REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 1 Introduction of a Novel Quick Reference Guide for Certified Registered Nurse Anesthetists to Assist in Perioperative Fire Prevention: A Quality Improvement Project Erin T. F. Stevens, BSN, SRNA Dr. Angela Ciuca, DNAP, CRNA, Project Chair Nurse Anesthesia Program College of Nursing, East Carolina University Submitted in partial fulfillment of the requirements for the degree of Doctor of Nursing Practice December 7, 2021 REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 2 Abstract Perioperative fires are traumatizing events that may lead to patient and staff morbidity and mortality. CRNAs are in a unique position for monitoring, assessing, and intervening to prevent perioperative fires yet fire prevention resources designed specifically for anesthesia providers are not available. In this quality improvement project, a perioperative fire prevention quick reference guide tailored to the distinct role of the CRNA was created. This guide was distributed to CRNAs for use in practice at an ambulatory surgical center and its utility was evaluated via pre- and post-intervention participant surveys. Participants indicated that availability of the reference guide improved confidence in knowledge about perioperative fire prevention and decreased the amount of time it would take to access reference materials on the topic, should the need arise. The quick reference guide represents a cost-effective method of improving patient safety and staff efficiency. For future use, the guide may be tailored to suit the needs of other organizations based on procedures performed or equipment utilized. Keywords: perioperative fire, fire prevention, CRNA REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 3 Table of Contents Abstract …………………………………………………………………………….……………. 2 Section I: Introduction ...………………………………………………………………………… 5 Background………………………………………………………………….…………… 5 Organizational Needs Statement……………………………………………......…………5 Problem Statement……………………………………………………………...…………8 Purpose Statement…………………………………………………………………………8 Section II: Evidence……………………………………………………………………………….9 Literature Review……………………………………………………………………….…9 Evidence-Based Practice Framework……………………………...…………………….15 Ethical Consideration and Protection of Human Subjects……………………………….15 Section III: Project Design………………………………………………………….……………17 Project Site and Population…………………………………………………….………...17 Project Team……………………………………………………………………..………17 Project Goals and Outcomes Measures……………………………………..……………18 Implementation Plan…………………………………………………………..…………19 Timeline………………………………………………………………………………….19 Section IV: Results and Findings………………………………………………………...………20 Results……………………………………………………………………...…………….20 Section V: Interpretation and Implications………………………………………………………24 Cost-Benefit Analysis……………………………………………………………………24 Resource Management………………………………………………………...…………24 Implications of the Findings………………………………………………………..……25 REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 4 Sustainability ……………………………………………….……………………………26 Dissemination Plan ……………………………………………………...………………27 Section VI: Conclusion………………………………………………………………………..…28 Limitations…………………………………………………………………….…………28 Recommendations for Others……………………………………………………………28 Recommendations for Further Study…………………………………………….………28 References…………………………………………………………………………………..……29 Appendices…………………………………………………………………………….…………33 Appendix A: Literature Search Concepts…..……………………………………………33 Appendix B: Literature Search Summary…………………………………..……………34 Appendix C: Literature Matrix……………………………………………..……………35 Appendix D: IRB Waiver…………………………………………………………..……36 Appendix E: Organizational Approval Form………………………………………….…39 Appendix F: Surgical Fire Prevention Quick Reference Guide…………………….……43 Appendix G: Pre-Intervention Questionnaire……………………………………………44 Appendix H: Post-Intervention Questionnaire……………………………………...……46 Appendix I: Email Invitation to Participate in Quality Improvement Project……...……48 Appendix J: Second Email to Project Participants………….……………………...……49 Appendix K: DNP Project Timeline……………………………………………...…...…50 Appendix L: Summary of Results……………………………………………………….51 REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 5 Section I. Introduction Background Perioperative fires are traumatic events for patients and staff. In the United States, approximately 650 operating room (OR) fires are voluntarily reported annually (Jones et al., 2019). These fires are thought to contribute to two to three patient deaths per year although the actual number of OR fires, and their impact on patient outcomes, is unclear. Three components, known as the triad of fire, have been identified as essential for a fire to occur: an oxidizer, an ignition source, and a fuel. These three components are present in nearly all surgical procedures (Jones et al., 2019). Despite the risk of fire being commonplace, Coletto et al. (2018) found that 99% of Certified Registered Nurse Anesthetists (CRNAs) and Student Registered Nurse Anesthetists (SRNAs) surveyed self-reported their knowledge of operating room fire risks and prevention was inadequate. This statistic is alarming as anesthesia providers are responsible for the administration and management of the two oxidizers identified as contributing to perioperative fires: oxygen and nitrous oxide. Organizational Needs Statement The partnering organization for this quality improvement project was an ambulatory surgical center in the southeastern United States. At the time of project implementation, this organization had been in operation for over 25 years and performed 12,000 surgeries annually. The organization had an OR fire safety policy that outlined staff responsibility and training, contained a fire risk assessment tool, and provided suggested interventions to prevent or manage a fire. All perioperative personnel at the organization were required to participate in annual perioperative fire prevention and management education and skills validation. The organization also required that a fire risk assessment be performed prior to each operation and documented by REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 6 the circulating nurse. The organization did not have fire risk training or resources designed specifically for anesthesia providers. Anesthesia providers are directly responsible for the management of all oxidizers utilized in the OR, thus their role in OR fire prevention is unique. Fire requires the presence of all three components of the triad of fire—the oxidizer, ignition source, and fuel. The identification and mitigation of just one component, such as the oxidizer, would prevent a fire; therefore, anesthesia providers’ management of oxidizers is crucial to preventing OR fires. Improving the safety and quality of healthcare is a priority for American health professionals and multiple initiatives outline measures to achieve these goals. The Institute of Healthcare Improvement (2020) has created the Triple Aim for Populations, a framework that “describes an approach to optimizing health system performance” by “applying integrated approaches to simultaneously improve care, improve population health, and reduce costs per capita” (para. 1). Additionally, every decade since the 1980s, the U.S. Department of Health and Human Services has produced updates to its Healthy People initiative—a “guide to national health promotion and disease preventions efforts to improve the health of the nation” (Centers for Disease Control and Prevention, 2020, para 1). One of the Healthy People 2030 goals is to “improve health care” as “high-quality health care helps prevent diseases and improve quality of life” (Office of Disease Prevention and Health Promotion [ODPHP], 2020, para 1). The authors of this goal also note that “strategies to make sure health care providers are aware of treatment guidelines and recommended services are also key to improving health” (ODPHP, 2020, para 1). In the spirit of these initiatives, CRNAs should work to improve the health of the surgical patient population by improving the safety and quality of anesthesia care provided. The creation of a REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 7 perioperative fire prevention quick reference guide is a strategy to aid CRNAs in this mission by ensuring timely access to fire prevention guidelines. The unique role CRNAs perform in the prevention of OR fires has been acknowledged by the American Association of Nurse Anesthetists (AANA), the professional organization representing CRNAs nationwide, which has joined as a collaborating partner in the U.S. Food and Drug Administration’s (FDA) Preventing Surgical Fires Initiative (AANA, 2020). Having an OR fire prevention resource specifically for anesthesia providers could help ensure the practice of the partnering organization’s CRNAs reflects the standards established by the AANA and help ensure the organization performs to the standards established by the FDA. Not only is operating room safety paramount to the patient and staff, but also to the financial wellbeing of the healthcare organization. The largest share of American health spending, 29%, is sponsored by the federal government, and the Affordable Care Act of 2010 mandated that a value-based purchasing program be implemented for Medicare reimbursement to ambulatory surgical centers (Centers for Medicare and Medicaid Services [CMS], 2020a, 2020b). This value-based purchasing program requires that ambulatory surgical centers report data on identified performance measures and ties Medicare reimbursement to the facility’s outcomes. The first performance measure identified by this value-based purchasing program for ambulatory surgical centers was “patient burn” (CMS, 2018, para. 3). This performance measure mandates that ambulatory surgical centers report the number of admissions that experience a burn prior to discharge—this includes not only a burn experienced with a surgical fire, but also chemical, electrical, or radiation burns (CMS, 2018). Facilities with high numbers of patient burns, or those determined to be low-performing based on other performance measures, receive a decreased reimbursement amount from Medicare for all services provided at the facility. REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 8 Problem Statement OR fires are traumatizing events that may lead to staff and patient morbidity and mortality. Fire prevention requires constant vigilance of OR staff (Jones et al., 2019). Although the anesthesia provider is in a unique position for monitoring, assessing, and intervening to prevent OR fires, the partnering organization did not have OR fire prevention resources in place designed specifically for anesthesia providers. Purpose Statement The purpose of the proposed DNP quality improvement project was to create, implement, and assess providers’ perception of adequacy of a newly developed quick reference guide designed specifically for anesthesia providers about perioperative fire prevention with the goal of improving ease of access to reference materials tailored to the anesthesia provider’s unique role in perioperative fire prevention. REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 9 Section II. Evidence Literature Review To determine the underlying cause of OR fires, and best practice prevention methods, a literature review was performed. The primary concepts utilized for the literature search included “operating room fire prevention” and “cognitive aids in anesthesia.” The term “cognitive aid” was determined to be more inclusive than “reference guide” and thus employed during the literature review. Keywords, PubMed MeSH terms, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) subject headings used are summarized in Appendix A. Articles related to OR fire prevention as well as the use of cognitive aids in anesthesia were reviewed in PubMed, CINAHL, and ProQuest. Initially resources were excluded if the publication date was not within five years but, due to a lack of relevant articles and professional practice guidelines in that date range, the inclusion criteria was expanded to publication within the last ten years (2010-2020). The search strategy is displayed in Appendix B. Additional resources were gathered through a manual review of references listed in articles determined applicable to the topic as well as through searches of Google Scholar and websites of pertinent organizations. Articles determined pertinent to this project were appraised for relevancy, currentness, and level of evidence using Melnyk & Fineout-Overholt’s (2019) level of evidence guidelines. Within this system, Level I evidence, systematic reviews and meta-analyses of randomized controlled trials, provide the strongest and most desired level of evidence, but few such resources were available. Additional levels include: Level II evidence: randomized controlled trials; Level III: quasi-experimental or non-randomized controlled trials; Level IV: case control and cohort studies; Level V: systematic reviews of descriptive and qualitive studies; Level VI: qualitative or REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 10 descriptive studies; Level VII: opinion of authorities or reports of expert committees (p. 101). Most articles pertinent to this issue were level IV-VII. Over 400 articles were reviewed during literature searches, ten were used to support the project. Appendix C contains a literature matrix summarizing utilized resources and identifying their level of evidence. Current State of Knowledge Three components are essential for the creation of fire—an oxidizer, an ignition source, and a fuel. Jones et al. (2019) identified common sources of each component found in operating rooms: oxidizers- oxygen, nitrous oxide; fuels- alcohol-based skin preps, drapes, gowns, gauze, sponges, endotracheal tubes, intestinal gasses; and ignition sources- electrosurgical units, lasers, fiberoptic light sources, drills, high-speed Burrs, and defibrillators. Anesthesia providers hold the primary responsibility for the management of the oxidizer component of the fire triad—oxygen and nitrous oxide (Ahmed & Girshin, 2013). It is also noteworthy that objects that may serve as fuel for a fire are influenced by varying oxygen concentrations; nearly all objects can become a fuel source once oxygen content is increased to greater than 30% (Jones et al., 2019; Kezze et al., 2018). A standard endotracheal tube is combustive when oxygen concentration is greater than 25% (Bansal et al., 2013). Mehta et al. (2013) reviewed closed malpractice claims in the American Society of Anesthesiologists Closed Claims Database between 1985-2013. Oxygen was determined to have served as the oxidizer in 95% of electrocautery-induced OR fires and 100% of OR fires with other ignition sources. Electrocautery in the presence of supplemental oxygen during monitored anesthesia care (MAC) cases was identified as the most common cause of OR fires. In 2013, the American Society of Anesthesiologists (ASA) task force on operating room fires published their most current Practice Advisory for the Prevention and Management of REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 11 Operating Room Fires. In this report, several key concepts were defined. According to the ASA (2013), “an oxidizer-enriched atmosphere occurs when there is any increase in oxygen concentration above room air level, and/or the presence of any concentration of nitrous oxide” (p. 1). High-risk procedures were defined as any procedure where “an ignition source can come in proximity to an oxidizer-enriched atmosphere” (ASA, 2013, p. 2). Tonsillectomy, tracheostomy, removal of laryngeal papilloma, cataract or eye surgery, burr hole surgery, or removal of any lesion of the face, head, or neck were all identified as high-risk procedures (ASA, 2013, p. 2). It was also noted that any time supplemental oxygen is administered in the OR, it is a high-risk situation (ASA, 2013, p. 2). Given the vital role supplemental oxygen plays in the occurrence of perioperative fires, it is recommended that the anesthesia circuit be checked for leaks prior to each case and oxygen should be turned off after each case (Spruce, 2016). ASA (2013) also recommended that each surgery should begin with a fire risk assessment that is communicated to the entire OR team and also provided a number of specific practice recommendations, including: • Avoid using ignition sources in close proximity to an oxidizer-enriched atmosphere. • Configure surgical drapes so minimize the accumulation of oxidizers. • Suction the zone around the head to limit oxygen and nitrous oxide gasses accumulation in that area. • Scavenge the oropharynx with suction during oral cases • Allow sufficient drying time for flammable skin prepping solutions. • Moisten sponges and gauze when used in close proximity to ignition sources. REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 12 • Laser resistant endotracheal tubes should be used during laser surgeries and the tube cuff should be filled with saline tinted blue with methylene blue to act as a marker for cuff puncture by laser. • For surgeries inside the airway, cuffed, rather than uncuffed, endotracheal tubes should be used. • If the airway is to be accessed with an electrosurgical device, nitrous oxide should be discontinued and oxygen should be reduced to <30% for 1-5 minutes. • During oral procedures, the oropharynx should be scavenged with suction device during procedure. • For surgeries around the head/face/mouth, a closed oxygen delivery system should be considered when supplement oxygen is required (ASA, 2013, p. 5-7). Surgeries of the airway or in the lungs also have high potential for fire. It is recommended that during these surgeries the anesthesia provider ensure there is no air leak from the endotracheal tube and that they consider suctioning the ipsilateral lumen of a dual lumen endotracheal tube to decrease oxygen near electrocautery (Bansal et al., 2013). It is also best practice to discuss oxygen delivery with the surgeon and to ask the surgeon to announce intent to use an ignition source (Di Pasquale & Ferneini, 2017). In 2018, the FDA Safety Communication, Recommendations to Reduce Surgical Fires and Related Patient Injury was produced. According to this communication, “An open oxygen delivery system, such as a nasal cannula or mask, presents a greater risk of fire than a closed delivery system, such as a laryngeal mask or endotracheal tube” (para. 5). It is recommended that anesthesia providers avoid the administration of supplemental oxygen, if possible (Jones et al., 2019; The Joint Commission, 2003; FDA, 2018). If supplemental oxygen is required, it should REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 13 be administered with the use of an oxygen blender or via the common gas outlet of the anesthesia machine to avoid administration of 100% oxygen. In surgical cases that are considered high risk for fire where the patient requires greater than 30% oxygen, the anesthesia provider is strongly urged to place a supraglottic airway or endotracheal tube (FDA, 2018; Jones et al., 2019). Echoing the recommendation of ASA (2013) and Spruce (2016), the FDA (2018) recommended that a fire risk assessment should be performed at the beginning of each surgical procedure, noting that staff should “be aware that the highest risk procedures involve an ignition source, delivery of supplemental oxygen, and use of an ignition source near the oxygen (e.g., head, neck, or upper chest surgery)” (para. 7). The Silverstein Fire Risk Assessment is a risk assessment tool that can be utilized by anesthesia providers to rapidly assess fire risk (Mathias, 2006). The assessment consists of three items that are scored one point each for their presence in the surgery—"open oxygen source,” “presence of an ignition source,” and “surgery at/above the xiphoid.” A score of 0-1 is considered low risk for fire. A score of 2 is considered intermediate risk while a score of 3 should be considered high risk for fire (Mathias, 2006). Current Approaches to Solving Population Problems Multiple researchers have published studies reporting the outcomes of interventions to prevent OR fires. Tola et al. (2018) implemented an OR fire prevention educational session for OR staff, including anesthesia providers, and found that the one-time education session improved staff members’ knowledge and use of prevention strategies. Kishiki et al. (2019) found that healthcare professionals who participated in OR fire simulation scenarios scored significantly higher on an OR fire competency test than healthcare professionals who participated in classroom only training. Coletto et al. (2018) found that CRNAs and SRNAs had “positive and favorable attitudes toward fire risk assessment and the use of checklists in the OR” (p. 106). REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 14 According to Stiegler and Tung (2014), external decision support tools are effective ways to reduce errors in anesthesia decision making, noting that, “these tools are commonly used in aviation and include checklists, written algorithms, clinical decision aids built into electronic medical records, and guidelines” (p. 214). McEvoy et al. (2014) found that use of an electronic decision support tool improved anesthesia provider adherence to guidelines in simulated emergency management. Evidence to Support the Intervention Identified evidence showed greatest support for in-person and simulation training, however, this intervention was planned during the novel Corona Virus Disease 2019 (COVID- 19) pandemic. In-person gatherings had been limited across the nation in an attempt to slow the spread of the virus, while American healthcare professionals had been called upon to work long hours under extraordinarily difficult conditions. With consideration of these unprecedented circumstances, it was decided that the intervention should be implemented in a remote manner to prevent unnecessary congregation of staff and to allow participation without unnecessary direct contact. The findings of Stiegler and Tung (2014) and McEvoy et al. (2014), supported the creation and electronic delivery of a novel cognitive aid for OR fire prevention tailored to the needs of anesthesia providers. With consideration of the partnering organization’s needs, results of previously mentioned studies, and pandemic precautions, it was decided that a quick reference guide would be created and distributed to the organization’s anesthesia providers. To tailor this intervention to the anesthesia providers’ role in OR fire prevention, findings from the literature supported inclusion of a brief fire risk assessment tool as well as case-specific tips and guidance from best practice guidelines. REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 15 Evidence-Based Practice Framework Identification of the Framework The framework for the intervention was adapted from the “four-element implementation strategy” outlined by Goldhaber-Fiebert and Howard (2013, p. 1153) for the implementation of emergency manuals in anesthesia settings. The four elements are: create, familiarize, use, and integrate. First, the cognitive aid was created with consideration of both content and design. Then electronic delivery of the aid and an introduction video were utilized as training to familiarize the target audience with the tool. The third element, use, involved consideration of the accessibility of the cognitive aid for success in the clinical setting. Electronic delivery of the tool provided CRNAs with the flexibility to keep a copy of the tool on a phone or work computer or to print a copy, per their preference. To integrate the tool into the organization, Goldhaber- Fieber and Howard (2013) suggest “practitioner feedback and involvement in the other 3 elements (create, familiarize, and use) ensures more successful implementation both by integrating helpful suggestions and by increasing stakeholder buy-in” (p. 1158). To aid integration, a subject matter expert was consulted and served to evaluate the cognitive aid prior to dissemination. Ethical Consideration & Protection of Human Subjects Through the collaboration of East Carolina University’s Institutional Review Board (IRB), the College of Nursing, and the partnering organization, this quality improvement project was deemed exempt from full IRB review, see Appendices D and E. The primary investigator completed the Collaborative Institutional Training Initiative (CITI Program) courses “Human Research” and “Responsible Conduct of Research” in August 2020. The project participants were limited to CRNAs practicing in the OR setting of the partnering organization who REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 16 volunteered to participate. No patient information was collected. There was no more than minimal potential for risk to the target population as the information and processes fall within usual practice for the organization. Identified risks included potential for a small amount of added stress and increased time demands on participants. REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 17 Section III. Project Design Project Site and Population Description of the Setting The project setting was an ambulatory surgical center in the southeastern United States. This facility had a dedicated staff of seven CRNAs. Additionally, three to four CRNAs, from a pool of greater than one hundred, rotated to the facility daily from the local hospital. The facility performs more than 12,000 surgeries annually. The project was implemented primarily in a digital medium. Description of the Population The population of interest in this project was CRNAs who provided anesthesia services exclusively at the partnering organization. These CRNAs are employed by a large, physician- owned anesthesia practice in the southeastern United States. The project’s sample was composed of CRNAs from this population who volunteered to participate in this quality improvement project. Project Team The project team included the graduate nursing student, an SRNA, performing the project, a clinical CRNA faculty member who recruited participants, the CRNA faculty member as chair, the Nurse Anesthesia program director, a non-CRNA faculty member who facilitated the process, and a partner from the clinical setting. The quick reference guide was created in collaboration with three other SRNAs in the Doctor of Nursing Practice in Nurse Anesthesia program; however, the implementation, data collection, and data analysis were performed independently. REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 18 Project Goals and Outcome Measures Description of the Methods and Measurement After project approval was obtained, a pre-and post-survey methodology was used to complete the “integration” element of the project’s framework, Goldhaber-Fiebert and Howard’s (2013) “four-element implementation strategy.” The goal was to assess CRNA volunteer perceptions of adequacy of a newly developed quick reference guide designed specifically for anesthesia providers. Participants were recruited from the ambulatory surgical center by a CRNA faculty member. Each participant received an email containing the pre-intervention survey, introductory video, and a copy of the quick reference guide. The survey consisted primarily of Likert scale and dichotomous questions as well as a single free-response question. Participants were instructed to complete the survey prior to watching the educational video. A printed, laminated copy of the reference guide was then provided to participants and they were asked to utilize the tool for two weeks in their practice setting. After the two weeks utilization period they were asked to complete a post-intervention survey. Appendix F contains a copy of the tool while Appendices G and H contain the surveys. Discussion of the Data Collection Process The project email (see Appendix I) sent to participants included an anonymous link to the nine-question, pre-intervention survey delivered through Qualtrics survey software. Participants were asked to complete the survey prior to watching the introductory video and utilizing the new reference guide. After a period of two weeks a second email (see Appendix J) containing an anonymous link to the post-intervention survey via Qualtrics was sent to participants for completion. Data was immediately available for viewing on the Qualtrics platform. Data analysis was performed as appropriate to question type. REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 19 Implementation Plan Once voluntary participants were recruited, the project survey and tool were sent to the participants at the email of their selection. A copy of the invitation email sent can be found in Appendix I. Participants were to utilize the tool in their practice for a period of two weeks and then complete the post-intervention questionnaire which was emailed to them at the completion of the two-week timeframe (see Appendix J). The lead SRNA completed a clinical rotation at the project’s setting during project implementation and was available for participant questions intermittently in-person and otherwise via email. Timeline Topic exploration began in approximately May 2020 with literature search completion in November 2020. Project design and development was completed in February and March of 2021. Implementation took place over a two-week period from mid-April to early May 2021. Data analysis was completed in June of 2021. The dissemination of findings occurred in the fall of 2021. The project timeline is provided in Appendix K. REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 20 Section IV. Results and Findings Results Seven CRNAs agreed to participate in the project. On April 19, 2021, the initial project description email with links to the introductory video, the novel perioperative fire prevention quick reference guide, and the Qualtrics pre-intervention questionnaire was sent to the participants’ work email addresses. Seven anonymous responses were received to the pre- intervention questionnaire. On May 3, 2021, the second email with the Qualtrics post- intervention questionnaire link was sent to project participants. Six participants completed the post-intervention questionnaire. The data collected is displayed in Appendix L. In the pre-intervention questionnaire, 100% of respondents reported having received education on perioperative fire while only four respondents indicated that they had received continuing education on perioperative fire prevention. On the 1-5 Likert scale question, “how confident are you in your knowledge about perioperative fire prevention?” all participants rated their confidence between 3 and 5 with 5 being “very confident.” All respondents indicated that they had participated in a procedure where all elements of the fire triad were present, while only one respondent indicated that they had experienced a fire. On the second Likert scale question (1-5) all seven respondents rated themselves as 4-5 (with 5 being very confident) in their ability to identify a surgical procedure that has a high risk of fire. Four of seven participants indicated that they did not currently have perioperative fire prevention guidelines they could access quickly while at work and indicated it would take them between one and nine minutes to access material to answer a clinical question about perioperative fire prevention. All seven respondents indicated that an easily accessible reference guide would provide them support in decision- making regarding high fire risk procedures. REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 21 In the post-intervention questionnaire, 4 of 6 respondents indicated that they had participated in 9 or more procedures that were high risk for fire during the two week implementation period. The question regarding usefulness of the guide produced mixed responses. One participant indicated it was “not useful at all,” two indicated it was “very useful,” and three scored it as 3 or 4 on the 1 to 5 Likert scale. Four respondents felt the reference guide was easily accessible in the clinical setting but two did not agree. All seven participants found the guide visually appealing. Two respondents felt the reference guide saved them time while four did not. Of the six respondents, five felt they could access this reference guide within 1-3 minutes while at work while one felt it would take them 10 or more minutes to access it. Fifty percent of respondents thought they would use this reference guide in their work. Confidence in knowledge about OR fire prevention was again rated by all participants as 3-5 on a 1 to 5 Likert scale, with higher scores than in the pre-intervention questionnaire. Analysis Despite all CRNA participants indicating that they had received education on perioperative fire prevention, self-reported confidence scores gathered from pre-intervention question 3, How confident are you in your knowledge about perioperative fire prevention? and post-intervention question 8, After reviewing this reference material, how confident are you in your knowledge about perioperative fire prevention? indicated that reviewing perioperative fire prevention guidelines in the project’s intervention increased CRNA confidence in their own fire prevention knowledge. Responses are displayed in Figure 1. REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 22 Figure 1 Self-Reported Confidence Level Pre- and Post-Intervention 4 3 2 2 1 1 Not at all confident Slightly confident Somewhat confident Fairly confident Very confident Pre-Intervention (n=7) Post-Intervention (n=6) Interestingly, four of six post-intervention questionnaire participants indicated that the reference guide created did not save them time in their practice, yet comparison of pre- intervention question 8, If you had a question about perioperative fire prevention, approximately how long do you think it would take you to find reference material to answer the question? and post-intervention question 6, If saved to your mobile phone or work computer how long would it take you to access this reference guide? indicated that the participants estimated that it would take them less time to access the provided reference guide than find reference materials. Participant responses are displayed in Figure 2. REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 23 Figure 2 CRNA Estimated Time to Access Reference Material 1-3 minutes 4-6 minutes 7-9 minutes 10 or more minutes 5 3 2 2 1 0 0 0 Pre-Intervention (n=7) Post-Intervention (n=6) When the project participants were asked about their perception of usefulness of the tool, the majority indicated the tool could be useful for an anesthesia department. Responses to the post-intervention question, What is your perception of usefulness of this reference guide for an anesthesia department? are displayed in Figure 3. Figure 3 Perception of Usefulness of Reference Guide (n=6) 2 2 1 1 Not at all useful Slightly useful Somewhat useful Fairly useful Very useful REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 24 Section V. Interpretation and Implications Cost Benefit Analysis The project and intervention were extremely cost effective. The only costs incurred were related to having the reference guide professionally printed and laminated and purchasing a stand to hold the printed guides for a total cost of approximately $50. According to Mehta et al., (2013), the median malpractice claims payment to patients after an OR fire was $120,166; this amount does not reflect the cost of traumatization of staff, which is unquantifiable. If access to the guide prevented one OR fire, the return on investment would be more than $2,400 per $1 spent. The cost-benefit analysis is more complex if the project were implemented by the organization rather than an unpaid student. There would be salary/work hours that would need to be dedicated to the staff member that created the reference guide, prepared the questionnaires, and analyzed the data gathered. The project utilized Qualtrics survey software, a cost that was covered by the university. The project benefits were also difficult to quantify. Saving CRNAs time in accessing reference materials would improve efficiency within the organization but converting that efficiency to a dollar amount was beyond the scope of the project. Resource Management The successful outcome of this project was facilitated by the organization having CRNAs that were willing to participate in the project. One barrier to the project was that the organization’s anesthesia staff do not utilize computers in their job—all anesthesia records are kept on paper and the anesthesia workstation does not have a computer. This limitation prevented the project from being implemented in an entirely digital medium and necessitated the printing of the reference guide. REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 25 Implications of Findings Goldhaber-Fiebert and Howard (2013) identified four elements of implementation of emergency manuals in anesthesia settings: create, familiarize, use, and integrate. The fire prevention guide was created based on current best evidence as well as a quick view format that allows users to develop familiarity with the tool expending minimal time and effort prior to using the tool in practice. This project included three of the elements identified by Goldhaber-Fiebert and Howard (2013), create, familiarize, and use, but not the final element, integrate. Half of the CRNAs who completed the post-intervention survey indicated that they would use the reference guide in their practice as a CRNA. This indicates that the organization’s CRNAs are receptive to practice aids. The organization is affiliated with more than 100 CRNAs. If the project participants’ opinions are representative of the entire practice, then the guide could be provided to all CRNAs, utilized by more than 50, and potentially prevent countless fires. Implications for Patients As discussed previously, improving the quality and safety of healthcare in America is a priority for virtually all healthcare and healthcare-adjacent organizations, including the U.S. Department of Health and Human Services, the AANA, U.S. FDA, and CMS. Despite multiple initiatives to improve patient safety, approximately 650 OR fires still occur each year and two to three patients per year succumb to the injuries they sustain during these fires (Jones et al., 2019). CRNA access to the reference guide could create a medium for achieving the goal of improved patient safety by preventing OR fires. Implications for Nursing Practice Achieving improved patient safety should not only be a priority for organizations, but a priority for every individual healthcare provider. Access to this reference guide will provide REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 26 CRNAs with evidence-based reference material that can be accessed quickly and efficiently in the clinical setting to apply to real-world scenarios. The oxidizer component of the triad of fire is primarily managed by the CRNA member of the surgical team. Managing anesthesia equipment to minimize the risk of fire is a component of the AANA’s Standards of Nurse Anesthesia Practice (AANA, 2019). The reference guide provides CRNAs with reliable information and could save staff time that would otherwise be spent researching guidelines and aids staff in upholding the standards of nurse anesthesia practice. Impact for Healthcare System The healthcare system has a vested interest in improving patient safety—insurance reimbursement is often tied to quality of care. Preventing OR fires improves patient safety and improves the quality of care delivered by the healthcare system. This, in turn, improves the financial wellbeing of the organization. In addition to increasing reimbursement for services rendered, preventing OR fires prevents staff morbidity associated with such events. This could mean the organization has less staff missing days of work or requiring worker’s compensation for injuries sustained on the job. Also, having quickly accessible reference material that saves CRNAs time during the workday improves the organizational efficiency. Sustainability “Integration” is the final element of the “four-element implementation strategy” framework utilized for this project. The cost effectiveness of this project provides for significant longevity and ease of integration. Once the guide has been created, an annual literature review should be performed to verify information is current. Beyond that maintenance measure, there would be no additional costs to the organization for continuing the project in a digital medium. If REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 27 staff were to request a hard copy of materials, there may be a nominal fee associated with printing. Dissemination Plan The results of this project were presented in a poster format as well as oral presentation both in-person and via digital medium to East Carolina University’s College of Nursing faculty, staff, and students as well as the CRNAs of the partnering organization. The project participants were invited but not required to attend. The paper was also posted in East Carolina University’s digital archive of scholarly output, The ScholarShip. REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 28 Section VI. Conclusion Limitations Project sample size was small with only six participants completing the intervention. This small sample size prevented any descriptive statistics of data collected and limits the generalizability of results. It is also of note that the project was implemented in an outpatient surgical center, but CRNA staff members of the same practice are required to work at that facility as well as in inpatient settings. The utility of the tool for inpatient anesthesia care was not evaluated. Recommendations for Others For others considering reproducing or continuing the current project, attempts should be made to obtain a larger sample size. In a setting where computer charting is utilized, it may be helpful to send each project participant a copy of the tool and have the tool readily available on the work computers of the facility, such as in the form of a desktop icon. It may also be beneficial to create a smart phone application in addition to a PDF document for dissemination. Recommendations for Further Study It would be useful to know the prevalence of OR fires in the partnering organization and the circumstances surrounding the fire events. The tool was created with generic OR fire prevention information but could be customized to the organization’s needs if a root cause of fire occurrence were identified. REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 29 References Ahmed, O. I. & Girshin, M. (2013). Fire safety in the operating room. APSF Newsletter, 28(1), 17. American Association of Nurse Anesthetists. (2019). Standards for nurse anesthesia practice. Retrieved September 13, 2021 from https://www.aana.com/docs/default-source/practice- aana-com-web-documents-(all)/professional-practice-manual/standards-for-nurse- anesthesia-practice.pdf?sfvrsn=e00049b1_20 American Association of Nurse Anesthetists. (2020). Surgical fires. Retrieved October 1, 2020 from https://www.aana.com/practice/clinical-practice-resources/surgical-firesb American Society of Anesthesiologists. (2013). Practice advisory for the prevention and management of operating room fires: An updated report by the American Society of Anesthesiologists task force on operating room fires. Anesthesiology, 118(2), 1-20. https://doi.org/10.1097/ALN.0b013e31827773d2 Bansal, A., Bhama, J. K., Varga, J. M., & Toyoda, Y. (2013). Airway fire during double-lung transplantation. Interactive CardioVascular and Thoracic Surgery, 17(6), 1059-1060. https://doi.org/10.1093/icvts/ivt357 Centers for Disease Control and Prevention. (2020). Healthy people. Retrieved November 1, 2020 from https://www.cdc.gov/nchs/healthy_people/index.htm Centers for Medicare and Medicaid Services. (2018). Ambulatory surgical center specifications manuals. https://qualitynet.cms.gov/asc/specifications-manuals#tab4 Centers for Medicare and Medicaid Services. (2020a). Ambulatory surgical center (ACS) payment. Retrieved December 27, 2020 from https://www.cms.gov/Medicare/Medicare- Fee-for-Service-Payment/ASCPayment REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 30 Centers for Medicare and Medicaid Services. (2020b). NHE fact sheet. Retrieved December 27, 2020 from https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends- and-Reports/NationalHealthExpendData/NHE-Fact- Sheet#:~:text=Medicare%20spending%20grew%206.7%25%20to,31%20percent%20of% 20total%20NHE Coletto, K., Tariman, J. D., Lee, Y., & Kapanke, K. (2018). Perceived knowledge and attitudes of certified registered nurse anesthetists and student registered nurse anesthetists on fire risk assessment during time-out in the operating room. AANA Journal, 86(2), 99-108. Di Pasquale, L. & Ferneini, E. M. (2017). Fire Safety for the Oral and Maxillofacial Surgeon and Surgical Staff. Oral and Maxillofacial Surgery Clinics of North America, 29(2), 179–187. https://doi.org/10.1016/j.coms.2016.12.004 Goldhaber-Fiebert, S. N., & Howard, S. K. (2013). Implementing emergency manuals: Can cognitive aids help translate best practices for patient care during acute events? Anesthesia Patient Safety Foundation, 117(5), 1149-1161. Institute for Healthcare Improvement. (2020). Triple aim for populations. Retrieved November 1, 2020 from http://www.ihi.org/Topics/TripleAim/Pages/Overview.aspx Jones, T. S., Black, I. H., Robinson, T. N., & Jones, E. L. (2019). Operating room fires. Anesthesiology,130(3), 492-501. https://doi.org/10.1097/ALN.0000000000002598 Kezze, I., Zoremba, N., Rossaint, R., Reig, A., Coburn, M., & Schalte, G. (2018). Risks and prevention of surgical fires. Anaesthesist, 67, 426-447. https://doi.org/10.1007/s00101- 018-0445-2 Mathias, J. M. (2006). Scoring fire risk for surgical patients. OR Manager, 22(1), 1-3. REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 31 McEvoy, M. D., Hand, W. R., Stoll, W. D., Furse, C. M., & Nietert, P. J. (2014). Adherence to guidelines for the management of local anesthetic toxicity is improved by an electronic decision support tool and designated “reader.” Regional Anesthesia and Pain Medicine, 39(4), 299-305. Mehta, S. P., Bhananker, S. M., Posner, K. L., & Domino, K. B. (2013). Operating room fires: A closed claim analysis. Anesthesiology, 118(5), 1133-1139. Melnyk, B. M. & Fineout-Overholt, E. (2019) Evidence-based practice in nursing and healthcare: A guide to best practice. (4th ed.). Wolters Kluwer. Office of Disease Prevention and Health Promotion. (2020). Goal: Improve health care. Retrieved November 28, 2020 from https://health.gov/healthypeople/objectives-and- data/browse-objectives/health-care Spruce, L. (2016). Back to basics: Preventing surgical fires. AORN Journal, 104(3), 217-224.e2. https://doi.org/10.1016/j.aorn.2016.07.002 Steigler, M. P. & Tung, A. (2014). Cognitive processes in anesthesiology decision making. Anesthesiology, 120(1), 204-217. The Joint Commission. (2003). Sentinel event alert: Preventing surgical fires. Retrieved November 3, 2020 from https://www.jointcommission.org/- /media/tjc/documents/resources/patient-safety-topics/sentinel-event/sea_29.pdf Tola, D. H., Jillson, I. A., & Graling, P. (2018). Surgical fire safety: An ambulatory surgical center quality improvement project. AORN Journal, 107(3), 335-344. http://doi.org/10.1002/aorn.12081 United States Food and Drug Administration. (2018). Recommendations to reduce surgical fires and related patient injury: FDA safety communication. Retrieved October 1, 2020 from https://wayback.archive-it.org/7993/20191216153510/https://www.fda.gov/medical- REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 32 devices/safety-communications/recommendations-reduce-surgical-fires-and-related-patient- injury-fda-safety-communication REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 33 Appendix A Literature Search Concepts Keywords, PubMed MeSH, and CINAHL Subject Headings Used for Literature Searches Concept Operating Room Fire Prevention Cognitive Aid Anesthesia Fire prevention Operating room Cognitive aid Fire elimination Operation Reference material Anesthesia Keywords Fire precaution Surgery Checklist Fire avoidance Procedure room Guide Fire safety Operating room Fires PubMed MeSH Room, operating Checklist Anesthesia Fire Rooms, operating Surgical fires Operating rooms CINAHL Subject Terms Fire safety Checklists Anesthesia Surgery, operative Fires Checklist ProQuest Search Operating room Fire Anesthesia Cognitive aid REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 34 Appendix B Literature Search Summary Search Strategy Database Number of Rationale for Search or Search Search Citations Inclusion/Exclusion Date Engine Strategy Limits Applied Sorted by found/kept of Items Fire AND English language, Found: 151 November (operating publication 2015- Best Reviewed: Quality of evidence, PubMed 2020 room OR 2020, abstract match 151 relationship to topic anesthesia) available Kept: 16 English language, Found: 488 Anesthesia November publication 2015- Best Reviewed: Quality of evidence, PubMed AND 2020 2020, abstract match 200 relationship to topic Checklist available Kept: 5 Anesthesia English language, Found: 56 November AND publication 2015- Best Reviewed: Quality of evidence, PubMed 2020 Cognitive 2020, abstract Match 56 relationship to topic Aid available Kept: 3 Boolean/Phrase, Surgical Found: 12 Abstract Available, November fires AND Reviewed: Quality of evidence, CINAHL English Language, Newest 2020 Operating 12 relationship to topic Published 2010- rooms Kept: 2 2020 Boolean/Phrase, Found: 38 Checklists Abstract Available, Repeated articles, November Reviewed: CINAHL AND English Language, Relevance quality of evidence, 2020 38 anesthesia Published 2010- relationship to topic Kept: 2 2020 Found Scholarly journals, Anesthesia 8,281 November ProQuest last 10 years No new related AND Relevance Reviewed: 2020 Search (2010-2020), articles found checklist 200 English Kept: 0 Found: Anesthesia Scholarly journals, 3,530 November ProQuest AND last 5 years (2015- No new related Relevance Reviewed: 2020 Search Cognitive 2020), English, articles found 200 aid peer reviewed Kept: 0 Found: Scholarly journals, Operating 6,589 Repeated articles, November ProQuest last 5 years (2015- room AND Relevance Reviewed: quality of evidence, 2020 Search 2020), English, fire 50 relationship to topic Peer reviewed Kept: 1 REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 35 Appendix C Literature Matrix Literature Matrix Level of Citation Objective Method Results/Conclusion Evidence American Society of Anesthesiologists. (2013). Practice advisory for the prevention and management of operating room fires: An updated report by Summarize recommendations for OR Multiple recommendations and identification VII Expert panel, literature review. the American Society of Anesthesiologists task force on operating room fire prevention and management. of high-risk scenarios. fires. Anesthesiology, 118(2), 1-20. Bansal, A., Bhama, J. K., Varga, J. M., & Toyoda, Y. (2013). Airway fire Recommendations for decreasing fire risk in during double-lung transplantation. Interactive CardioVascular and Thoracic VII Clinical scenario discussion Case description lung surgery. Surgery, 17(6), 1059-1060. https://doi.org/10.1093/icvts/ivt357. Coletto, K., Tariman, J. D., Lee, Y., & Kapanke, K. (2018). Perceived Examine perceived knowledge and Questionnaires were sent to Positive attitudes towards fire risk knowledge and attitudes of Certified Registered Nurse Anesthetists and attitudes of CRNAs and SRNAs on fire 1,600 active members of the VI assessment, self-reported information needs Student Registered Nurse Anesthetists on fire risk assessment during time- risk assessment during surgical time- Illinois Association of Nurse on OR fire risk assessment. out in the operating room. AANA Journal, 86(2), 99-108. outs Anesthetists Di Pasquale, L., & Ferneini, E. M. (2017). Fire Safety for the Oral and Maxillofacial Surgeon and Surgical Staff. Oral and Maxillofacial Surgery Review concepts of fire safety important Recommendations for decreasing fire risk in VII Literature review Clinics of North America, 29(2), 179–187. for oral and maxillofacial surgeries. oral/maxillofacial surgical procedures. https://doi.org/10.1016/j.coms.2016.12.004 Goldhaber-Fiebert, S. N. & Howard, S. K. (2013). Implementing emergency manuals: Can cognitive aids help translate best practices for patient care Identify method for implementation of Outlined the “four-element implementation VII Literature review/discussion during acute events? Anesthesia Patient Safety Foundation, 117(5), 1149- cognitive aids in anesthesia care. strategy” for cognitive aids 1161. This review analyzes each fire component to Jones, T. S., Black, I. H., Robinson, T. N., & Jones, E. L. (2019). Operating determine the optimal clinical strategy to room fires. Anesthesiology,130(3), 492-501. DOI: VII Review causes/implications of OR fires. Literature review/discussion reduce the risk of fire. Surgical checklists, 10.1097/ALN.0000000000002598 team training, and the specific management of an OR fire are also reviewed. Emphasizes the fatal role of an oxygen- Kezze, I., Zoremba, N., Rossaint, R., Reig, A., Coburn, M., & Schalte, G. Systematic review of intraoperative fire enriched environment. Even “fire-safe” (2018). Risks and prevention of surgical fires. Anaesthesist, 67, 426-447. V risks and the impact of each component Literature review/discussion materials may be flammable or at least https://doi.org/10.1007/s00101-018-0445-2 of the fire triad. smoldering in oxygen-rich environments. Assess the patterns of injury and liability Mehta, S. P., Bhananker, S. M., Posner, K. L., Domino, K. B. (2013). An analysis of fire-related associated with OR fires in closed Identification of patient payouts after OR fire Operating room fires: A closed claim analysis. Anesthesiology, 118(5), VII claims was performed to malpractice claims in the ASA Closed claims, major causes of OR fires. 1133-1139. identify causative factors. Claims Database since 1985 Spruce, L. (2014). Back to basics: Implementing the surgical checklist. Review strategies for surgical checklist Key strategies for successful checklist AORN Journal, 100(5), 466- 476. VII Review Article implementation. implementation are provided. http://dx.doi.org/10.1016/j.aorn.2014.06.020 To improve knowledge and awareness Purposive sample of The findings suggest that a brief educational Tola, D. H., Jillson, I. A., & Graling, P. (2018). Surgical fire safety: An of surgical fire risk and increase participants that included all intervention regarding fire risk assessment ambulatory surgical center quality improvement project. AORN Journal, VI practitioners’ use of a fire risk surgical team members of a contributes to improving staff member 107(3), 335-344. http://doi.org/10.1002/aorn.12081 assessment tool during the surgical metropolitan ambulatory knowledge and use of prevention strategies. safety communication process. surgical center. Note. Evidence-based practice in nursing & healthcare: A guide to best practice (4th ed.) by B. M. Melnyk and E. Fineout-Overholt. Copyright 2019 by Wolters Kluwer Health. REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 36 Appendix D IRB Waiver Request REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 37 REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 38 REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 39 Appendix E Organizational Approval Form REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 40 REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 41 REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 42 REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 43 Appendix F Surgical Fire Prevention Reference Guide REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 44 Appendix G Pre-Intervention Questionnaire REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 45 REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 46 Appendix H Post-Intervention Questionnaire REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 47 REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 48 Appendix I Email Invitation to Participate in Quality Improvement Project Link to introductory video: https://prezi.com/v/qc-l_u954_li/perioperative-fire-prevention/?preview=1 REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 49 Appendix J Second Email to Project Participants REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 50 Appendix K DNP Project Timeline Timeline of DNP Project May-August 2020 Explored existing literature pertinent to topic August-December 2020 Completed literature review, created cognitive aid January 2020 Recorded video to introduce tool April-May 2020 Implemented intervention, data collection June 2020 Data analysis November 2021 Public presentation and upload to digital repository REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 51 Appendix L Summary of Results Table L1 Summary of Pre-Intervention Survey Data Total Number Responses Question Answer Choices of Received Responses Have you ever received education on perioperative Yes 7 7 fire prevention? No -- Have you received continuing education on Yes 4 7 perioperative fire prevention? No 3 (Very confident) 5 1 4 4 How confident are you in your knowledge about 7 3 2 perioperative fire prevention? 2 -- (Not at all confident) 1 -- Have you participated in a procedure where all the Yes 7 7 elements of the fire triad were present? No -- Yes 1 Have you ever experienced a perioperative fire? 7 No 6 (Very confident) 5 4 4 3 How confident are you in your ability to identify a 7 3 -- surgical procedure that has a high risk of fire? 2 -- (Not at all confident) 1 -- Do you currently have perioperative fire Yes 3 prevention guidelines that you can quickly access 7 No 4 while at work? If you had a question about perioperative fire 1-3 minutes 2 prevention, approximately how long do you think 4-6 minutes 2 7 it would take you to find reference material to 7-9 minutes 3 answer the question? 10 or more minutes -- Would an easily accessible reference guide provide Yes 7 you support in decision making regarding high fire 7 No -- risk procedures? REFERENCE GUIDE FOR PERIOPERATIVE FIRE PREVENTION 52 Table L2 Summary of Post-Intervention Survey Data Total Number Responses Question Answer Choices of Received Responses 0-2 2 Approximately how many procedures did you 3-5 -- participate in over the last two weeks that qualified 6 6-8 -- as high-risk for fire? 9 or more 4 (Very useful) 5 2 4 2 What is your perception of the usefulness of this 6 3 1 reference guide for an anesthesia department? 2 -- (Not at all useful 1 1 Was this reference guide easily accessible in the Yes 4 6 clinical setting? No 2 Did you find this reference guide visually Yes 6 6 appealing? No -- Yes 2 Did this reference guide save you time? 6 No 4 1-3 minutes 5 If saved to your mobile phone or work computer, 4-6 minutes -- how long would it take you to access this reference 6 7-9 minutes -- guide? 10 or more minutes 1 Do you think you will use this reference guide in Yes 3 6 your practice as a CRNA? No 3 (Very confident) 5 2 4 3 After reviewing this reference material, how 3 1 confident are you in your knowledge about 6 2 -- perioperative fire prevention? (Not at all confident) -- 1 Make it available in every OR. If it Do you have any recommendations to improve this was in the 6 Free response reference guide? (i.e. is something missing?) OR I didn’t see it No No