1. Kroning, Maureen EdD, RN
  2. Yezzo, Phyllis DNP, RN, CPHQ, NEA-BC
  3. Leahy, Mary MD

Article Content

DURING INFECTION prevention rounds at a health system in New York, clinicians observed an egg timer in the OR. The surgical staff explained that the timer was set to ensure that the alcohol-based prep solution was allowed to dry according to manufacturer recommendations. The benefits of using the egg timer include its loud sound, its portability, and, most important, its value in reducing the risk of OR fires.


Alcohol-based prep solutions are often implicated in OR fires.1 This article discusses OR fires, the role of egg timers in reducing fire risks, and other strategies for improving safety in the OR.


Understanding OR fires

Although OR fires are rare (approximately 20 to 200 cases each year), they have devastating consequences for patients and often result in litigation against the surgeon, OR staff, and healthcare facility.1 OR fires occur when the three elements of the fire triangle are present: heat (an ignition source), an oxidizer (such as oxygen), and fuel. (See Understanding the fire triangle.) Each of these is typically present in the OR. In an alert, The Joint Commission warned healthcare professionals about the abundance of flammable materials typically present in the OR, including:2


* alcohol-based prep solutions


* ointments


* dressings


* linens, such as drapes, towels, gowns, hoods, masks, and other equipment or supplies used in surgical procedures.



Additionally, The Joint Commission stated that the ignition sources found in oxygen-enriched OR settings, such as electrocautery units, fiber optic light sources, and lasers, may produce incandescent sparks that could start a fire.2 Of approximately 100 OR fires reported in the US annually, 68% are ignited by electrical surgical factors, 19% by electrocautery units, and 13% by lasers.3


Alcohol-based antimicrobial agents, such as alcohol-based prep solutions, are often sources of fuel for OR fires because alcohol produces flammable vapors as it dries.1,4 One study found that many OR fires had resulted from skin preps that had not dried sufficiently or had been left in close proximity to ignition sources.5 Egg timers can help prevent surgical fires by ensuring that staff allows for sufficient drying time as directed by the product manufacturer.


Keeping time with an egg timer

Although skin cannot be truly sterilized, transient microorganisms may be removed and residential microorganisms diminished with friction and a skin prep agent.6 This combination helps prevent surgical site infections (SSIs).6


Alcohol-based prep solutions remove debris, reduce microbes to a minimum, and hinder additional microbe growth during surgery.6 Compared with alcohol alone, these are also less flammable and have greater residual microbial activity persistence.7 However, to minimize risks and maximize benefits, clinicians must follow the manufacturer's guidelines to allow sufficient drying time before surgery commences.


Using an egg timer can help to ensure that enough time has passed for the alcohol-based prep solution to dry sufficiently. One manufacturer recommends leaving the skin prep to dry for at least 3 minutes on skin with sparse hair, 6 minutes on areas with skin folds, and up to an hour on hairy areas.4 Besides minimizing fire risks, this step also allows the skin prep to achieve optimal effectiveness before an incision is made.


Other fire prevention strategies

Hospitals and healthcare facilities can incorporate various strategies to prevent surgical fires, including:8


* staff communication


* safe use of oxidizers, fuel sources, and potential ignition devices such as oxygen administration devices


* fire drills.



The FDA recommends that OR staff complete a fire risk assessment before each procedure. Staff should make sure they are communicating, recognize fuel and ignition sources, and plan and practice what to do in the event of a surgical fire.9 For example, staff can utilize patient handoffs, huddles before procedures, and surgical time-outs to ensure effective communication.


According to the Association of periOperative Registered Nurses, some frequently overlooked strategies and guidelines must be included in fire education and training efforts.10 These include annual fire drills to mimic real-life situations on all shifts. Additionally, staff should ensure all fire extinguishers are working properly and that staff members are appropriately trained to use fire extinguishers, to roll and smother a fire with fire blanket, and to utilize patient evacuation protocols when necessary. The healthcare staff should also commit to ongoing training and drills involving the local fire department.


Teamwork required

Each member of the staff must play a role in surgical fire prevention by minimizing elements of the fire triangle. For example, the anesthesia care provider ensures the safe delivery of oxygen; the surgeon monitors heat sources, such as lasers, lights, and drills; and the nurses and surgical technologists prevent fuel sources, such as alcohol-based products, hand sanitizers, and certain dressings and skin preps, from being too close to sources of ignition.11


By using an egg timer in the OR, the hospital staff helps to ensure safe quality care. Although an OR fire has not occurred in the authors' facility, SSIs are a growing concern. Working to address and prevent both surgical fires and SSIs will help ensure safety and prevent patient harm.




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4. BD. ChloraPrep FAQs. 2019. [Context Link]


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6. Association of Surgical Technologies. AST standards of practice for skin prep of the surgical patient. 2008. [Context Link]


7. George J, Klika AK, Higuera CA. Use of chlorhexidine preparations in total joint arthroplasty. J Bone Jt Infect. 2017;2(1):15-22. [Context Link]


8. Knowles M. FDA: 6 guidelines to prevent surgical fires. Becker's Healthcare. 2018. [Context Link]


9. US Food and Drug Administration. Recommendations to reduce surgical fires and related patient injury: FDA safety communication. 2018. [Context Link]


10. Association of periOperative Registered Nurses. Fire education and training: 7 overlooked areas. 2017. [Context Link]


11. Miller-Hoover S. Only you can prevent surgical fires. 2018. [Context Link]