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Compliance News: Operating Room Fire Loss Prevention and Emergency Procedures

| David Stymiest

One important change in NFPA 99-2012 was the addition of Chapter 15, Features of Fire Protection.  Within that chapter is a new Section 15.13, entitled Fire Loss Prevention in Operating Rooms.

Subsection 15.13.1, Hazard Assessment, requires an evaluation of FIRE hazards that could be encountered during surgical procedures, including “hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment.”  This subsection also requires periodic reviews of surgical operations and procedures that include any changes “in materials, operations, or personnel.”  We suggest that these assessments and periodic reviews be established, rigorously enforced, and well-documented.

Subsection (Paragraph) 15.13.2, Fire Prevention Procedures, requires that operating room fire prevention procedures be established.  We suggest that these procedures be established with appropriate training, rigorously enforced, and with ongoing compliance documented.

Subsection 15.13.3, Germicides and Antiseptics, is quite comprehensive.  It includes requirements related to packaging and use of sanitizers, germicides and antiseptics.  It also discusses requirements related to drapery and the use of electrosurgery, cautery, or a laser.  It further requires a preoperative “time out” period for stipulated fire loss prevention processes.

This subsection also requires related safety policies and procedures as well as related emergency procedures.  The emergency procedures must include “alarm actuation, evacuation, and equipment shutdown procedures and provisions for control of emergencies that could occur in the operating room, including specific detailed plans for control operations by an emergency control group within the organization or a public fire department.”

And finally, this subsection includes requirements for orientation and training, continuing safety education and supervision, monthly reviews, and fire exit drills.

CMS K-Tag K933, Features of Fire Protection – Fire Loss Prevention in Operating Rooms states the following:

“Periodic evaluations are made of hazards that could be encountered during surgical procedures, and fire prevention procedures are established. When flammable germicides or antiseptics are employed during surgeries utilizing electrosurgery, cautery or lasers:

  • packaging is non-flammable.
  • applicators are in unit doses.
  • Preoperative “time-out” is conducted prior the initiation of any surgical procedure to verify:
    • application site is dry prior to draping and use of surgical equipment.
    • pooling of solution has not occurred or has been corrected.
    • solution-soaked materials have been removed from the OR prior to draping and use of surgical devices.
    • policies and procedures are established outlining safety precautions related to the use of flammable germicide or antiseptic use.

Procedures are established for operating room emergencies including alarm activation, evacuation, equipment shutdown, and control operations. Emergency procedures include the control of chemical spills, and extinguishment of drapery, clothing and equipment fires. Training is provided to new OR personnel (including surgeons), continuing education is provided, incidents are reviewed monthly, and procedures are reviewed annually. 15.13 (NFPA 99)”

On a more general note, all of Chapter 15 is invoked by CMS K-Tag K932, Features of Fire Protection, which states “List in the REMARKS section any NFPA 99 Chapter 15 Features of Fire Protection requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 15 (NFPA 99).”

Both CMS and the Accrediting Organizations are surveying to these requirements now.

As an example, TJC Director of Engineering George Mills indicated during his presentation at the March 2017 PDC Conference that TJC surveyors are likely to score noncompliances with CMS K-Tag K932 (which requires compliance with NFPA 99-2012 Chapter 15 as stated above) at Leadership Standard LD.04.01.01 Element of Performance 2 (“The hospital provides care, treatment, and services in accordance with licensure requirements, laws, and rules and regulations”) until a new EP is issued that specifically mentions Chapter 15.

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