Out of approximately 65 million surgical cases each year, there are an estimated 200-240 surgical fires, a frequency comparable to that of other surgical safety events, such as wrong-site surgery and unintended retention of foreign objects.1 There is no data of reported fires specific to any electrophysiology (EP) labs that implant permanent pacemakers (PPM) and implantable cardioverter-defibrillators (ICD).2 However, at Brigham and Women’s Hospital in Boston, the hospital’s fire assessment tool categorizes the procedures performed in EP as the highest risk for a potential procedural fire.
The factors that contribute to a procedural fire are called a fire triad, which consists of an ignition source, an oxidizer, and a fuel.3 The incidents of a procedural fire can increase when staff demonstrates lack of awareness and failure to communicate risk of fire prevention.4 Key components for fire prevention are acknowledgement and communication of risk, creation and nurturing of a culture of safety, and continuous education. Communication is the key contributing component that nursing can assume responsibility for. A well-established culture of fire prevention in procedural settings leads to a decreased incidence of fire events. In the event of a fire, staff know the appropriate steps to take because they are informed and educated in fire prevention. Establishing and creating a culture of fire prevention safety is a nursing initiative that promotes patient and staff safety.
An event in September 2017 at Brigham and Women’s Hospital was the catalyst for the development of a fire prevention plan for our EP lab. A patient in another department was severely injured from a surgical fire. The staff and patient were physically and emotionally traumatized from this catastrophic event. The root cause analysis (RCA) revealed the staff were ill-informed regarding fire prevention. The RCA identified several issues: 1) there was a lack of a formal safety pause with fire prevention details; 2) there was a failure to delegate specific roles to staff in the event of a fire; 3) there was also a failure to activate the fire pull station; and 4) there was a lack of intervention to extinguish the fire. The development and implementation of fire prevention interventions is an evidence-based practice that all institutions should implement. Application of these efforts makes for a safer environment for staff and their patients. More than 1,000,000 pacemakers and 200,000 ICDs are implanted worldwide each year.5 The safety of this patient population requires implementation of proven interventions in fire prevention.
Brigham and Women’s Hospital received Magnet Designation in 2018. The development of a culture of fire prevention in the EP lab is highly relevant to the 2019 ANCC National Magnet Conference goals. This initiative translated evidence-based strategies into solutions and leveraged the Magnet nursing culture to optimize organizational performances and enhance patient safety.
Strategy and Implementation
A fire prevention initiative in the EP lab requires collaborative efforts with nursing staff and leadership, environmental engineers, respiratory therapists, and the hospital’s fire marshal. Our first step in the process of the fire prevention initiative was to review current evidence-based practice, which revealed a lack of nursing research pertaining to procedural-specific fire prevention. The Association of periOperative Registered Nurses (AORN) has been a longstanding champion of fire safety in the operating room, initially publishing guidelines on this subject in 2005.6 However, these guidelines fall short of addressing procedural areas that rely on nursing intravenous conscious sedation (IVCS). Based on this review of literature, a fire safety and prevention initiative was developed.
Based on the hospital’s established fire risk assessment tool, we were able to assess that EP lab procedures were categorized into the highest risk level. It was decided that a universal team time-out already occurring in the EP lab prior to each procedure was the best place to add a fire prevention safety pause. Specific roles were assigned to each staff member in the event of a fire. The roles were defined and communicated to all staff present: the radiologic technologist would activate the fire pull station, the attending would pull back the surgical drape to ensure access to the fire, the physician fellow would pour a bowl of sterile normal saline on to the fire, and the nurse (who is the only staff member with direct access to the patient) would immediately turn off the oxygen delivery system and activate the fire extinguisher if needed. The time-out specifically addresses the questions of what the fire risks for the procedure are, and what can be done to lower the risk of fire. Having staff identify both the aspects of the case that can pose an increased risk for fire and interventions to decrease the risk of a fire is an effective tool. Posters of the key points in the fire prevention team were developed and placed in each EP lab for easy reference.
The fire pull station was originally placed outside the EP lab in an unidentified and obstructed area, but later relocated to a centrally accessible and clearly marked area. Prior to implementation of the fire safety initiative, fire extinguishers were located outside of the procedural rooms. They are now on moveable carts that contain the defibrillator, which is attached to every patient undergoing a pacemaker or ICD procedure in the EP lab. The placement of a fire extinguisher in each EP lab ensures strategic access during an emergency and decreases the risk of obstruction.
Additionally, various oxygen delivery systems were trialed. Altering the oxygen administration was the only factor that could be changed in a proactive manner, since the other elements in the fire triad are more hospital based (i.e., surgical drapes and towels, alcohol-based prep solution, and cautery). According to VanCleave et al, “fire safety research has identified the reserve of a pooled or trapped oxygen-enriched environment, e.g., in or around a patient’s tissue, under a surgical drape, or in the environment generally, as a major exacerbating factor in the onset of surgical fires.”7 The pre-fire prevention oxygen delivery via simple mask was 8-10 liters per minute of oxygen. After extensive consultation with respiratory therapy, an oxygen blender system was trialed in the EP lab. This new system allowed nursing to deliver a fraction of inspired oxygen (FiO2) of 20-100% with a reduced oxygen flow of 3-6 liters per minute. The hypothesis was that the oxygen blender would decrease the percentage of oxygen administration, and therefore, decrease the risk of an oxygen-enriched atmosphere (OEA) under the surgical drape. This intervention would, in turn, lessen the risk of a potential procedural fire. The reduction in oxygen delivery decreased to 30-40% FiO2, which led to an average decrease in the patient’s oxygen saturation from 98-100% to 98-99% on average. Given the minimal amount of change in the patient’s oxygen saturation, a MiniOX 3000 (Ohio Medical Corporation) was applied to the procedure. A MiniOX 3000 is an oxygen saturation analyzer that displays continuous analysis of the OEA under the surgical drape, providing a value from zero to 100%. The analyzer showed an average oxygen concentration of 21-25% under the surgical drape.
Next, oxygen delivery via a Ventimask (Flexicare) was trialed. Again, there was little to no change in oxygen concentration under the surgical drape and no adverse reaction of its implementation. However, the EP nurses noted that the Ventimask frequently became disconnected during the procedure, posing a safety risk to patients. As a result, use of the Ventimask was stopped.
The goal remained to further decrease the OEA under the surgical drape, given that oxygen concentrations greater than 30% can dramatically increase the potential for a surgical fire. Due to the minor change in the oxygen concentration under a surgical drape, the use of a simple mask at the lower oxygen delivery rate of 6 liters per minute was reinstituted. Nurses currently have two options for oxygen delivery: a simple mask connected to the blender or to the wall oxygen but at a reduced rate. The MiniOX 3000 continues to be utilized during procedures.
The entire EP staff completed computer-based education on surgical and procedural fire prevention and safety. An EP-specific didactic presentation on fire prevention was provided, followed by an open forum, to ensure all staff had the opportunity to raise questions and engage in discussions.
The primary goal of the fire prevention initiative was to reduce the risk of a procedural fire in the EP lab. Since the implementation of the fire safety initiative, there has been no procedural fires. There was an incident of a spark from a cautery device; however, no harm resulted to the staff or patient. At the debriefing of the event, staff verbalized the benefit to being knowledgeable about fire prevention, and expressed appreciation to the assigned roles made during the safety pause.
A secondary outcome of the fire prevention initiative to establish a culture of fire safety in the EP lab. The collaborative efforts of the multidisciplinary group of medical and fire professionals ensured all facets of fire prevention were included. The nurse-driven innovations led to changes in practice based on evidence. The multidisciplinary approach helped secure engagement from all staff involved in the EP lab, spurring enthusiasm and commitment. Allowing open forums provided an opportunity for nursing to provide input to the multidisciplinary group. When implementing a change in practice, acceptance by nursing and other staff members directly correlates with the success of the change. Successful buy-in by all staff made the adaptation of fire prevention efforts seamless.
Prior to introducing fire safety, the staff had limited knowledge of the most appropriate steps to take in the event of a procedural fire. There was no systematic protocol for staff to follow. Staff now have precise and clearly defined roles. Education ensured knowledge of the fire triad and risk factors for procedural fires. Staff can identify the newly relocated fire emergency equipment, fire pull stations, and evacuation routes. Continued didactic and computer-based education on fire safety and protocols for the EP lab are included in annual competency days. There is 100% compliance with the computer-based education and post-test.
Implications for Practice
A universal protocol for fire prevention in the procedural setting is needed. Procedural nursing is on a path of expansion. Nurses are predominately utilized for managing sedation and pain control in these areas. Establishing a culture of safety and knowledge in fire prevention is a must. The effects of a fire in a hospital are disastrous. Nurse-driven interventions plan an active role in fire prevention. The best line of treatment is prevention instead of reacting after a fire occurs. Further nursing research is needed to assess effective fire prevention interventions for the ever-expanding procedural areas outside of the operating room. Even one procedural fire that harms a patient or staff member is simply too many.
Disclosures: The authors have no conflicts of interest to report regarding the content herein.
- Castro G. Only you can prevent surgical fires. Published October 12, 2017. Available at https://bit.ly/2VGvTTO. Accessed May 15, 2019.
- Hempel S, Maggard-Gibbons M, Nguyen D, et al. Wrong-site surgery, retained surgical items, and surgical fires: a systematic review of surgical never events. JAMA Surg. 2015;150(8):796-805.
- Brigham and Women’s Hospital. Fire Policy. 2017.
- Coletto K, Tariman J, Lee Y, Kapanke K. Perceived knowledge and attitudes of certified registered nurse anesthetists and student registered nurse anesthetists on fire risk assessment during time-out in the operating room. AANA Journal. 2018;86(2):99-107.
- Coviderc P. Wire-free die-on-die technology for electronic module manufacturing in implantable devices. Published April 14, 2017. Available at https://bit.ly/2Ebnv3U. Accessed May 15, 2019.
- AORN guidance statement: fire prevention in the operating room. AORN J. 2005;81(5):1067-1075.
- VanCleave AM, Jones JE, McGlothin JD, Saxen MA, Sanders BJ, Vinson LA. The effect of intraoral suction on oxygen-enriched surgical environments: a mechanism for reducing the risk of surgical fires. Anesth Prog. 2014;61:155-161.