How GPs can avoid minor surgery risks

Risks can be avoided with adequate training and review. By MPS adviser Dr David Coombs

High quality minor surgery services in primary care is something that patients value
High quality minor surgery services in primary care is something that patients value
This article originally appeared in Your Practice, Vol. 4, No 2 (2010) titled "Minor surgery, major risks"

Minor surgery has long been an important element of the service provided by many GPs and the current GP contract rewards GPs for providing this service locally. Like all areas of primary care, there are inherent risks in providing minor surgery services, but with sensible forethought and audit these can be minimised.

Procedures and training
GPs undertaking minor surgery need to decide what procedures they are going to undertake. This could include ‘additional services’, such as cautery, curettage and cryotherapy, ‘enhanced services’ such as excisions, incisions, aspirations or injections, or more complex services, such as vasectomies.

Perhaps more importantly, GPs need to consider whether any procedure is actually necessary. Could a lesser procedure be used, such as shave excision or curettage rather than formal excision? It is not only important that those performing minor surgery have the training and skills to perform the procedures, but to be able to offer alternatives.

The GMS directed enhanced service (DES) states that GPs should have skills in line with those of a GPwSI.1,2 It is important for GPs to maintain their skills by regularly updating or enhancing their training. Courses are available from a variety of sources, including:

  • RCGP
  • Primary Care Dermatology Society (PCDS)
  • British Society for Dermatological Surgery (BSDS)

Facilities
Premises should be adequate for performing minor surgery and leave enough space to work around the patients. Appropriate equipment should be provided to perform the procedures accurately. Guidance states that facilities for resuscitation should be available.3

Infection control
It is important to be aware of infection control guidelines. Practices can get advice from their primary care organisation or their local consultants in communicable disease control. Practices should:

  • Ensure there is a clean dedicated area without carpet
  • Provide hands-free taps, liquid soap and alcohol hand gel
  • Provide protective clothing, including aprons and sterile gloves (perform health and saftey assesment if using latex gloves)
  • Not re-use cautery tips (can be an infection-transmission hazard)
  • Use protective covers for cautery or hyfrecater handles
  • Ensure hepatitis B immunity is adequate

The Department of Health provides guidance on the prevention and control of healthcare associated infections and sets out how to meet the requirements of the Health and Social Care Act 2008.4

Health and safety
Practices should have undertaken a general control of substances hazardous to health regulation assessment, but there may be particular issues relevant to minor surgery. Practices providing cryotherapy need to explore issues around the use, storage, decanting and transport of liquid nitrogen. It is not unusual for practices to collect small volumes of it from secondary care and transport it by car.

The safe disposal of sharps and used instruments is important, yet it is surprising how frequently practices place sharps bins in accessible places, overfill them, or do not store safely them once full.

Histology
Practices all too often do not send samples. All samples should be sent for histological analysis. Practices should have robust systems for handling the histology results and ensuring they are actioned, if necessary, and that patients are informed of the results.

Audit
Practices should undertake regular audit of their minor surgery activities. The minor surgery DES specifies that practices audit clinical outcomes, infection rates and unexpected or incomplete excision of malignant lesions. In order to do this, practices need to keep a log of all minor surgical procedures and also undertake significant event analysis. Patient satisfaction questionnaires can also be helpful in improving services and hopefully provide some rewarding feedback.

Consent
Adequate consent is essential and practices should always record it in the medical records. A GP should:

  • Discuss the nature and purpose of the procedure
  • Explain the risks involved
  • Hand out a leaflet
  • Discuss alternatives

It may be a contractual obligation to obtain a signed consent form, but it is more important that the above issues have been fully addressed and documented and that it is clear that the patient has the capacity to understand the issues. The NHS consent form 3 is the most appropriate consent form to use for general practice, it can be a useful aide memoir about what discussions took place.

In 2009 the Department of Health published guidance on obtaining consent, understanding the provisions of the Mental Capacity Act, the concept of parental responsibility and other legal judgements.

GPs often do not document the specific risk that are discussed and just write ‘informed consent’. Frequently, there is also no record of consent for joint and soft tissue injections.

Guidance
NICE has produced new guidance on how to manage low-risk basal cell carcinomas (BCCs) in the community and how skin cancer services can be commissioned.5 This guidance clarifies the role of GPs in treating BCCs.

Conclusion
Providing local, but high quality minor surgery services in primary care is something that patients value and can be very rewarding for GPs. Risks can be addressed with adequate training and review.

Case study: Hypertrophic scar
A 25-year-old woman consulted Dr P about a small lump on her upper chest, which was tender at times and had developed a brown mark around it. She thought it may have started as an insect bite, but was now worried that it could be skin cancer.

Dr P was unsure what it was, but did not think it was a skin tumour. In view of the patient’s anxiety he offered to excise the lesion. The histology report confirmed a benign dermatofibroma.

Twelve-months later the patient returned complaining that she had a red raised itchy scar and wished she had not had the lump removed. Dr P was sure he had warned her that there would be a visible scar, but could not recall the precise advice given. His computer records stated ‘informed consent for procedure given’. He prescribed a very potent topical steroid to try and flatten down the scar, but a formal complaint against him.

Learning points from case study

  • Given the history a diagnosis of dermatofibroma was likely.
  • Was excision necessary? If Dr P was uncertain he could have referred to a dermatologist or GPSI.
  • The risk of hypertrophic scarring is greater in certain areas of skin and in certain patients; the upper trunk in young women is a high-risk area.
  • Did Dr P obtain informed consent? The medical records do not give sufficient detail. A signed consent form with risks outlined and/or provision of an information leaflet would be supportive evidence in the event of a complaint.
  • Could a lesser procedure have been used? Small lesions can be excised in their entirety by punch biopsy producing a smaller scar.
CPD IMPACT: EARN MORE CPD CREDITS
These further action points may allow you to earn more credits by increasing the time spent and the impact achieved.
  • Attend a training course on performing minor surgery.
  • Have a practice meeting to discuss minor surgery risks and ensure that relevant health and safety measures are in place
  • Spend some time researching the different procedures that GPs can carry out in the community and ensure your knowledge base is up to date.

Save this article and add notes with your free online CPD organiser at gponline.com/cpd

Take clinical tests and claim certificates for CPD at myCME.com

  • Dr Coombs is a clinical risk assessment facilitator for the Medical Protection Society, and GPSI in dermatology

References

  1. BMA. Minor surgery - Specification for a directed enhanced service. www.bma.org.uk/employmentandcontracts/independent contractors/enhanced_services/DESsurgery.jsp
  2. DoH. Guidance and competencies for the provision of services using GPs with Special Interests. 2007. www.pcc.nhs.uk/uploads/pwsis/gpwsis_dermatology.pdf
  3. BMA guidance. Minor surgery in general practice. www.bma.org.uk/employmentandcontracts/independent_contractors/providing_gp_services/GeneralguidanceMinorsurgeryingeneralpracticeJuly2001MASTER.jsp?page=1
  4. DoH. The health and social care act 2009. www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_093762
  5. NICE. Improving outcomes for people with skin tumours including melanoma (update): The management of low-risk basal cell carcinomas in the community. 2010 www.nice.org.uk/nicemedia/live/10901/48878/48878.pdf

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