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Fire Response Guidelines - Surgical Services (6.01)

Fire Response Guidelines - Surgical Services (6.01) - Policies, Clinical, UWHC Clinical, Department Specific, Surgical Services, Safety

6.01

UNIVERSITY OF WISCONSIN
POLICY & PROCEDURE

EFFECTIVE DATE

JUNE 1987
ORIGINAL
 REVISION

JUNE 2017
PAGE 1
OF 6
POLICY #

6.01
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER SURGICAL
SERVICES – ADMINSTRATIVE
MANUAL
TITLE
FIRE RESPONSE GUIDELINES – INTRAOPERATIVE
AREAS





I. PURPOSE

To establish guidelines in responding to a fire situation, in the Intraoperative areas and to ensure the safety
of patients, visitors, and staff as well as prevent fire situations through implementation of safety measures.


II. PROCEDURE

A. Refer to the Environment of Care Management Plans – Fire Safety Management.
B. Surgical case progression, initiation of new cases and transfer of patients will be evaluated with
the Anesthesia Schedule Coordinator and the Charge Nurse in consultation with the Command
Center. The Anesthesia Schedule Coordinator and the Charge Nurse will respond to the involved
intraoperative area/hallway to provide direction in patient and staff movement. Smoke fumes and
air safety issues may result in shutdown of close proximity operating/patient rooms and hallways.
This will be determined by Director of Safety and Plant Engineering.
C. Unassigned staff will report to the Control Station/Charge Nurse to be available for assistance.
Staff will be directed to follow fire response guidelines.
D. Evacuation of patient care units will be directed by the Anesthesia Schedule Coordinator and
Charge Nurse in coordination with the Fire Department officials, if available. Evacuation of an
operating room suite (O.R.) with a fire will be coordinated by the anesthesiologist, surgeon and
nursing staff caring for the patient. Nursing staff are responsible for instructing rescue personnel
of any special consideration regarding patients.
E. If the O.R. suite is evacuated, and time permits, the outside compressed gas valves (O2, Nitrous
Oxide, compressed air, and suction lines) will be shut off under the direction of Anesthesia. Shut
off valves are located in the patient/staff corridors outside each operating room (Inpatient O.R.,
Outpatient O.R., AFCH O.R., and The American Center O.R.). Oxygen lines in the O.R. area
will have special seals. The joints will stay intact when heated to 900 θ
F. Staff will review the Fire (Code Red) Quick Response Guide on an annual basis and participate
in the fire drills.
G. Halon 1211 ABC extinguishers will be located in every operating room.

III. FIRE MANAGMENT

A. Fire Prevention Plan

UNIVERSITY OF WISCONSIN
POLICY & PROCEDURE

EFFECTIVE DATE

JUNE 1987
ORIGINAL
 REVISION

JUNE 2017
PAGE 2
OF 6
POLICY #

6.01
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER SURGICAL
SERVICES – ADMINSTRATIVE
MANUAL
TITLE
FIRE RESPONSE GUIDELINES – INTRAOPERATIVE
AREAS


1. During the time out the fire safety risk score assessment is completed by the surgical team and
interventions are implemented accumulative to risk score
B. Fire Management Plan
1. Consider the general precaution with the potential for a fire hazard if paper or plastic items are
stored in a confined space where they may be exposed to excessive heat (like from a light source)
or electrical sparking/arcing.
2. Hot equipment inside a cabinet or drawer may overheat items directly above or below it.
3. Pay particular attention to fiberoptic light sources. High-brightness fiberoptic cables can ignite
paper drapes and/or burn a patient’s skin.
4. Clinical knowledge of the fire triangle.
a. Oxidizers – Anesthesia influence
b. Fuels – Nursing influence
c. Ignition Sources – Surgeon influence

C. In the case of an O.R. suite fire
1. Halt the procedure for any warning signs of a fire and ask for an evaluation
2. If the fire is in an endotracheal tube, remove it immediately.
3. Stop the flow of all anesthetic gases.
4. Remove burning drapes and other materials from patient.
5. Extinguish with water/saline from the sterile field or a CO2 fire extinguisher
6. If fire persists, activate the fire alarm, evacuate patient, close O.R. suite door and under the
direction of the Anesthesiology turn off gas supply to the room.
7. If fire is extinguished, re-establish ventilation avoiding an oxidizer-enriched atmosphere if
clinically appropriate (i.e. ventilate with room air)

D. After an airway fire:
1. Examine the tracheal tube for tears which could have left behind fragments in the airway
2. Consider rigid bronchoscopy to evaluate for damage or the presence of foreign bodies in the
airway
3. Assess patient status and devise plan for further management

IV. Fire Evacuation Plan
1. Below is a suggested delegation plan when the need to evacuate an anesthetized patient from an
O.R. is required as follows:
a. O.R. Charge Nurse
i. Activate fire alarm.
ii. Notify PACU area and Preop/Post-op area of Fire Alert in the respective O.R. areas,

UNIVERSITY OF WISCONSIN
POLICY & PROCEDURE

EFFECTIVE DATE

JUNE 1987
ORIGINAL
 REVISION

JUNE 2017
PAGE 3
OF 6
POLICY #

6.01
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER SURGICAL
SERVICES – ADMINSTRATIVE
MANUAL
TITLE
FIRE RESPONSE GUIDELINES – INTRAOPERATIVE
AREAS


such as, Inpatient, AFCH, Outpatient and The American Center.
iii. Identify vacant O.R. suites and other evacuation locations as defined in j below.
iv. Assume the role of the Pharmacy Technician/Pharmacist and Anesthesia
Technician/Anesthesia Materials Specialists if unavailable (e.g. nights/weekends).
v. If not present, notify Faculty Surgeon/Anesthesiologist.
b. Scrub Personnel
i. Remove necessary instruments, sponges, and suture material from the back table and
mayo stand and place on the O.R. table, between the patient’s legs.
ii. Assist with movement of O.R. table.
iii. Assist extinguishing the fire on the patient with wet towels and water/saline in the basin
or graduate.
c. Circulating Nurse
i. Move equipment away to clear path from table to door.
ii. Alert O.R. the Charge Nurse of the fire.
 AFCH Inpatient O.R.’s, and The American Center: “Red Emergency Phones”
 OSC: Telephone the Control Station
iii. Assist the anesthesiologist with disconnecting the patient from the anesthesia machine,
monitoring devices, etc.
iv. Move anesthesia supply cart from room.
v. Ensure patient transport monitor and Propofol are in route.
d. Anesthesia Staff
i. Remove I.V. bags and lines from poles and place on table with patient.
ii. Disconnect monitor EKG leads, blood pressure cuff, pulse ox, etc. from the anesthesia
machine and connect to transport monitor.
iii. Remove patient from anesthesia circuit and maintain patient respirations with Ambu
Bag and O2 tank.
iv. Shut off anesthesia machine and disconnect line from patient.
v. Instruct staff to shut off compressed gas lines (O2, Nitrous Oxide, etc.) outside of O.R.
suite.
vi. Bring table to “wheels” position or transfer patient to O.R. cart or bed.
e. Surgical Resident/Fellow
i. Assist in moving O.R. table or transferring patient to cart or bed.
f. Surgeon (or Surgical Resident/Fellow in his absence)
i. Stabilize patient.
ii. Pack the open wound.
iii. Give final directions to move.
g. Nursing Assistants or Patient Care Techs (PCT)

UNIVERSITY OF WISCONSIN
POLICY & PROCEDURE

EFFECTIVE DATE

JUNE 1987
ORIGINAL
 REVISION

JUNE 2017
PAGE 4
OF 6
POLICY #

6.01
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER SURGICAL
SERVICES – ADMINSTRATIVE
MANUAL
TITLE
FIRE RESPONSE GUIDELINES – INTRAOPERATIVE
AREAS


i. Clear path in corridor from perioperative area to the evacuation site, and assist as
needed.
ii. Bring cart or bed to the room for transport.
iii. At The American Center the PCT will bring the transport monitor and will report to the
OR Charge RN for additional instruction.
h. Anesthesia Technician/Anesthesia Materials Specialists
i. Bring transport monitor to the room.
ii. Report to O.R. Charge Nurse for additional instruction regarding further evacuations.
i. Pharmacy Technician/Pharmacist –
i. Deliver emergency IV anesthetic (100 ml of Propofol) to O.R.
ii. Location of Propofol Stock
 Pharmaceuticals Room:
 Inpatient: O.R./FDS/PACU - E7/391
 Outpatient: O.R./Ambulatory Surgery - F6/206
 AFCH: OR/Pre-op/PACU – 3311
 If Pharmaceutical Room access is blocked, back up Propofol will be obtained from
the sterile products area. Minimum stock of Propofol
 Inpatient: Eleven - 100 ml vials
 Outpatient: Six - 100 ml vials
 AFCH: Ten - 100 ml vials
iii. Report to O.R. Charge Nurse for additional instructions regarding further evacuations.
J. Suggested Evacuation Route in Order of Availability
1. Inpatient O.R. (third floor)
a. First available Inpatient O.R. in opposing color-coded block - refer to the Inpatient Fire
Evacuation Map
b. Inpatient PACU
c. FDS
d. Cath Lab
2. Outpatient O.R.
a. Available O.R. in adjacent block (i.e. A1-A6 to B1-B3) - refer to the Outpatient Fire
Evacuation Map
b. Ambulatory Procedure Center - refer to the Outpatient Fire Evacuation Map
3. AFCH O.R.
a. Refer to AFCH Evacuation Map
4. The American Center O.R.
a. If fire in Zone 1 (OR Rooms 1-8 and sterile core), evacuate to Zone 2 (OR Rooms 9-14 and
their prep rooms)

UNIVERSITY OF WISCONSIN
POLICY & PROCEDURE

EFFECTIVE DATE

JUNE 1987
ORIGINAL
 REVISION

JUNE 2017
PAGE 5
OF 6
POLICY #

6.01
ADMINISTRATIVE MANUAL
NURSING MANUAL
OTHER SURGICAL
SERVICES – ADMINSTRATIVE
MANUAL
TITLE
FIRE RESPONSE GUIDELINES – INTRAOPERATIVE
AREAS


b. If fire in Zone 2 (OR Rooms 9-14 and their prep rooms), evacuate to Zone 1 (OR Rooms 1-
8 and sterile core).
c. PACU

III. REFERENCES
Emergency Management Section C Annex M: Code Red (found on U-Connect).
American Society of Anesthesiologists, Practice Advisory for the Prevention and Management of
Operating Room Fires, Anesthesiology 2013: 118:00-00

IV. ATTACHMENTS

Attachment: Inpatient Fire Evacuation Map
Attachment: Outpatient Fire Evacuation Map
Attachment: AFCH Fire Evacuation Map
Attachment: TAC Fire Evacuation Map
Attachment: Fire Risk Assessment Interventions Scoring

REVIEWED BY

Denise Dillon, Clinical Operations Manager, 1/2017
Joseph Hilgers, Nurse Clinician, AFCH-OR 1/2017
Ann White, Surgical Services Manager of Education and Informatics 12/2016
Marisa Bartlett, Director of Safety, UW Health 1/2017
Megan Donovan, Clinical Pharmacist 1/2017
Surgical Services Policy and Procedure Committee 6/2017
Jill Barrier, Surgical Services Supervisor 1/2017
Dr. Christopher Turner, MD Associate Professor of Anesthesiology 1/2017
Dr. Deborah Rusy, MD, Associate Professor of Anesthesiology 1/2017
Tricia Ejzak, Manager of Operating Room at TAC 1/2017


SIGNED BY
Anne Mork, MHCDS, MS, RN
Director, Surgical Services