code red in the or—implementing an or fire drill

Flowers APRIL 2004, VOL 79, NO 4

Code Red in the OR- Implementing an

Fire Dri l l OR I

Jane Flowers, RN

fire in the OR is one of the most frightening events that a surgi- A cal 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. On June 24,2003, the Joint Commis-

sion on Accreditation of Healthcare Organizations published a Sentinel Event Alert regarding fires in the OR. This document references the ECFU rec- ommendation that

training on the use Offire-fighting equipment; proper methods for rescue and escape; the ident@mtion and 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. Mana- gers 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,

0 aim the nozzle, 0 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.

POLICY RMEW 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 Flowers

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 later- ally 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 members caring for patients. plan should The planValso Lstructs staff members who are specify what not directly caring for patients at the time of a every team fire where to wait for members' job instructions. It is imDor- tant that every Cam member knows what his would b in the

The plan divides fire control into two cate-

gories involving patien- small 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 investiga- tion 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

areas outside of the surgical services department.

After the OR fire plan was revised and approved by the hospital-wide facilities management 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 con- tacted 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 pro- tective 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 ROLL OUT 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

798 AORN JOURNAL

or her job would be in the event of a fire. EVENT OF A FIRE.


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, fiber- optic endoscopes and light sources, electrocardiogram leads, anything with a plug)?

The discussic% highlighted safety fea- tures 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 ade- quately vent under the drapes of patients having face or neck surgery to prevent highly concentrated oxygen pockets from developing. This provid- ed 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 tech- nologists, 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 FIRE DRILL The drill was designed to involve as

many staff members as possible using hands-on role play in different situa- tions 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 educa- You are tion A coordinators, three perioperative resource Working with an

arthroscope. One nurses, and an adminis- trative secretary-to act

of the scrubbed as facilitators dking the fire drill. Six of these staff

team members members would facili- tate the fire scenarios,

puts the lighted arthroscope on

the sterile

one would monitor the charge desk, and one would monitor staff lounge activity during the drill, for a total of eight observation points. Six fire drill scenarios were develoDed. drapes, ignitfng

I

1. You are closing the the drape abdomen of a trauma patient when YOU hear a snap, crackle, and matedale What POP, *and the x-ray would you do? view box ignites. What would yocdo?

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

2. You are preparing to

AORN JOURNAL 799


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.

Facilitators were given discussion

questions designed to

reinforce the fire protection plan and ensure that

each team received the same

information during the drill.

AS you enter the A&, you notice that thick black smoke is coming though the ventilation system. The m b person is overcome by the smoke. What would you do?

6. You are doing a trans- myocardial revascu- larization procedure using a laser. The laser operator forgets to put the equipment in standby mode. The laser is fired, igniting a laparotomy sponge. What would you do? At a meeting of the

facilitators, each was given his or her own scenario, in addition to copies of all the other scenarios and 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

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

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 fk 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 evacuation techniques. 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

alarm pull stations?

800 AORN JOURNAL


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 howl- edge 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 following questions relating to the charge nurse’s role were considered. 0 Did the charge nurse assign some-

one to receive emergency calls? 0 Did the charge nurse assign someone

to the front entrance of the OR to direct the fire brigade 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 decision-

making 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)?

0 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 caus- ing anxiety to patients and their family members.

THE DRILL During a 7 AM staff meeting in

October, staff members were told that they would be participating in a hands- on, 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 back- up 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

802 AORN JOURNAL


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 hospital- wide 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 approx- imately 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, role- playing 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 announce- ment "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 surgical procedures. This announce- ment 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-

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 pro- cedm 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 flames to show the origin The

types of potential fires and how they would handle them. They learned secureflalerted more about fires because they considered scenarios staff members of interest to them.

scenario was established.

forming a human chain and crawling out of the room to get below the level of the smoke (Figure 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 following week, 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.

"'code red, OR

In OR h e , a smoke that the fire was team evacuated by contained and

they now could begin elective

AORN JOURNAL 803

of the fire (Figure 2). Her team discussed diffemt

tANNOUNCEMENT


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 loca- tions 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 demon- strated 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,

804 AORN JOURNAL


and sales representatives. 0 Several fire extinguishers are avail-

able 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 prob- lems 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 facilitators were 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 under- way 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.

SUMMARY Surgical fires can be a devastating

experience. The best way to combat surgical fires is prevention. Understanding the principles of fire safety and know- ing the elements of the fire triangle are critical for fire prevention. By educating staff members about the OR fire safety plan and conducting a fire drill, the facility will be better able to prevent or handle OR fires.

The OR fire plan was presented to staff members through a variety of edu-

cational techniques. The challenge was to inform and review fire safety, incor- porating 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 this review 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+let ters/sen tinel+eve nt+alert$ea-29.htm (accessed 11 Feb 2004). 3. "The patient is on fire! A surgical fires rimer,' ECRI, http:/lwww.mdsr.em'.org 4 accessed 12 Feb 2004).

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," (Patient Safe First) AO& Journal 78

Phillips, N F. Berry 6 Kohn's Operating Room Technique, 10th ed (St Louis: Mosby,

"Recommended ractices for electro-

Practices, and Guidelines (Denver: AORN, Inc, 2004) 245-259.

"Recommended practices for skin reparation of patients," in Standards,

Lcommended Practices, and Guidelines (Denver: AORN, Inc, 2004) 357-360.

Rothrock, J C; Smith, D A. "Patient and environmental safety," in Alexander's Care of the Patient in surgery, 12th ed (St Louis:

(October 200 r ) 664-666.

surgery," in Standar B s, Recommended

2004) 220-222,354-355.

MOSby, 2003) 19-20.

AORN JOURNAL 805

code red in the or—implementing an or fire drill

Documents