gen in a tube, al­low­ing the fire to spread to the sur­gi­cal mask.

In 2009 and 2010, the 1,268bed Cleve­land Clinic had a se­ries of op­er­at­ing-room fires that left three pa­tients with burns that hospi­tal in­spec­tors said were caused by set­ting al­co­hol-based an­ti­sep­tics on fire. Each sit­u­a­tion trig­gered a se­vere “im­me­di­ate jeop­ardy” warn­ing that led to ex­ten­sive staff train­ing on fire preven- tion. Of­fi­cials with each hospi­tal de­clined to com­ment on the fires.

Ex­perts say the most com­mon ig­ni­tion source is a class of elec­tro­sur­gi­cal tools com­monly called “bovie” pens, named for their in­ven­tor Wil­liam T. Bovie. The elec­tric tools are used in place of tra­di­tional metal scalpels in more than 80% of all surg­eries be­cause they are more con­ve­nient, and can be used to cauterize wounds dur­ing surgery. The Bovie Sur­gi­cal Corp., which man­u­fac­tures a line of bovie pens, warns its prod­ucts pose a fire or ex­plo­sion haz­ard if used in the pres­ence of flammable ma­te­ri­als.

Many of the best fire-safety prac­tices de­vel­oped in re­cent years stem from the work at Chris­tiana Care Health Sys­tem, Ne­wark, Del., af­ter two pa­tients caught fire in op­er­at­ing rooms within eight months in 2003.

They pi­o­neered their own process, which in­volves dis­cussing the risk of fire dur­ing the sched­uled time-out be­fore surgery. The hospi­tal hasn’t burned a pa­tient since.

Pro­to­cols like Chris­tiana’s have been widely dis­sem­i­nated. Yet, Chris­tiana says it still get calls sev­eral times a month from hos­pi­tals that are just start­ing to im­ple­ment a sys­tem. “It’s a bit of an up­hill slog,” said Dr. Kenneth Sil­ver­stein, chair­man of Chris­tiana’s depart­ment of anes­the­si­ol­ogy. “The bot­tom line is, in or­der to have a cul­ture of safety in your in­sti­tu­tion, you have to get people be­hind it.”

ECRI In­sti­tute con­ducted lab­o­ra­tory tests to ex­plore the risk of fire in oxy­ge­nen­riched en­vi­ron­ments. As oxy­gen con­cen­tra­tions in­crease, so does fire risk. This im­age, taken dur­ing an ex­per­i­ment, does not de­pict an ac­tual pa­tient.

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