- Email: [email protected]
Code Red in the OR—Implementing an OR Fire Drill
APRIL 2004, VOL 79, NO 4
Flowers
Code Red in the ORImplementing an I
OR Fire Drill
Jane Flowers, RN
aim the nozzle, squeeze the handle, and 0 sweep at the base of the fire. No fire drill, however, had ever been held in the OR. The time had come to determine OR staff members’ strengths and weaknesses during a fire drill. 0
0
A
fire in the OR is one of the most frightening events that a surgical team can experience. Team members have to be acutely aware of the types of fires that can erupt, procedures for handling each type of fire, processes for informing others without creating a panic, the location of fire fighting equipment and how to operate the equipment effectively, and, most importantly, how to prevent fires from erupting in the first place. For a surgical team the first question may be ”what is burning-the inside of the patient or the outside?”’ With this question in mind, fire safety takes on new meaning. O n June 24,2003, the Joint Commission on Accreditation of Healthcare Organizations published a Sentinel Event Alert regarding fires in the OR. This document references the ECFU recommendation that training on the use Offire-fighting equipment; proper methods for rescue and escape; the ident@mtionand location of medical gas, ventilation, and electrical systems and controls,as well as when, where, and how to shut of these systems; and the use of the hospital’s alarm systems and system for contacting the localfire department2 should be conducted in the OR. Managers are responsible for keeping staff members up-to-date on the various aspects of fire safety. Peninsula Regional Medical Center, Salisbury, Md, holds yearly instruction on fire safety. Staff members have been taught how to use fire extingushers using the PASS method: 0 pullthepin,
POLICYRMEW A fire safety committee, led by the manager for perioperative education and consisting of OR education coordinators, the OR clinical manager, and the director of surgical services, formed to update the OR fire safety plan. The committee members’ first major activity was to search the Internet for the latest information on handling fires in the OR. Next, they conducted a complete review of facility-wide and OR fire safety plans. The OR fire safety plan was revised and expanded to adhere to the facility-wide
ABSTRACT 0 KNOWLEDGE OF FIRE PREVENTION and fire safety is essential for every OR staff member. In the event of a surgical fire, the quick and knowledgeable response of surgical team members will affect their own safety and that of their patients. 0 A NEW FIRE SAFETY PLAN was developed at Peninsula Regional Medical Center, Salisbury, Md. To update staff members’ knowledge of the facility’s fire plan and special instructions for the OR, a comprehensive educational program on fire safety was presented, and an OR fire drill was conducted. 0 THIS ARTICLE describes the facility’s quest to improve knowledge of fire safety by providing multiple educational opportunities. AORN J 79 (April 2004) 797-805.
AORN JOURNAL
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APRIL 2004, VOL 79, NO 4
guidelines and to incorporate information from other sources, such as ECRI, to establish a complete and comprehensive plan of action. The original fire plan was short and lacked specific information. It stated that patients would be transferred laterally and that one of the prime functions of the charge nurse was to designate someone to answer the telephones. The revised OR fire safety plan is specific regarding the roles and responsibilities of all members of the surgical team. The plan lists many of the activities to be performed by managers and the A fire safety charge nurse, as well as the duties of staff memplan should bers caring for patients. The planValso Lstructs specify what staff members who are not directly caring for every team patients at the time of a fire where to wait for members' job instructions. It is imDortant that every Cam would b in the member knows what his or her job would be in the EVENT OF A FIRE. event of a fire. The plan divides fire control into two categories involving patiensmall fire that can be extinguished easily and a larger, more involved fire. The plan also details equipment, supplies, and supply packaging material that must be isolated and saved for use in the fire investigation that will ensue. The plan stresses continued care and management of patients during the fire. The fire plan includes evacuation steps and designates the facility personnel who will authorize evacuation and the evacuation routes. In the event of a single room evacuation, the location of choice may be as close as the nearest safe room or the next available operating suite. Evacuation occurs first in a lateral movement and can extend to
798
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areas outside of the surgical services department. After the OR fire plan was revised and approved by the hospital-wide facilitiesmanagement fire team, the first OR fire drill was planned. Planning for the drill required coordination among many individuals. The committee met with the facilities management team and set a date in October to conduct the fire drill.The fire department was contacted in advance to prevent them from responding to the drill. The facilities management safety officer gave the fire safety committee permission to call a code red in the OR at this time. The protective services department and the telephone switchboard operators also were notified. The date selected allowed the perioperative educators time to educate staff members about the updated fire policy.
PROGRAM ROLLOUT An hour-long educational program was presented at a staff meeting in early August. The manager for perioperative education began the program by discussing ways that perioperative nurses can prevent OR fires and reviewing the components of the fire triangle-heat, fuel, and oxygen. The OR environment is rich in all of these elements. According to ECRI, electrosurgical units (ESUs) and lasers are among the most common ignition sources for fires? Both require a heat exchange to produce desired results. Use of ESU holsters to prevent accidental discharge of electrical energy was discussed, as was the importance of ensuring that the laser is placed in stand-by mode. Another source of fires in the OR are fiber-optic headlights and endoscopes that commonly are used for many different procedures. It is important never to leave a lighted endoscope or light source lying on surgical drapes. This is
APRIL 2004, VOL 79,
Flowers
a fire waiting to happen. Commonkel sd&ces include the patient (eg, hair, gastrointestinal gases, such as methane); prepping solutions (ie, degreasers, alcohol-based prepping agents); dressings (ie, gauze, sponges, collodion); ointments (ie, petroleum jelly, benzoin, aerosols); and equipment (eg, ESUs, lasers, fiberoptic endoscopes and light sources, electrocardiogram leads, anything with a plug)? The discussic% highlighted safety features to use when working with these agents or pieces of equipment.Staff members participated in the discussion, asking many excellent questions and relating some of their personal experiences. The third component of the fire triangle, oxygen, is in plentiful supply in the OR. A discussion about oxygen use occurred, including the need to adequately vent under the drapes of patients having face or neck surgery to prevent highly concentrated oxygen pockets from developing. This provided an excellent opportunity to discuss where the oxygen shut-off valves are located for each of the rooms and how to turn off the valves. The educators completed the program by introducing the newly revised fire safety plan. Throughout the program, they stressed the importance of fire prevention. The facility is staffed 24 hours a day, seven days a week, so there is never a time when all staff members are present. To provide fire safety information to the entire OR staff, including RNs, licensed practical nurses, surgical technologists, and nursing assistants, all staff members were given a copy of the plan and a 20-question competency to be returned two weeks before the fire drill date. The plan builds on the hospital-wide fire plan and the annual updates but specifically targets the OR.
PLANNING THE
NO 4
FIRE DRILL
The drill was designed to involve as many staff members as possible using hands-on role play in different situations involving simulated fires. The facility routinely operates 12 O h . The plan involved staging six fire scenarios in the odd numbered rooms. In addition to herself, the manager for perioperative education selected seven staff members-an RN manager, two DerioDerative educaYou are tion coordinators, three Working with an perioperative resource nurses, and an administrative secretary-to act arthroscope. One as facilitators dking the the scrubbed fire drill. Six of these staff members would faciliteam members tate the fire scenarios, one would monitor the charge desk, and one puts the lighted would monitor staff arthroscope on lounge activity during the drill, for a total of the sterile eight observation points. Six fire drill scenarios drapes, ignitfng were develoDed. I 1. You are closing the the drape abdomen of a trauma patient when YOU hear matedale What a snap, crackle, and POP, *and the x-ray would you do? view box ignites. What would yocdo? 2. You are preparing to do a laparoscopic cholecystectomy. You have prepped the patient with an alcohol-based prepping solution, and the solution has pooled in the umbilical area. The surgeon begins the procedure, immediately asking for the electrosurgery pencil. What would you do? 3. You m working with an arthroscope. One of the scrubbed team members puts the lighted arthroscope on the sterile drapes, igniting the drape A
of
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material. What would you do? 4. You notice that one of the electrical cords in the room is frayed, but you decided to use it anyway.As the procedure progressesr you notice smoke coming from the electrical equipment. What would you do? 5. You are walking a healthy young patient to the OR for a breast bioDsv. AS you enter the A&, you notice that thick black smoke is coming Facilitators were though the ventilation system. The m b pergiven discussion son is overcome by the smoke. What would questions you do? 6. You are doing a transdesigned to myocardial revascularization procedure reinforce the fire using a laser. The laser operator forgets to put protection plan the equipment in standby mode. The and ensure that laser is fired, igniting a laparotomy sponge. each team What would you do? At a meeting of the received the same facilitators,each was given his or her own scenario, in information addition to copies of all the during the drill. other scenariosand the fire protection plan. The facilitators were instructed to assign employees on their teams to various O R rdes-(ie, circulating nurse, scrub person, patient, anesthesia care provider, surgeon) and to use discussions and role play. The facilitator was to read the scenario and have the team members demonstrate or discuss fully what they would be responsible for doing. Facilitators also were given discussion questions designed to reinforce the fire protection plan and ensure that everyone received the same information. The following discussion questions were used. With what would you extingush the
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fire? What type of fire extinguisher would be used, and where is the nearest fire extinguisher located? 0 Do you need to sound the fire alarms? If yes, how would you sound the alarms? Where are the fire alarm pull stations? 0 What would you do to continue caring for the patient? 0 Communication is essential. With whom would you communicate? 0 Where are the oxygen shut-off valves located for each OR and how do you shut off the oxygen? 0 What equipment would you collect if you needed to evacuate the patient? 0 What route would you use for evacuation? Where is the next available safe room? 0 Do you need to isolate any equipment or products? What and why? (Answer: The rationale for isolation of equipment is in the hospital's safe medical device policy.) 0 What departments outside of the OR would be involved? 0 How would you document this event? (Answer: An incident report should be completed after the event.) 0 If the f k became a large fire, what additional steps would you take? 0 In the event of smoke, what evacuation precautions would you take? 0 What other fire safety factors should you consider?(Answer:Other factors to consider include unplugging equipmentr shutting doors, placing a wet towel at the base of the doors). It was suggested that if a facilitator's group could quickly identlfy everyhng that should be done in the event of a fire, the facilitator should expand the scenario from a small fire to a large fire and practice evacuationtechniques. If a team completed its scenario successfully the facilitator was instructed to present another scenario. Only the team in room one was instructed to call the charge desk. The
APRIL 2004, VOL 79, NO 4
Flowers
The charge nurse gathered essential information for evacuation and directed available staff members to help with the evacuation of the patient in OR one. rationale for this was that it is unlikely that six separate OR fires would occur at one time. The perioperative educators also wanted to evaluate the howledge of the charge nurses, and it was more realistic to have the charge nurse handle only one fire at a time. The charge nurse is vital to the smooth flow of cases through the department. This nurse facilitates implementation of the fire plan. One of the goals was to monitor her activities and knowledge of the plan during the drill.The followingquestionsrelating to the charge nurse’s role were considered. 0 Did the charge nurse assign someone to receive emergency calls? 0 Did the charge nurse assign someone to the front entrance of the OR to direct the firebrigade to the fire location? 0 Did the charge nurse gather information about who m t l y was in the OR (eg, patients, staff members, students, visitors, x-ray technicians, surgeons, surgical assistants) in case of evacuation? 0 Did the charge nurse gather staff members’ home telephone numbers in case of evacuation and the need to call in additional help? 0 Did the charge nurse notify managers about the fire? In addition, the following four questions were considered to refine the plan and to better educate the charge nurses about their role and responsibilities. 0 With what other personnel would the charge nurse be in communication? 0 Who would coordinate the decisionmaking hospital-wide for evacuation (eg, the fire chief, chief executive officer or designee, anesthesia care provider, surgeon)? 0 What would the charge nurse do to direct staff member activities (eg, coordinate evacuation; assign someone to get transport supplies, oxygen tanks, and monitors; turn off the oxygen lines)?
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What other tasks (eg, closing doors, unplugging equipment) might the charge nurse delegate? Before the OR staff meeting, patients and their family members awaiting surgery in the same day surgery area were alerted that the OR staff members would be involved in an educational activity on fire safety and that the fire alarms in the OR would sound.It was important to conduct the drill without disrupting the flow of surgery or causing anxiety to patients and their family members. 0
THEDRILL During a 7 AM staff meeting in October, staff members were told that they would be participating in a handson, role-playing activity. They were divided into eight groups led by eight facilitators. The staff members were asked to go immediately to their assigned rooms after the assignments had been read. The scenario was revealed by their facilitator when they arrived in their rooms. No supplies were to be opened, and all supplies on the OR bed were to be set aside during the exercise. Three nurses who work 12-hour day shifts cover the charge desk. On the day of the drill, two of the charge nurses were working. For the purpose of the drill, both the charge nurse and backup charge nurse were placed at the desk. They were not told what was going on until they heard the fire bells sounding. Several staff members were assigned to the staff lounge to await instructions. The team members in room one were told that they were completing a procedure when the x-ray box burst into flames, and they had to decide what to do. The circulating nurse was asked to sound the hospital-wide fire alarms. When “code red, OR one” sounded overhead, the charge nurse went into
Flowers
action. She was given a list of where all the employees were stationed, and she quickly assigned someone to go outside the department to alert the hospitalwide fire brigade where the fire was located. The charge nurse then gathered essential information for potential evacuation and directed available staff members to help with the evacuation of the patient in room one. Team members in room one quickly assessed their needs and planned for an evacuation to the postanesthesia care unit (PACU).It took them approximately seven minutes to gather transfer equipment and evacuate the room. Seven minutes is a long time, but the perioperative educators believe that if this scenario actually were to occur, staff members would react more quickly, instead of in a slower, roleplaying mode. At one point, it looked as though a team of race car drivers was exiting the room. They came through the door of the OR with a staff member acting as a patient, an ambu bag, and three members of the surgical team on each side of the OR bed (Figure 1). The charge nurse directed the transfer to the PACU. It was very impressive to have the hospital-wide fire brigade arrive in the OR. The charge nurse directed them to the fire in room one. The hospital-wide nursing supervisor who had responded to the "code red, OR" told the switchboard operator to make the announcement "code red, OR secured." When code red is sounded for any location in the facility, OR staff members are instructed not to begin any further elective surgicalprocedures. This announcement alerted them that the fire was contained and they now could begin elective procedures. The arthroscope, laser, and ESU fire scenarios were discussed in other rooms. Everyone was asked how to sound the alarm using various tech-
APRIL 2004, VOL 79,
NO 4
niques (eg, calling appropriate telephone numbers, activating fire pull stations, verbally calling for help). Staff members went into the hallways to idenbfy the location of fire extinguishers, fire pull stations, and oxygen valves. Discussions were held concerning proc e d m for putting out fires,as well as what staff members should save in accordance with the hospital's safe medical device policy Reviews of incident reporting also occurred. To create realism in her scenario, one of the facilitators made crepe paper The flames to show the origin t of the fire (Figure 2). Her ANNOUNCEMENT team discussed diffemt types of potential fires "'code red, OR and how they would handle them. They learned secureflalerted more about fires because they considered scenarios staff members of interest to them. In OR h e , a smoke that the fire was scenario was established. team evacuated by contained and forming a human chain and crawling out of the they now could room to get below the level of the smoke (Figure begin elective 3). Staff members using this scenario found that procedures. they were not sure how to manually override the locks on the electric OR bed. They inspected the bed until they were able to unlock it manually and evacuate it. During the followingweek, a number of managers outside the OR mentioned hearing "code red, OR," and many stated that it was the first time that they heard a "code red, OR" paged. The head of the radiology department was very interested in the drill and said that the radiology department might conduct its own fire drill using the guidelines employed in the OR drill. AORN JOURNAL
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Flowers
Figures 1 to 3 Perioperative staff members evacuate a mom with a patient (top), extinguish a fire caused by a light source (center), and form a human chain and crawl out of a mom to avoid smoke inhalation (bottom) during an OR fin drill.
CRITIQUE At a staff meeting the next week, time was devoted to critiquing the fire drill. The perioperative educators began by thanking all the staff members who participated in the drill and briefly describing the previous week’s fire drill for those who had not been in attendance. Many staff members said they learned a great deal from the drill and thought it should be repeated. Overall, the drill was a success. 0 Staff members said that participating in the educational roll out helped them feel more competent to handle OR fires, and they had learned from the scenarios presented during the fire drill. 0 Staff members identified the locations of all the oxygen shut-off valves, fire extinguishers, and fire pulls and how to use these pieces of equipment. 0 Evacuation of patients and staff members was reviewed. 0 The charge nurses’ performances were outstanding, and they demonstrated that they knew what to do in the event of a fire. 0 The need to communicate the safety of the patient and surgical team to the charge nurse was reinforced. Staff members also pinpointed areas that they thought needed improvement. 0 More oxygen tanks and regulators would be needed in the event of a total evacuation of the department. 0 Splash basins must be filled with water for every procedure, for fire safety as well as clean up. 0 It is important to be able to idenbfy everyone who is in the department at the time of a fire.This includes but is not limited to all of the patients, staff members, physicians and their assistants, anesthesia care providers and anesthesia support providers, core technicians, x-ray technicians, students, visitors, contracted employees,
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Flowers
and sales representatives. Several fire extinguishers are available throughout the department, but it might be necessary to equip each room with a fire extinguisher. There were a few negative aspects of the drill as well. Several communication difficulties arose. For example, the nurse who was requested to contact the switchboard about the fire was hesitant because she did not want to sound a false alarm. Communication problems such as this likely resulted because staff members were role-playing and were not completely aware of the importance of communicating during a drill. Initially, staff members thought the facilitatorswere there to judge them. It took time for the staff members to realize that the drill was an educational tool to improve the department's knowledge of fire safety. In general, everyone was pleased with the results of the first ORIspeclfic fire drill, and plans already are underway for a second drill. During the next drill, the perioperative educators hope some of the anesthesia care providers and surgeons will participate. Operating room fire safety is the responsibility of every member of the surgical team. 0
cational techniques. The challenge was to inform and review fire safety, incorporating information on types of surgical fires, location and use of fire fighting equipment, rescue and evacuation routes, medical gases, use and shut-off of valves, and procedures for sounding fire alarms. Having an OR fire drill was an effective way to put together all of the pieces of fire safety. Staff members benefited from thisreview and drill and reinforced the facility's commitment to safety first. 0
Jane Flowers, RN, MSN, CNOR, is the manager for perioperative education, Peninsula Regional Medical Center, Salisbury, Md. NOTES 1. AORN, Fire Safety in the Puiqerative Setting (Woodbury, COM:CinkMed, 1999) Videotape. 2. "Preventing surgical fires,'' Sentinel Event Alert 29 (June 24,2003), http://www .jcaho.or /abou t+us/news+letters/sentinel+eve nt+alert$ea-29.htm (accessed 11Feb 2004). 3. "The patient is on fire! A surgical fires rimer,' ECRI, http:/lwww.mdsr.em'.org accessed 12 Feb 2004).
4
RESOURCES
Ball,K A. "Sur 'cal modalities," in Alexander's Care ofihe Patient in Sur ey, 12th ed (St Louis: Mosby, 2003) 80-& Ekyea, S C. "Preventin fires in the OR,"
r
(Patient Safe First) AO& Journal 78 (October 200 ) 664-666. SUMMARY Phillips, N F. Berry 6 Kohn's Operating Surgical fires can be a devastating Room Technique,10th ed (St Louis:Mosby, experience. The best way to combat sur- 2004) 220-222,354-355. gical fires is prevention. Understanding "Recommended ractices for electrothe principles of fire safety and know- surgery," in Standar s, Recommended and Guidelines (Denver:AORN, ing the elements of the fire triangle are Practices, Inc, 2004) 245-259. critical for fire prevention. By educating "Recommended practices for skin staff members about the OR fire safety reparation of patients," in Standards, plan and conducting a fire drill, the Lcommended Practices, and Guidelines facility will be better able to prevent or (Denver: AORN, Inc, 2004) 357-360. Rothrock, J C; Smith,D A. "Patient and handle OR fires. environmental safety," in Alexander's Care of The OR fire plan was presented to the Patient in surgery, 12th ed (St Louis: staff members through a variety of edu- MOSby, 2003) 19-20.
B
AORN JOURNAL
805
Flowers
Code Red in the ORImplementing an I
OR Fire Drill
Jane Flowers, RN
aim the nozzle, squeeze the handle, and 0 sweep at the base of the fire. No fire drill, however, had ever been held in the OR. The time had come to determine OR staff members’ strengths and weaknesses during a fire drill. 0
0
A
fire in the OR is one of the most frightening events that a surgical team can experience. Team members have to be acutely aware of the types of fires that can erupt, procedures for handling each type of fire, processes for informing others without creating a panic, the location of fire fighting equipment and how to operate the equipment effectively, and, most importantly, how to prevent fires from erupting in the first place. For a surgical team the first question may be ”what is burning-the inside of the patient or the outside?”’ With this question in mind, fire safety takes on new meaning. O n June 24,2003, the Joint Commission on Accreditation of Healthcare Organizations published a Sentinel Event Alert regarding fires in the OR. This document references the ECFU recommendation that training on the use Offire-fighting equipment; proper methods for rescue and escape; the ident@mtionand location of medical gas, ventilation, and electrical systems and controls,as well as when, where, and how to shut of these systems; and the use of the hospital’s alarm systems and system for contacting the localfire department2 should be conducted in the OR. Managers are responsible for keeping staff members up-to-date on the various aspects of fire safety. Peninsula Regional Medical Center, Salisbury, Md, holds yearly instruction on fire safety. Staff members have been taught how to use fire extingushers using the PASS method: 0 pullthepin,
POLICYRMEW A fire safety committee, led by the manager for perioperative education and consisting of OR education coordinators, the OR clinical manager, and the director of surgical services, formed to update the OR fire safety plan. The committee members’ first major activity was to search the Internet for the latest information on handling fires in the OR. Next, they conducted a complete review of facility-wide and OR fire safety plans. The OR fire safety plan was revised and expanded to adhere to the facility-wide
ABSTRACT 0 KNOWLEDGE OF FIRE PREVENTION and fire safety is essential for every OR staff member. In the event of a surgical fire, the quick and knowledgeable response of surgical team members will affect their own safety and that of their patients. 0 A NEW FIRE SAFETY PLAN was developed at Peninsula Regional Medical Center, Salisbury, Md. To update staff members’ knowledge of the facility’s fire plan and special instructions for the OR, a comprehensive educational program on fire safety was presented, and an OR fire drill was conducted. 0 THIS ARTICLE describes the facility’s quest to improve knowledge of fire safety by providing multiple educational opportunities. AORN J 79 (April 2004) 797-805.
AORN JOURNAL
79 7
APRIL 2004, VOL 79, NO 4
guidelines and to incorporate information from other sources, such as ECRI, to establish a complete and comprehensive plan of action. The original fire plan was short and lacked specific information. It stated that patients would be transferred laterally and that one of the prime functions of the charge nurse was to designate someone to answer the telephones. The revised OR fire safety plan is specific regarding the roles and responsibilities of all members of the surgical team. The plan lists many of the activities to be performed by managers and the A fire safety charge nurse, as well as the duties of staff memplan should bers caring for patients. The planValso Lstructs specify what staff members who are not directly caring for every team patients at the time of a fire where to wait for members' job instructions. It is imDortant that every Cam would b in the member knows what his or her job would be in the EVENT OF A FIRE. event of a fire. The plan divides fire control into two categories involving patiensmall fire that can be extinguished easily and a larger, more involved fire. The plan also details equipment, supplies, and supply packaging material that must be isolated and saved for use in the fire investigation that will ensue. The plan stresses continued care and management of patients during the fire. The fire plan includes evacuation steps and designates the facility personnel who will authorize evacuation and the evacuation routes. In the event of a single room evacuation, the location of choice may be as close as the nearest safe room or the next available operating suite. Evacuation occurs first in a lateral movement and can extend to
798
AORN JOURNAL
Flowers
areas outside of the surgical services department. After the OR fire plan was revised and approved by the hospital-wide facilitiesmanagement fire team, the first OR fire drill was planned. Planning for the drill required coordination among many individuals. The committee met with the facilities management team and set a date in October to conduct the fire drill.The fire department was contacted in advance to prevent them from responding to the drill. The facilities management safety officer gave the fire safety committee permission to call a code red in the OR at this time. The protective services department and the telephone switchboard operators also were notified. The date selected allowed the perioperative educators time to educate staff members about the updated fire policy.
PROGRAM ROLLOUT An hour-long educational program was presented at a staff meeting in early August. The manager for perioperative education began the program by discussing ways that perioperative nurses can prevent OR fires and reviewing the components of the fire triangle-heat, fuel, and oxygen. The OR environment is rich in all of these elements. According to ECRI, electrosurgical units (ESUs) and lasers are among the most common ignition sources for fires? Both require a heat exchange to produce desired results. Use of ESU holsters to prevent accidental discharge of electrical energy was discussed, as was the importance of ensuring that the laser is placed in stand-by mode. Another source of fires in the OR are fiber-optic headlights and endoscopes that commonly are used for many different procedures. It is important never to leave a lighted endoscope or light source lying on surgical drapes. This is
APRIL 2004, VOL 79,
Flowers
a fire waiting to happen. Commonkel sd&ces include the patient (eg, hair, gastrointestinal gases, such as methane); prepping solutions (ie, degreasers, alcohol-based prepping agents); dressings (ie, gauze, sponges, collodion); ointments (ie, petroleum jelly, benzoin, aerosols); and equipment (eg, ESUs, lasers, fiberoptic endoscopes and light sources, electrocardiogram leads, anything with a plug)? The discussic% highlighted safety features to use when working with these agents or pieces of equipment.Staff members participated in the discussion, asking many excellent questions and relating some of their personal experiences. The third component of the fire triangle, oxygen, is in plentiful supply in the OR. A discussion about oxygen use occurred, including the need to adequately vent under the drapes of patients having face or neck surgery to prevent highly concentrated oxygen pockets from developing. This provided an excellent opportunity to discuss where the oxygen shut-off valves are located for each of the rooms and how to turn off the valves. The educators completed the program by introducing the newly revised fire safety plan. Throughout the program, they stressed the importance of fire prevention. The facility is staffed 24 hours a day, seven days a week, so there is never a time when all staff members are present. To provide fire safety information to the entire OR staff, including RNs, licensed practical nurses, surgical technologists, and nursing assistants, all staff members were given a copy of the plan and a 20-question competency to be returned two weeks before the fire drill date. The plan builds on the hospital-wide fire plan and the annual updates but specifically targets the OR.
PLANNING THE
NO 4
FIRE DRILL
The drill was designed to involve as many staff members as possible using hands-on role play in different situations involving simulated fires. The facility routinely operates 12 O h . The plan involved staging six fire scenarios in the odd numbered rooms. In addition to herself, the manager for perioperative education selected seven staff members-an RN manager, two DerioDerative educaYou are tion coordinators, three Working with an perioperative resource nurses, and an administrative secretary-to act arthroscope. One as facilitators dking the the scrubbed fire drill. Six of these staff members would faciliteam members tate the fire scenarios, one would monitor the charge desk, and one puts the lighted would monitor staff arthroscope on lounge activity during the drill, for a total of the sterile eight observation points. Six fire drill scenarios drapes, ignitfng were develoDed. I 1. You are closing the the drape abdomen of a trauma patient when YOU hear matedale What a snap, crackle, and POP, *and the x-ray would you do? view box ignites. What would yocdo? 2. You are preparing to do a laparoscopic cholecystectomy. You have prepped the patient with an alcohol-based prepping solution, and the solution has pooled in the umbilical area. The surgeon begins the procedure, immediately asking for the electrosurgery pencil. What would you do? 3. You m working with an arthroscope. One of the scrubbed team members puts the lighted arthroscope on the sterile drapes, igniting the drape A
of
AORN JOURNAL
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APRIL 2004, VOL 79, NO 4
material. What would you do? 4. You notice that one of the electrical cords in the room is frayed, but you decided to use it anyway.As the procedure progressesr you notice smoke coming from the electrical equipment. What would you do? 5. You are walking a healthy young patient to the OR for a breast bioDsv. AS you enter the A&, you notice that thick black smoke is coming Facilitators were though the ventilation system. The m b pergiven discussion son is overcome by the smoke. What would questions you do? 6. You are doing a transdesigned to myocardial revascularization procedure reinforce the fire using a laser. The laser operator forgets to put protection plan the equipment in standby mode. The and ensure that laser is fired, igniting a laparotomy sponge. each team What would you do? At a meeting of the received the same facilitators,each was given his or her own scenario, in information addition to copies of all the during the drill. other scenariosand the fire protection plan. The facilitators were instructed to assign employees on their teams to various O R rdes-(ie, circulating nurse, scrub person, patient, anesthesia care provider, surgeon) and to use discussions and role play. The facilitator was to read the scenario and have the team members demonstrate or discuss fully what they would be responsible for doing. Facilitators also were given discussion questions designed to reinforce the fire protection plan and ensure that everyone received the same information. The following discussion questions were used. With what would you extingush the
800
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fire? What type of fire extinguisher would be used, and where is the nearest fire extinguisher located? 0 Do you need to sound the fire alarms? If yes, how would you sound the alarms? Where are the fire alarm pull stations? 0 What would you do to continue caring for the patient? 0 Communication is essential. With whom would you communicate? 0 Where are the oxygen shut-off valves located for each OR and how do you shut off the oxygen? 0 What equipment would you collect if you needed to evacuate the patient? 0 What route would you use for evacuation? Where is the next available safe room? 0 Do you need to isolate any equipment or products? What and why? (Answer: The rationale for isolation of equipment is in the hospital's safe medical device policy.) 0 What departments outside of the OR would be involved? 0 How would you document this event? (Answer: An incident report should be completed after the event.) 0 If the f k became a large fire, what additional steps would you take? 0 In the event of smoke, what evacuation precautions would you take? 0 What other fire safety factors should you consider?(Answer:Other factors to consider include unplugging equipmentr shutting doors, placing a wet towel at the base of the doors). It was suggested that if a facilitator's group could quickly identlfy everyhng that should be done in the event of a fire, the facilitator should expand the scenario from a small fire to a large fire and practice evacuationtechniques. If a team completed its scenario successfully the facilitator was instructed to present another scenario. Only the team in room one was instructed to call the charge desk. The
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The charge nurse gathered essential information for evacuation and directed available staff members to help with the evacuation of the patient in OR one. rationale for this was that it is unlikely that six separate OR fires would occur at one time. The perioperative educators also wanted to evaluate the howledge of the charge nurses, and it was more realistic to have the charge nurse handle only one fire at a time. The charge nurse is vital to the smooth flow of cases through the department. This nurse facilitates implementation of the fire plan. One of the goals was to monitor her activities and knowledge of the plan during the drill.The followingquestionsrelating to the charge nurse’s role were considered. 0 Did the charge nurse assign someone to receive emergency calls? 0 Did the charge nurse assign someone to the front entrance of the OR to direct the firebrigade to the fire location? 0 Did the charge nurse gather information about who m t l y was in the OR (eg, patients, staff members, students, visitors, x-ray technicians, surgeons, surgical assistants) in case of evacuation? 0 Did the charge nurse gather staff members’ home telephone numbers in case of evacuation and the need to call in additional help? 0 Did the charge nurse notify managers about the fire? In addition, the following four questions were considered to refine the plan and to better educate the charge nurses about their role and responsibilities. 0 With what other personnel would the charge nurse be in communication? 0 Who would coordinate the decisionmaking hospital-wide for evacuation (eg, the fire chief, chief executive officer or designee, anesthesia care provider, surgeon)? 0 What would the charge nurse do to direct staff member activities (eg, coordinate evacuation; assign someone to get transport supplies, oxygen tanks, and monitors; turn off the oxygen lines)?
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What other tasks (eg, closing doors, unplugging equipment) might the charge nurse delegate? Before the OR staff meeting, patients and their family members awaiting surgery in the same day surgery area were alerted that the OR staff members would be involved in an educational activity on fire safety and that the fire alarms in the OR would sound.It was important to conduct the drill without disrupting the flow of surgery or causing anxiety to patients and their family members. 0
THEDRILL During a 7 AM staff meeting in October, staff members were told that they would be participating in a handson, role-playing activity. They were divided into eight groups led by eight facilitators. The staff members were asked to go immediately to their assigned rooms after the assignments had been read. The scenario was revealed by their facilitator when they arrived in their rooms. No supplies were to be opened, and all supplies on the OR bed were to be set aside during the exercise. Three nurses who work 12-hour day shifts cover the charge desk. On the day of the drill, two of the charge nurses were working. For the purpose of the drill, both the charge nurse and backup charge nurse were placed at the desk. They were not told what was going on until they heard the fire bells sounding. Several staff members were assigned to the staff lounge to await instructions. The team members in room one were told that they were completing a procedure when the x-ray box burst into flames, and they had to decide what to do. The circulating nurse was asked to sound the hospital-wide fire alarms. When “code red, OR one” sounded overhead, the charge nurse went into
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action. She was given a list of where all the employees were stationed, and she quickly assigned someone to go outside the department to alert the hospitalwide fire brigade where the fire was located. The charge nurse then gathered essential information for potential evacuation and directed available staff members to help with the evacuation of the patient in room one. Team members in room one quickly assessed their needs and planned for an evacuation to the postanesthesia care unit (PACU).It took them approximately seven minutes to gather transfer equipment and evacuate the room. Seven minutes is a long time, but the perioperative educators believe that if this scenario actually were to occur, staff members would react more quickly, instead of in a slower, roleplaying mode. At one point, it looked as though a team of race car drivers was exiting the room. They came through the door of the OR with a staff member acting as a patient, an ambu bag, and three members of the surgical team on each side of the OR bed (Figure 1). The charge nurse directed the transfer to the PACU. It was very impressive to have the hospital-wide fire brigade arrive in the OR. The charge nurse directed them to the fire in room one. The hospital-wide nursing supervisor who had responded to the "code red, OR" told the switchboard operator to make the announcement "code red, OR secured." When code red is sounded for any location in the facility, OR staff members are instructed not to begin any further elective surgicalprocedures. This announcement alerted them that the fire was contained and they now could begin elective procedures. The arthroscope, laser, and ESU fire scenarios were discussed in other rooms. Everyone was asked how to sound the alarm using various tech-
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niques (eg, calling appropriate telephone numbers, activating fire pull stations, verbally calling for help). Staff members went into the hallways to idenbfy the location of fire extinguishers, fire pull stations, and oxygen valves. Discussions were held concerning proc e d m for putting out fires,as well as what staff members should save in accordance with the hospital's safe medical device policy Reviews of incident reporting also occurred. To create realism in her scenario, one of the facilitators made crepe paper The flames to show the origin t of the fire (Figure 2). Her ANNOUNCEMENT team discussed diffemt types of potential fires "'code red, OR and how they would handle them. They learned secureflalerted more about fires because they considered scenarios staff members of interest to them. In OR h e , a smoke that the fire was scenario was established. team evacuated by contained and forming a human chain and crawling out of the they now could room to get below the level of the smoke (Figure begin elective 3). Staff members using this scenario found that procedures. they were not sure how to manually override the locks on the electric OR bed. They inspected the bed until they were able to unlock it manually and evacuate it. During the followingweek, a number of managers outside the OR mentioned hearing "code red, OR," and many stated that it was the first time that they heard a "code red, OR" paged. The head of the radiology department was very interested in the drill and said that the radiology department might conduct its own fire drill using the guidelines employed in the OR drill. AORN JOURNAL
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Figures 1 to 3 Perioperative staff members evacuate a mom with a patient (top), extinguish a fire caused by a light source (center), and form a human chain and crawl out of a mom to avoid smoke inhalation (bottom) during an OR fin drill.
CRITIQUE At a staff meeting the next week, time was devoted to critiquing the fire drill. The perioperative educators began by thanking all the staff members who participated in the drill and briefly describing the previous week’s fire drill for those who had not been in attendance. Many staff members said they learned a great deal from the drill and thought it should be repeated. Overall, the drill was a success. 0 Staff members said that participating in the educational roll out helped them feel more competent to handle OR fires, and they had learned from the scenarios presented during the fire drill. 0 Staff members identified the locations of all the oxygen shut-off valves, fire extinguishers, and fire pulls and how to use these pieces of equipment. 0 Evacuation of patients and staff members was reviewed. 0 The charge nurses’ performances were outstanding, and they demonstrated that they knew what to do in the event of a fire. 0 The need to communicate the safety of the patient and surgical team to the charge nurse was reinforced. Staff members also pinpointed areas that they thought needed improvement. 0 More oxygen tanks and regulators would be needed in the event of a total evacuation of the department. 0 Splash basins must be filled with water for every procedure, for fire safety as well as clean up. 0 It is important to be able to idenbfy everyone who is in the department at the time of a fire.This includes but is not limited to all of the patients, staff members, physicians and their assistants, anesthesia care providers and anesthesia support providers, core technicians, x-ray technicians, students, visitors, contracted employees,
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and sales representatives. Several fire extinguishers are available throughout the department, but it might be necessary to equip each room with a fire extinguisher. There were a few negative aspects of the drill as well. Several communication difficulties arose. For example, the nurse who was requested to contact the switchboard about the fire was hesitant because she did not want to sound a false alarm. Communication problems such as this likely resulted because staff members were role-playing and were not completely aware of the importance of communicating during a drill. Initially, staff members thought the facilitatorswere there to judge them. It took time for the staff members to realize that the drill was an educational tool to improve the department's knowledge of fire safety. In general, everyone was pleased with the results of the first ORIspeclfic fire drill, and plans already are underway for a second drill. During the next drill, the perioperative educators hope some of the anesthesia care providers and surgeons will participate. Operating room fire safety is the responsibility of every member of the surgical team. 0
cational techniques. The challenge was to inform and review fire safety, incorporating information on types of surgical fires, location and use of fire fighting equipment, rescue and evacuation routes, medical gases, use and shut-off of valves, and procedures for sounding fire alarms. Having an OR fire drill was an effective way to put together all of the pieces of fire safety. Staff members benefited from thisreview and drill and reinforced the facility's commitment to safety first. 0
Jane Flowers, RN, MSN, CNOR, is the manager for perioperative education, Peninsula Regional Medical Center, Salisbury, Md. NOTES 1. AORN, Fire Safety in the Puiqerative Setting (Woodbury, COM:CinkMed, 1999) Videotape. 2. "Preventing surgical fires,'' Sentinel Event Alert 29 (June 24,2003), http://www .jcaho.or /abou t+us/news+letters/sentinel+eve nt+alert$ea-29.htm (accessed 11Feb 2004). 3. "The patient is on fire! A surgical fires rimer,' ECRI, http:/lwww.mdsr.em'.org accessed 12 Feb 2004).
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RESOURCES
Ball,K A. "Sur 'cal modalities," in Alexander's Care ofihe Patient in Sur ey, 12th ed (St Louis: Mosby, 2003) 80-& Ekyea, S C. "Preventin fires in the OR,"
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(Patient Safe First) AO& Journal 78 (October 200 ) 664-666. SUMMARY Phillips, N F. Berry 6 Kohn's Operating Surgical fires can be a devastating Room Technique,10th ed (St Louis:Mosby, experience. The best way to combat sur- 2004) 220-222,354-355. gical fires is prevention. Understanding "Recommended ractices for electrothe principles of fire safety and know- surgery," in Standar s, Recommended and Guidelines (Denver:AORN, ing the elements of the fire triangle are Practices, Inc, 2004) 245-259. critical for fire prevention. By educating "Recommended practices for skin staff members about the OR fire safety reparation of patients," in Standards, plan and conducting a fire drill, the Lcommended Practices, and Guidelines facility will be better able to prevent or (Denver: AORN, Inc, 2004) 357-360. Rothrock, J C; Smith,D A. "Patient and handle OR fires. environmental safety," in Alexander's Care of The OR fire plan was presented to the Patient in surgery, 12th ed (St Louis: staff members through a variety of edu- MOSby, 2003) 19-20.
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