Hospital acts over surgery fires

By ANGELA GREGORY

Waitakere Hospital will change its surgical procedures to reduce the risk of setting patients on fire following an urgent investigation which has confirmed medical equipment ignited a sterilising solution.

A 17-year-old woman was badly burned 10 days ago during a caesarean in the maternity unit, and has since undergone two skin graft operations.

The hospital's general manager, Rachel Haggerty, said preliminary findings of an independent forensic investigation had shown alcohol vapour ignited when theatre staff used a diathermy electro-surgical instrument to cauterise a capillary.

Ms Haggerty said she was certain the theatre staff had complied with standard practice for surgical operations.

She was confident the diathermy equipment, which had been extensively tested, did not malfunction and was not misused.

The sterilising solution swabbed on the woman was regularly used in operating theatres in preference to other products. It had been allowed to dry before surgery began, as was practice.

Despite that, changes to procedures would be made to minimise the risk of any repeat.

She was confident preventive measures would be identified and expected other hospitals would follow suit once the findings were finalised.

Ms Haggerty said the Accident Compensation Corporation had reported only two previous such fires in New Zealand.

At least 10 factors had to coincide for alcohol solutions to cause a fire during surgery. They could include the proportion of alcohol, solution run-off, patient body hair, movement and body position, safety strapping, diathermy setting, type of surgical drapes and their ventilation, as well as the temperature of the room, alcohol solution and the patient.

Ms Haggerty said the hospital had meanwhile stopped using alcohol-based products in operating theatres in favour of iodine, as had two other hospitals since the incident.

Alcohol-based swabbing solutions were used worldwide as they were fast and effective in killing bacteria.

Ms Haggerty said the burned woman was still recovering in Middlemore Hospital. "She is progressing ... as well as could be expected."

Although the injury was significant, it had been limited by the "heroic" theatre staff, who had acted promptly to douse the fire with sterilised water, she said. As soon as they started the diathermy there was a "whoomph" sound and they knew something was wrong.

Multiple pockets of fire broke out, including on the theatre bed. The temperature of an alcohol-fuelled fire was much higher than that of a normal fire.

The Waitakere Fire Service deputy chief fire officer, Ben Basevi, said he was confident the risk of future surgical fires could be managed.

He was "uniquely qualified' to comment as he was also a registered obstetric nurse.