Effective Jan 1, 2018, TJC standard EC.02.03.01 EP 12, mandates that for surgeries and procedures where electrosurgery, cautery, or lasers and flammable germicides or antiseptics, will be used, that all materials that are soaked with the flammable solution must be removed from the room. This is supported by NFPA 99-2012: “188.8.131.52 —Any solution-soaked materials shall be removed from the operating room prior to draping or use of electrosurgery, cautery, or a laser.”
Consultants from C&A have been conferring with TJC Standards Interpretation Group, AORN, and NFPA. Here is a summary of recommendations to comply with the requirements until this topic and the verbiage of the standard has been reviewed by governing bodies and changed pending CMS review and approval.
- Have the organization define solution-soaked.
For example, in the fire risk assessment policy defines solution soaked as saturated; substantially wet and likely to readily drip upon light pressure.
- Develop a mechanism to meet the intent of the requirement as it stands now.
Such as: For an operating room, have a kick bucket outside the door and identify through signage that it is not to be removed or emptied until the end of the case thereby meeting the TJC/NFPA intent and AORN’s guideline to contain all materials until the end of the procedure.