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Alert/Letters

The Use of Alcohol Based Skin Preparation in Operating Theatres

This letter was faxed to all Hospitals for CEOs, Operating Departments and Surgeons on 15 October 2002. 

 

Wellington

 

15 October 2002

 

 

 

Attention:	CEO Operating Departments, Surgeons	Ref:  TT05-16-3-2

 URGENT SAFETY ALERT

The Use of Alcohol Based Skin Preparations in Operating Theatres

This safety alert is to remind operating theatre staff of the potential flammability of alcohol based skin preparations.

Action:

Hospitals should review their policies and procedures on whether or not alcohol based skin preparations should be used in theatres. If alcohol skin preparations are used procedures must be in place to minimise danger to the patient.

Background: Patients have received burns following the use of an alcohol based skin preparation solution in theatre.

Both the Waitemata District Health Board and New Zealand Fire Service have produced reports on the recent operating room fire (ref: www.medsafe.govt.nz/hot/alerts.htm for the Waitemata report and www.fire.org.nz/news/media.htm for NZ Fire Service report).

The Royal Australasian College of Surgeons (RACS) New Zealand National Board is reviewing the use of alcohol based skin preparations in operating theatres. (The publications on operating room fires by the American College of Surgeons and on infection control by the Royal Australasian College of Surgeons should be noted: www.facs.org/about/committees/cpc/oper0897.html and www.racs.edu.au/wedo/publications/infection15.html)

Until the review by RACS is completed, if an alcohol based skin preparation is used the following measures are recommended:

1. The quantity of flammable fluid used to prepare the skin should be kept to a minimum in order to avoid run-off and pooling either on or around the patient. The amount of fluid in the bowl handed to the surgeon should be restricted and generally less than 100 ml.
2. The size of sponge applicators used for painting the skin should be reviewed. Some sponges can absorb up to 250-300 ml. Use of this volume will almost certainly lead to run-off.
3. Any run-off that occurs should be contained by absorbent material placed around the patient which is removed before the drapes are applied.
4. Time should be allowed for the alcohol to evaporate and disperse prior to applying the drapes.
5. The addition of coloured dye to the skin preparation may assist in reducing the amount used and hence reduce run off.

Other issues to consider include the use of fire retardant drapes, fire retardant patient gowns and a gel fire blanket as part of the operating theatre safety equipment.

Hospitals are reminded to please report any accident involving flammable material in an operating theatre to Medsafe.

Note: This Safety Alert is also available on the Medsafe website: www.medsafe.govt.nz/hot/alerts.htm

 

Clare Van der Lem Manager

Trevor J Nisbet Senior Advisor

 

Level 18, Grand Plimmer Tower, 2-6 Gilmer Terrace, P O Box 5013, Wellington.  Phone (04) 496 2000 Fax (04) 496 2229