Joint Commission representatives have begun emphasizing the need for an additional “NFPA Time Out” for some surgical cases. This time out is not required by the Joint Commission’s Universal Protocol, but it is referenced in the NFPA (National Fire Prevention Association) standards. We’ve received a number of questions as a result. In this blog, we provide you with insights to help you understand these frequently asked questions:
- Which cases require an NFPA time out?
- How do you tell if the skin preparation solution is flammable?
- What are the elements of an NFPA time out?
Cases requiring an NFPA Time Out
NFPA 99 (2012) is a national guideline (adopted by CMS) that addresses fire prevention in health facilities. Section 18.104.22.168 requires “a preoperative ‘time out’ period … prior to the initiation of any surgical procedure using flammable liquid germicides or antiseptics.”
How to tell if the skin preparation solution is flammable
There’s only one way to tell if a solution is flammable: you must read the package insert or the label on the original bottle (the Instructions for Use or “IFUs”).
In general, flammable germicides tend to have isopropyl alcohol as a primary ingredient.
“Povidone iodine such as Betadine® and chlorhexidine solutions such as Hibiclens® are not flammable prep solutions …” according to the Anesthesia Patient Safety Foundation (Cowles, CE; Chang, JL: “Flammable Surgical Preps Require Vigilance,” APSF Newsletter, Volume 29, No. 2. October 2014) and an NFPA Time Out would not be required when these or other non-flammable solutions are used.
The NFPA Time Out is separate from the Universal Protocol Time Out
NFPA does not say these are separate events. However, the NFPA Time Out must be performed prior to draping to verify that the antiseptic has dried and the Universal Protocol Time Out must be performed immediately prior to the procedure and after draping to verify the right patient, procedure and site. They therefore seem to be separate events.
Elements of an NFPA Time Out
The NFPA Time Out should verify that:
- The application site of the flammable germicide or antiseptic is dry prior to draping and use of electrosurgery, cautery, or a laser.
- Pooling of solution has not occurred or has been corrected.
- Any solution-soaked materials have been removed from the operating room prior to draping and use of electrosurgery, cautery, or a laser.
Individuals involved in the NFPA Time Out
The NFPA guidelines do not say.
Other Issues Related to Surgical Fires
Most of the other requirements related to surgical fires have been in place for some time and we won’t review them here. However, we encourage each hospital’s perioperative leadership team to work with the organization’s environmental safety officer to carefully review and validate compliance with NFPA 99 (2012), Chapter 15, Section 13, “Fire Loss Prevention in Operating Rooms.”
The Greeley Company has a rich history of providing innovative consulting, education, outsourcing solutions, interim staffing, and external peer review to healthcare organizations nationwide. We focus on contemporary needs and challenges related to medical staff optimization and physician engagement; accreditation and regulatory compliance; quality, performance and safety; and credentialing and privileging.
About the Authors:
Bud Pate has more than 40 years of high-profile problem solving to his work with hospitals and healthcare organizations across the country. Bud is a nationally recognized expert in CMS and Joint Commission compliance, clinical process simplification, clinical quality and patient safety. His work brings him to institutions and podiums across the country, sharing his unique approach to compliance: guiding his clients to shed overly-complicated, unrealistic expectations that don’t work for simple, common sense solutions that promote efficiency, protect patients, comply with external standards, and last.
Prior to joining The Greeley Company, Bud spent 15 years as an executive consultant and director of licensing and accreditation for Kaiser Permanente’s Southern California region. Before joining Kaiser, Bud was responsible for state licensing and Medicare certification for all hospitals, home care agencies, and clinics in Los Angeles County. Bud also represented the California and American Hospital Associations on various Joint Commission committees.
Steven A. MacArthur brings more than 30 years of experience in the healthcare environmental services and safety fields—including more than 20 years in acute care hospitals—to his work with hospitals and healthcare organizations across the country. He conducts on-site safety assessments, educational programs, and regulatory survey preparation for safety leaders.
If you would like to schedule a mock survey focused on these stated focus areas, let’s start that conversion.