Patient Death Reinforces Need for Surgical Fire Precautions

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.