# NCPS TIPS -- August/September, 2003

### Contents: 1. Surgical Fires and Patient Surgical Burns

2.  The Rationale Behind the Five Steps of the Ensuring Correct Surgery
    Directive

3.  Martinsburg VA Medical Center Launches Close Call Reporting Program

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4.  Power Failures in the Operating Room Suite During Open Heart Surgery

### 1. Surgical Fires and Patient Surgical Burns

By Joseph M. DeRosier, PE, CSP, NCPS program manager

Why now? Why is so much attention being focused on surgical room fires?
For a number of reasons --- primarily, because these types of fires are
a potentially devastating yet preventable adverse event.

The Joint Committee on Accreditation of Healthcare Organizations (JCAHO)
recently issued a sentinel event alert (Issue 29, June 24, 2003) on
surgical fires. ECRI, an independent non-profit health services research
agency, dedicated the January 2003 edition of their magazine, Health
Devices (Volume 32, Number 1), to surgical fire safety. Fires in the
operating room (OR) are not frequent. According to ECRI, only 50-to-100
surgical fires are reported each year --- but the fires can result in
serious consequences to patients, damage to equipment and interruptions
to operations.

Eleven reports of fires or burns to patients occurring within the OR
were reported by VHA during 2002. Six of these events were fires; the
remainder were reports of thermal burns to patients from direct contact
with a device, such as a bovie. We have often stated that what gets
reported and what actually occurs are two different issues. As Dr.
Bagian has said, \"We don\'t know whether we\'re looking at the tip of
the iceberg or the snowflake on the tip of the iceberg.\" However, we
are able to draw some conclusions and make recommendations based upon
reported events and the available literature.

As a reminder, here is a brief review of the three conditions that must
be in place for a fire to occur: something to burn (flammable or
combustible material), the presence of oxygen, and an ignition source.
When brought together, these components complete the fire triangle (see
Figure 1 below). Preventing a fire in the OR can be achieved by
controlling the elements that make up the fire triangle.

*Control Ignition Sources*

The most common ignition sources in the OR are electrosurgical and/or
electrocautery equipment and lasers. ECRI reports that approximately 68%
of surgical fires involve electrosurgical equipment and 13% involve
lasers. VHA root cause analysis and safety report data reveal that all
of the OR fires and patient burns reported during 2002 resulted from the
use of electrocautery and electrosurgical equipment; no reports of fires
resulting from the use of lasers were submitted.

The good news --- we have control over ignition sources.

ECRI recommends that during electrosurgery:

-   Remove unneeded foot switches to avoid inadvertent activation.

-   Place the electrosurgical pencil in its holster when not in active
    use and place the electrosurgical unit in the standby mode.

-   Allow the tip of the pencil to be activated only by the individual
    wielding it and when it is under direct observation of the surgeon.

-   Use only active electrode tips that are manufactured with insulating
    sleeves.

-   Do not use electrosurgery to enter the trachea.

-   Do not use electrosurgery in close proximity to combustible
    materials and oxygen-rich atmospheres.

-   Dispose of electrocautery pencils properly. For example, break off
    the cauterizing wire and cap the pencil.

ECRI recommends that during laser surgery:

-   Limit laser output to the lowest clinically acceptable power density
    and pulse duration.

-   Place the laser in standby mode when it is not in active use and
    activate it only when the tip is under the surgeon's direct vision.
    Only permit the person using the laser to activate it.

-   Use surgical devices designed to minimize laser reflectance.

-   Take steps to eliminate/minimize damage to the laser fibers by not
    clamping the fibers to drapes; and when performing surgery through
    endoscope, pass the laser fiber through the endoscope before
    introducing the scope into the patient.

-   Use appropriate laser-resistant tracheal tubes during upper airway
    surgery and follow directions on the label and in the literature
    regarding product use. This might include use of dyes in the cuff to
    indicate a puncture, use of saline fill to prevent cuff ignition,
    and immediate replacement of the tube if the cuff is punctured.

-   Place wetted gauze or sponges adjacent to the tracheal tube cuff and
    keep them wet, and keep gauze or sponges wet when used with uncuffed
    tracheal tubes.

-   Keep all moistening sponges, gauze, pledgets and their strings moist
    throughout the procedure.

-   Consider using towels soaked in saline or sterile water around the
    operative site.

*Control Oxygen Levels*

We control oxygen-rich environments in the OR, which include any
atmosphere where there is greater than 21% oxygen. Why is this
important? While oxygen will not burn or explode, it can cause materials
that will not ignite or that burn slowly in ambient air to easily ignite
and burn rapidly. The vapor density of pure oxygen (1.1) is slightly
heavier than air. This means that pure oxygen may collect in depressions
or under drapes or clothing.

Nitrous oxide use can increase effective oxygen levels above 21%. Like
oxygen, nitrous oxide also has a vapor density greater than 1.0. With a
vapor density of 1.53, it will collect in low-lying areas as well.

ECRI data shows that 74% of the reported surgical fires occurred when
oxygen levels were elevated above 21%. Of the surgical fires reported in
VHA during 2002, elevated oxygen levels were a contributing factor in
three of the six fires. It\'s important to understand that oxygen may
collect and its concentration become elevated: under surgical drapes; in
clothing; on the surface of the skin, due to the presence of vellus; and
around masks, tubes or nasal cannula when patients are provided oxygen
or nitrous oxide from compressed gas cylinders or piped medical gas
systems.

To control oxygen concentration levels ECRI recommends:

-   That the requirement for 100% oxygen for open delivery to the face
    (for example, when using nasal cannual) be questioned if a lower
    concentration is consistent with the patient needs.

-   Stopping supplemental oxygen at least one minute before using
    electrosurgery, electrocautery or laser surgery on the head or neck.

-   Titrating the delivery of oxygen to the patient based on the
    patient's blood-oxygen saturation.

-   Tenting drapes to allow gases to drain away from the operating
    table.

-   Using a properly applied incise drape, if possible, to help isolate
    head and neck incisions from oxygen-rich atmospheres.

-   Considering use of active gas scavenging of space beneath the drapes
    during oxygen delivery. When scavenging under the drapes, exercise
    caution so that the space beneath the drapes does not collapse.

-   Avoiding the use of nitrous oxide during bowel surgery.

During oropharyngeal surgery ECRI also recommends:

-   Suction be used as near as possible to any potential breathing gas
    leaks to scavenge the gases from the oropharynx of an intubated
    patient.

*Control Combustible Materials*

Combustible materials --- fuel that will burn --- surround the patient
in the OR and include: the operating table bedding, headrests, clothing,
straps, towels, drapes, sponges, dressings, hair, intestinal gases,
tracheal tubes, body tissue, bronchoscopes, breathing systems, petroleum
jelly, adhesives, hoses and equipment covering --- and this list is not
all inclusive. Flammable and combustible liquids are also present in the
OR, including skin prep solutions, tinctures, degreasers, suture pack
solutions and liquid wound dressings.

Understanding what can burn and what liquids are flammable or
combustible is the first step in managing the fuel load for a potential
fire. Allow flammable liquid preps (e.g., preps that are alcohol-based
or contain acetone) to fully dry before draping; avoid pooling the
liquids when they are applied. Be aware that pooled liquids can be
wicked up into sponges, drapes, etc., and may take longer to dry. ECRI
recommends that facial hair (e.g., eyebrows, beards and mustaches) be
coasted with a water-soluble surgical lubricating jelly to inhibit
combustion.

*Know and Practice the Fire Plan*

Service-specific fire plans have been required for many years. We
strongly recommend that the fire plan for surgical service be reviewed
annually and that quarterly fire drills be conducted. It is recommended
that surgical staff members participate in at least one fire drill
(conducted in the OR) every year, and it is especially important to:

-   Talk about what each OR team member will do if presented with a fire
    involving a patient.

-   Walk through the plan and look for areas where response can be
    improved.

-   Know who will be responsible to move the patient, where the patient
    will be moved, and who will be moving critical equipment.

*Not All Burns Are External*

Not all fires and burns are external to the patient. Internal fires have
been reported in the literature involving patients undergoing
laparoscopic procedures due to oxygen-rich atmospheres (oxygen was
mistakenly used for insufflation instead of carbon dioxide). They have
also been due to the use of lasers and non-metallic endotracheal tubes
that were ignited while in the patient. The burning endotracheal tube
created a fire similar to that which might have occurred had a blowtorch
scorched the lungs.

Stray electrosurgical burns can cause internal injury that may be
difficult to detect because they may not be visible to the surgeon.
\"Figures show that 67% of stray electrosurgical burns go unnoticed
during surgery and that 25% of the patients who suffer internal injuries
stemming from these burns during laparoscopic procedures die.\"^4^
Insulation failure on the electrosurgical device that results in burns
and capacitive coupling is cited as being the primary cause of burns
during laparoscopic procedures. With use, the tip of the ESU can become
extremely hot and, if inadvertently touched to targeted tissue, can
cause burns. Capacitive coupling can occur if there is microscopic
insulation failure in the device. The insulation failure provides an
alternate electrical current path between the active electrode and the
patient return electrode resulting in the burn. To minimize capacitive
coupling, use an electrosurgical waveform with the lowest voltage
necessary to achieve the desired surgical effect^.5^ Instruments that
use active electrode monitoring technology (AEM) are also effective to
prevent capacitive coupling.^4^ These devices are shielded and monitored
so 100% of their power is delivered where intended.

*Bibliography*

1\. Electrosurgical Burns and Fire Occurrences. (June 2003). NYPORTS
News & Alert, Department of Health, Issue 13.

2\. Focus on Surgical Fire Safety. (January 2003) Health Devices, Vol.
32, No. 1.

3\. Preventing Surgical Fires. (June 24, 2003). JCAHO Sentinel Event
Alert, Issue 29.

4\. Werner, C. (June 2002). Guarding against an unseen killer: stray
electrosurgical burns. Healthcare Purchasing News.

5\. Performance and Safety Issues Related to High Voltage, Innovations
in Electrosurgery,
http://www.valleylabeducation.org/ES_YTT/pages/inno_11.htm

6\. Avoiding Electrosurgical Injury During Laparoscopy: An Emerging
Patient Safety Issue. (August 1997) \[Videotape\] Washington:
Communicore.

**2. The Rationale Behind the Five Steps of the Ensuring Correct Surgery
Directive**

By Noel E. Eldridge, MS, NCPS executive assistant

### The Ensuring Correct Surgery Directive went into effect Jan. 1, 2003. The directive was designed to provide VHA with a process that would be effective in ensuring correct surgeries, as well as being compatible with the work process. Results to date are encouraging --- through June 2003 there have been no cases reported to NCPS in which the directive was followed and an incorrect surgery resulted. Nonetheless, many questions have been asked concerning the rationale behind the directive\'s steps. Here is a summary rationale for each of the five steps:

### 1) *Consent form requirements*. Looking at Root Cause Analyses (RCAs) submitted prior to 2003 that were associated with incorrect surgeries or invasive procedures, a significant fraction indicated that the consent process was a contributing factor. For instance, crucial information like the site or side of the procedure was left off or incorrect. Our 2002 analysis indicated that approximately 45% of incorrect surgeries could be averted if the consent form had provided the full name of the patient, the site, the side, the name of procedure, and the reason for the procedure, using language that the patient or surrogate understood.

### 2) *Marking the site*. This is a step recommended by many organizations, including the American Academy of Orthopedic Surgeons, and the Association of Perioperative Registered Nurses. Marking most sites has not been questioned. The rationale for marking sites on the midline of the trunk has been questioned. There are three basic reasons to mark all sites: (1) marking all sites ensures that there is always an indication of where the procedure is to be performed - midline procedures, especially urologic procedures, have not been impervious to wrong site mistakes; (2) to help prevent patient misidentification and mix-ups after correct identification; and (3) to bring the patient and surgeon face-to-face before the operation. This step may even help prevent incorrect procedures at the correct site.

### 3) *Patient identification*. Statements such as \"the patient confirmed their identity\" have been seen in multiple wrong-patient RCAs. It became clear that a patient answering \"yes\" or \"uh-huh\" is not always adequate to confirm identity. This communication gap can be addressed when a patient states their name, their SSN or birth date, as well as indicating the site of the procedure to operating room (OR) staff. Our review of RCAs indicated that this step would have prevented about 75% of the incorrect procedures.

### 4) *\"Time-out\" in the OR*. Like marking sites, this step is advocated by many organizations. It provides a quiet moment to focus on verifying the correct patient, site marked, procedure to be performed, and implant needed. Plans are stated aloud and the surgeon, anesthesia provider and circulating nurse verbally agree. This ensures that there is agreement on what the OR team will do.

### 5) *Checking imaging data*. Several RCAs describing incorrect surgeries indicated that needed images were not available or that the image present was incorrect to the patient or procedure. The directive requires that if images will be used to confirm a site, that at least two of the OR team confirm that images are present, correct, and properly labeled.

### The detailed directive is available on-line at http://vaww.ncps.med.va.gov/CorrectSurgDir.pdf and <http://www.va.gov/publ/direc/health/direct/12002070.doc>.

### 

### 3. Martinsburg VA Medical Center Launches Close Call Reporting Program

The Martinsburg VA Medical Center inaugurated a Close Call Reporting
Program February 2003. Using a modified "Reason\'s Swiss Cheese Model,"
Associate Medical Center Director/Nursing Geraldine A. Coyle, RN, Ed.D.,
CNAA, has presented this program to all levels of staff, veterans and
volunteers.

Staff members are encouraged to make submissions and are recognized for
them. They may call, e-mail, submit a Report of Contact, or complete an
Incident Report to the Quality Management/Patient Safety Coordinator for
review. The coordinator and the risk manager review the submissions
prior to presenting them to Dr. Coyle and Linda J. Morris, M.D., chief
of staff, who determine whether a close call has occurred.

Those who submit close calls are eligible for a \$500 cash award when a
system redesign is affected. All submitters are presented a
commemorative slice of Swiss cheese and a certificate by the director at
quarterly all-employee meetings.

Staff members have enthusiastically embraced this program as part of the
medical center\'s Culture of Safety.

**4. Power Failures in the Operating Room Suite During Open Heart
Surgery**

By Bryanne Patail, BS, MLS, NCPS biomedical engineer

NCPS received reports from two VA facilities this year regarding the
loss of electrical power in the operating room (OR) suite during open
heart surgery.

In the first facility, the isolation transformer simply could not handle
the load of all the devices brought in for the procedure. This is not
unusual in older facilities or facilities that have not gone through an
upgrade of their electrical power distribution system. The solution to
this particular problem was to provide a higher-rated isolation
transformer for that specific OR suite.

There are specific requirements and recommendations in the VA Electrical
Design Manual on the proper power rating of Isolated Power Systems (IPS)
for OR suites. To find the manual, click to
http://vaww.va.gov/facmgt/standard/manuals_elec.asp and then open
\"Hospital Projects.\"

Circuit breakers at the second facility opened (tripped) while a patient
was on a cardio pulmonary by-pass machine. The Uninterruptible Power
Source (UPS) activated to provide backup power, but also tripped its
breakers. The UPS\' batteries were weak and past their life expectancy.

Investigation by an independent contractor revealed the reason for the
initial loss of power: The insulation on an extension cord had broken
down due to mechanical damage from equipment rolling over it, resulting
in a short circuit.

Based on these two incidents and similar incidents that have been
investigated or reported in the past few years, the following should be
considered:

\(1\) Ensure that a multidisciplinary team periodically evaluates the
IPS and UPS (if installed) in the OR suite to determine if the isolation
transformer has the appropriate rating for the types of procedures the
suite is used for; also, that the UPS is appropriately matched for the
application.

> \(a\) At a minimum, the team should be drawn from two sources: first,
> plant facilities and engineering staff, to include electrical
> engineers, biomedical engineers and biomedical technicians; and
> second, from the OR staff, to include surgeons and nurses.
>
> \(b\) The team should simulate the actual setup of a specific
> procedure, noting the number of electrical receptacles on each wall,
> the location of each electrical device, and which electrical
> receptacles the devices might be plugged into without having to use
> extension cords.

\(2\) If UPS is an integral part of the electrical system, verify that
it will be available and effective when needed. This may be accomplished
through a preventive maintenance program, to include routine testing.

\(3\) Extension cords should not be used for a number of reasons: (a)
they have a high incidence of being improperly sized for the electrical
load, especially if they are serving more that one device at a time; (b)
they often serve as the only cable that crosses the path between the
wall and the table, thus increasing exposure to wheeled traffic,
resulting in insulation breakdown which can cause a short circuit; and
(c) they present a trip hazard.

If feasible, receptacles should be strategically placed (in booms, under
the table, etc.) to alleviate the need for these cords.