QUESTION: In response to the recent joint Commission on Accreditation of Healthcare Organizations (JCAHO) sentinel event alert regarding surgical fires, our facility manager claims that we need fire blankets, not fire extinguishers, in the ORs. Should fire blankets be used in the OR instead of fire extinguishers?

ANSWER: Fire blankets are not recommended for use in the OR. Fire blankets usually are made of wool that is impregnated with a fire-retardant chemical. They are meant to be wrapped around the burning person to smother the fire. According to ECRI, fire blankets should not be placed in an OR or used for patient fires. Following are the many reasons for this strong statement.

* The fire could be sustained by oxygen delivered to the patient, preventing the blanket from being effective.

* A blanket traps the fire next to and under the patient, causing further injury.

* Placing a fire blanket on a patient may displace instruments and cause further injury.

* Fire blankets will burn if used in oxygen-enriched atmospheres.

* Blankets are less effective at extinguishing fires on a patient than other methods, such as the use of a carbon dioxide fire extinguisher.

* Their use on a patient can lead to additional complications, such as wound contamination or even spreading the fire.

* If the blanket is placed in the OR, staff members may assume that it is suitable to use to extinguish a surgical fire, placing the patient at further risk. (1,2)

The JCAHO sentinel event alert on preventing surgical fires does not suggest that fire blankets be used in the OR or that they should replace fire extinguishers. The joint Commission does recommend that health care organizations do the following things to prevent surgical fires.

* Inform all surgical personnel about the importance of controlling heat sources by adhering to laser and electro-surgical safety practices, managing fuels by allowing sufficient time for patient prep, and establishing guidelines for minimizing oxygen concentration under drapes.

* Develop, implement, and test procedures to ensure appropriate response by all surgical team members to fires in the OR.

* Report any instances of surgical fires to JCAHO, ECRI, the US Food and Drug Administration, and appropriate state agencies as a method of raising awareness and preventing the occurrence of fires in the future. (3)

Fire extinguishers should be located in or near the OR to deal with fires that engulf or have migrated off the patient. Staff members should know when, how, and why to use fire extinguishers to put out a fire. Water-based, carbon dioxide C[O.sub.2], and dry-powder fire extinguishers commonly are used in the OR. According to ECRI, a 5-Ib C[O.sub.2] extinguisher should be mounted just inside the entry of each OR. (1) Local authorities have jurisdiction over specific requirements for health care facility portable fire extinguishers. Requirements for each type of fire extinguisher vary from state to state. Each state authority for fire regulations is governed either by the fire marshal or the state department of health. Some states may have local or regional regulations as well. Facilities should contact the local fire district for specific regulations for their area. (4)

QUESTION: Our infection control officer has asked OR staff members to evaluate alcohol-based surgical hand scrub products to replace the iodophor impregnated scrub brushes that we have used for years. Are these new brushless, alcohol-based scrub products acceptable?

ANSWER: Surgical hand scrubs have been known to play a vital part in preventing surgical site infections for many years, beginning with the pioneering work of Ignaz Philipp Simmelweiss, MD, and Joseph Lister, MD, in the 1860s. Antiseptic products and techniques used to perform the surgical hand scrub have evolved and improved, reflecting the continuing advancement of medical and nursing science.

In recent years, manufacturers have begun to introduce new hand scrub products that are challenging traditional lengthy scrub routines that use water, brushes, and, most commonly, either iodophor or chlorhexidine gluconate preparations. In the 2002 “Guidelines for hand hygiene in health care settings,” the CDC suggested that health care providers also consider the use of alcohol-based surgical hand scrub products when selecting hand hygiene agents, citing studies demonstrating that hand scrub formulations containing 50% to 90% alcohol combined with chlorhexidine gluconate are more effective than chlorhexidine gluconate, iodophor, and plain soap alone. (5) The publication of this CDC guideline produced a flurry of interest in the new brushless, alcohol-based surgical hand scrub products.

Many infection control and perioperative professionals are interested in trying these new products. Adapting traditional practices to new technology and innovation should be encouraged but approached with informed caution. Selection of surgical hand scrub products should not be taken lightly, and changes in products and technique should be made only after careful consideration and evaluation.

Surgical hand scrub products should be evaluated first for their ability to substantially reduce microorganisms on intact skin. The product should have broad-spectrum activity, be effective immediately, and have persistent activity. (6) A cumulative effect, measured after multiple applications during five days, also is desirable. An important additional consideration is the effect on the user’s skin over time. The product should not be irritating or damage skin after frequent and long-term use.

Alcohol-based brushless scrub products generally combine an antimicrobial agent, such as chlorhexidine gluconate with 60% to 70% alcohol, and added moisturizing emollients. They may or may not require the use of water. Hands should be pre-washed and nails cleaned with a nail pick under running water to remove gross debris and superficial microorganisms before applying the alcohol-based scrub product. Water will dilute the product and reduce its effectiveness; therefore, hands and arms should be dried thoroughly before the alcohol-based scrub is applied. The product contains alcohol and is flammable, so it must be allowed to dry before an individual dons gown and gloves. The entire process requires approximately three to five minutes.

The benefits of selecting a brushless, alcohol-based surgical hand product may include

* fast and easy application,

* limited or decreased damage to the user’s skin,

* improved compliance with hand antisepsis protocols,

* simplified application technique, and

* reduced material waste (ie, water, brushes, packaging).

Disadvantages may include

* user training needed;

* failure of the user to properly wash his or her hands before applying the product; and

* potential fire hazard (eg, failure of the user to allow the alcohol to evaporate before he or she dons sterile gloves and gown, improper storage).

Improper use and application technique as a result of user unfamiliarity with manufacturer instructions can be a problem. Physicians and other personnel who are new to the facility or who practice in multiple facilities may not be familiar with the important differences between the traditional scrub routine using a brush and antiseptic solution and the brushless technique using an alcohol-based scrub product. New users may not understand that hands still must be washed and nails cleaned before the alcohol-based product is applied, even though the product itself may be waterless. They may not understand the importance of allowing the product to dry completely before donning gown and gloves. Although the brushless technique is easy to learn, old habits often are difficult to break. Introducing a brushless surgical scrub product requires additional staff member preparation and education.

Alcohol is flammable, and alcohol-based scrub products must be used and stored carefully to minimize fire hazard. Although alcohol-based products have been used in health care settings for general hand hygiene without incident for some time, the American Journal of Infection Control recently reported an incidence of flash fire associated with the use of an alcohol-based hand antiseptic agent[..sup.7] Flash fires associated with use of alcohol-based hand hygiene products can have potentially severe consequences for health care workers and their patients. Health care workers should ensure complete drying or evaporation of the product before they engage in other activities. Other risk reduction strategies include maintaining ambient humidity within recommended limit (8) and avoiding use of 100% polyester gowns and drapes. If polyester gowns and drapes are used, they should have an antistatic carbon fiber or an antistatic finish.