FirstHealth of the Carolinas officials should know by the end of the month whether they have taken adequate corrective steps to prevent operating room fires like the one recently that burned the neck and shoulders of a patient during an emergency surgery at Moore Regional Hospital.
The N.C. Division of Health Service Regulation placed Moore Regional on “immediate jeopardy” status following an unannounced survey on Aug. 1, in response to the incident that occurred in late June.
FirstHealth’s corrective action plan is due Monday, after which follow-up surveys will be conducted by the state and the Centers for Medicare and Medicaid Services (CMS).
“We are working diligently to adopt and implement the recommendations noted in the survey,” David J. Kilarski, CEO of FirstHealth, said Friday. “We are committed to putting all the necessary policies and procedures in place to ensure every patient’s safety and provide the highest level of care.”
Kilarski called the fire “unfortunate.”
“We took immediate corrective steps that same day,” he said. “Our highest priority is for the safety of our patients and staff.”
FirstHealth, which operates Moore Regional and hospitals in Rockingham and Troy, revised its operating room fire safety policy “to prevent a surgical fire and to prevent injury to the patient in surgery,” according to records obtained by The Pilot.
“We’ve learned an awful lot from this, and hopefully it will never happen again,” said Dr. John F. Krahnert, chief medical officer for FirstHealth. “We are in a continuous quality and safety improvement environment.”
The initial survey followed two anonymous complaints: that a fire occurred in an operating room at Moore Regional, and that the hospital failed to notify the patient’s family.
“The complaint about the fire was substantiated,” Kilarski said. “The other complaint was unsubstantiated because we did notify the family.”
CMS defines immediate jeopardy as “a situation in which the provider’s noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment or death to a resident.”
According to the findings of the state survey, the Moore Regional operating room staff failed to ensure a patient’s health and safety. The hospital was cited for not following established fire safety prevention policies and procedures.
The fire that occurred has prompted CMS to review FirstHealth's operating room policies and procedures. That agency, which oversees hospitals’ ability to receive Medicare and Medicaid payment, conducts such reviews as a normal process to ensure hospitals develop and implement corrective policies.
During the emergency life-saving procedure in June, vapor from sterilizing fluid ignited, causing a brief flash fire that was immediately extinguished “with some sterile saline and wet towels,” Kilarski said.
The patient sustained small first- and second-degree burns to the neck and shoulders but no lasting injuries.
“The patient was discharged from the hospital and did not sustain any permanent injuries,” Krahnert said. “After a thorough investigation, we have determined that the operating room staff responded to the incident appropriately and then successfully continued with the original emergency procedure.
“Clearly, we preserved life in this case.”
The hospital was placed on immediate jeopardy status after the survey results were forwarded to the CMS office in Atlanta. Now both Moore Regional and its Richmond Memorial Hospital campus in Rockingham are subject to a full CMS survey, which FirstHealth’s administration expects will take place within a few weeks.
“These agencies are doing their job,” Kilarski said. "There was room for improvement for us. We’ve learned some things and can do a better job.”
With the immediate jeopardy status, both Moore Regional and Richmond Memorial risk losing their certification for Medicare and Medicaid reimbursement.
“It’s not going to happen,” Kilarski said. “I think we’ve got a wonderful plan that I think will satisfy them. If they want us to modify the plan, we’ll modify the plan. We’re confident that CMS will see the value of our plan.”
According to the records obtained by The Pilot, Moore Regional has already instituted several new policies to safeguard against a similar incident.
For example, alcohol-based skin preparation is now prohibited in any emergency surgery which does not allow sufficient drying time according to manufacturer’s instruction, usually three minutes or more.
Krahnert said FirstHealth has eliminated the use of alcohol-based preps “in an emergency situation where you have less than three minutes to save a life.”
“We’re going back to the non-alcohol-based preps such as Betadine,” he said.
ECRI Institute estimates 550 to 650 surgical fire accidents occur annually in the United States. Of those, only 20 to 30 are considered serious, which is defined as causing disfiguring or disabling patient injuries. One or two of the total fires are fatal, according to the ECRI website.
ECRI Institute is an independent, nonprofit organization based in Plymouth Meeting, Pa., that researches the best approaches to improving the safety, quality and cost-effectiveness of patient care.