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Patient Death Reinforces Need for Surgical Fire Precautions

 |  By HealthLeaders Media Staff  
   September 22, 2009

A patient's death following an operating room flash fire serves as a good reminder for surgical teams to review preventive measures.

It is also proof that this particular type of fire will generate above-normal interest from the media.

The incident occurred at Heartland Regional Medical Center in Marion, IL. The patient, identified by the Associated Press and other news outlets as Janice McCall, 65, of Energy, IL, died September 8 at another medical center after the fire allegedly burned her at Heartland Regional September 2.

Nearly four dozen-related news articles popped up on a Google search Monday from across the country, a status that few patient deaths reach.

Heartland Regional was tight-lipped about the incident when contacted Friday. "Right now, we are not going to comment on that," said a director of marketing. She hung up before answering other questions, and the hospital didn't return subsequent requests from HealthLeaders for information.

Robert Howerton, an Illinois attorney for McCall's family, told the Associated Press he has requested medical records from Heartland Regional, and otherwise had few details about the incident. Our attempts to reach Howerton were unsuccessful as of Monday afternoon.

Roots of surgical blazes are age-old
The causes of surgical fires have long been known, as these blazes require a confluence of elements known as the "fire triangle":

  • Ignition sources (e.g., electrocautery pens)

  • Fuels (e.g., drapes or alcohol prepping solutions)

  • Oxidizers (e.g., oxygen-enriched atmospheres)

A common scenario is for oxygen to pool in a fold of a surgical drape near an incision point. When a clinician activates an eletrocautery device, the heat of the device ignites the drape, causing a quick-burning flash fire. The fire is promoted by the presence of the pooled oxygen, though oxygen itself does not burn.

Patient injuries from the fires can range from minor singes to burned respiratory tracts to death.

Factors that would need to be examined in Heartland Regional's incident include whether oxygen was flowing near the patient's face, whether alcohol-based skin prep was used, and what type of surgical device was present, said Mark Bruley, BS, CCE, vice president for accident and forensic investigation at the ECRI Institute, an independent healthcare research firm in Plymouth Meeting, PA.

Until those details are released, it's hard to know what preventive measures might have been warranted, Bruley said.


New recommendations are pending
Expect updated guidance about surgery precautions on patients who need oxygen from the ECRI Institute in collaboration with the Anesthesia Patient Safety Foundation.

An upcoming issue of the ECRI Institute's Health Devices will detail the revised recommendations. The key change is that, with certain exceptions, the traditional practice of open delivery of 100% oxygen should be discontinued, Bruley said.

If supplemental oxygen is needed during a surgical procedure, the patient's airway should be sealed by using a tracheal tube or laryngeal mask, the ECRI Institute will recommend.

"These new recommendations represent significant changes to clinical practice for anesthesia professionals," Bruley says.

Last year, the American Society of Anesthesiologists published an industry advisory to help hospitals increase awareness about surgical fires.

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