New Joint Commission Fire Safety Standard-Jan 2018

New Joint Commission Fire Safety Standard-Jan 2018

posted by Leslie Scott on Feb 13, 2018 10:52 am

The new JC fire safety standards reads as follows...

EP12. When flammable germicides or antiseptics are used during surgeries utilizing electrosurgery, cautery, or lasers, the following are required: 
- Nonflammable packaging
- Unit-dose applicators 
- Preoperative "time-out" prior to the initiation of any surgical procedure to verify the following: 
- 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 operating room prior to draping and use of surgical devices 
(For full text, refer to NFPA 99-2012: 15.13)

I would like to know how other facilities are managing the last bullet regarding removing solution soaked materials from the operating room. Do you have a two-person verification of the bag contents before they leave the room? a special receptacle for them? We have always been taught that everything stays in the room until the case is complete so it is a bit difficult to wrap our heads around. Thank you in advance for your feedback!

Re: New Joint Commission Fire Safety Standard-Jan 2018

posted by Patricia Cady on Feb 14, 2018 10:48 am

I was trying to find this under the Joint commision website and I cannot find it.  Did Joint Commission mention this in their last visit to your facilty?  Is the Joint commission following the NFPA standards?  Thank you in advance.

Re: New Joint Commission Fire Safety Standard-Jan 2018

posted by Mary Fearon on Feb 14, 2018 6:11 pm

AORN has reached out to the Joint commission to discuss the interpretive statements for the NFPA code  AORN believes this is causing difficulty in compliance with both the Joint Commission standards and the AORN Guidelines.  Removing the solution soaked materials  prior to draping could require more door opening, removal of counted items from the room or remove the circulating RN from the room at a critical time of the procedure.  AORN is recommending that the solution soaked materials be contained within the room away from the ignition source.  Please work with the Joint Commission to resolve any concerns about meeting this requirement and escalate your concerns to the central office if it cannot be resolved.

Re: New Joint Commission Fire Safety Standard-Jan 2018

posted by Carole Mayes on Feb 15, 2018 8:56 am

Good morning.
I am thinking the key is "soaked materials." How often are materials soaked? Just a thought.


Re: New Joint Commission Fire Safety Standard-Jan 2018

posted by Michael McKay on Feb 15, 2018 11:40 am

I agree, "soaked", is a frightening concept.   We have always been taught to avoid the  pooling of prep solutions, so I feel leaving material "soaked" with prep solution beneath the patient during surgery is wrong from the start.

We have enough trouble in our OR keeping the surgeon from starting before the prep has dried.
 Containing and eliminating prep "soaked" materials prior to starting a procedure is another delay that could be hard to swallow. 

Re: New Joint Commission Fire Safety Standard-Jan 2018

posted by George Clark on Mar 6, 2018 9:18 am

I was asked to look at this for our VA OR.  After looking at the NFPA Code and the Joint Commission Chapter on Environment of Care; we have decided to do the following:
1.  Prep sticks and solution-soaked materials are placed in a separate trash bag, and placed in the outer core for disposal by Housekeeping prior to draping.
2.  Included in our "Time Out" and documented in our EMR are the phrases lifted out of the Joint Commissions standards:
Using a separate trash bag to contain prep materials precludes (hopefully) the possibility of counted materials leaving the room.
Disclaimer:  This change is being implemented and is still under review by the higher-ups in the chain of command.  I would suggest consulting your Safety/Fire Prevention specialists and Joint Commission experts so that everyone can feel better about any changes.


Re: New Joint Commission Fire Safety Standard-Jan 2018

posted by Aimee Kellogg on Apr 2, 2018 5:54 pm

Hello, We are trying to figure out a solution to this at our facility. Our first reaction was to question removing anything from the OR after items are counted. At the AORN expo, we spoke to someone that already had their JC survey. The surveyor told them that the NFPA code trumped AORN recommendations. It sounds like this has been a code/regulation for a while and it's just popping up on the radar now. I would love to hear other experiences with JC surveys regarding this as well how others are changing their practice. Thanks!

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