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Minor surgery, major risks

“There is no such thing as minor surgery, only minor surgeons” raises a cautionary note for all those engaged in the provision of surgical services

Minor surgery in primary care offers enormous benefits to patients, practices, GPs and indeed the HSE. Minor surgery in general practice fulfils the HSE mantra of “quality, access and cost”.1 GPs offer a high quality minor surgical service. This is readily accessible both in terms of waiting time (often a matter of days) and in terms of proximity to the patient’s home. The costs are modest, especially compared to similar procedures undertaken in secondary care. The key issues to address are consent, training, and infection control.

“There is no such thing as minor surgery, only minor surgeons” raises a cautionary note for all those engaged in the provision of surgical services. There are pitfalls, which can be anticipated and hopefully avoided. In our constantly evolving medicolegal climate an awareness of hazards and active risk management is crucial. Make your minor surgery a “win-win” situation for patients and doctors.

What surgery?

The range of lesions treated in primary care is extensive. They vary from simple repair of uncomplicated lacerations, to GPs undertaking injections, incisions, excisions, flaps, grafts, and vasectomies. The management of skin cancer in primary care is a complex issue, complicated by the potential for suboptimal waiting times for assessment in secondary care. The management of a low risk basal cell carcinoma in a housebound elderly patient is clearly different to urgent management of a younger person with a suspected melanoma. GPs providing skin cancer care must be aware of evolving national and international guidelines, and personalise such guidance to ensure timely management of each patient.2

Premises

You should ensure your practice has appropriate space, lighting, and facilities to undertake minor surgery. Many doctors use magnification to enhance the cosmetic outcome.

All equipment necessary for the procedure, including possible complications (eg, unexpected bleeding) should be readily available. Appropriate resuscitation facilities are crucial. Doctors undertaking suturing at sports events, remote from the GP premises, must have ready access to normal resuscitation facilities.

Regular training helps ensure skills are up-to-date, and may expand the range of procedures safely offered

Training in minor surgery

This is essential. Many GPs already have extensive surgical training and use these skills to benefit their patients. Regular training helps ensure these skills are up-to-date, and may expand the range of procedures safely offered. The Primary Care Surgical Society (PCSS) lead the way, ably supported by the ICGP and Primary Care Dermatology Society. Some doctors choose to travel to the UK or further afield to obtain training and to up-skill. In the unfortunate event of an adverse outcome, such training may strengthen your defence.

Infection control

Infection control evolves and improves constantly. Comprehensive and practical advice, Infection Prevention and Control Guidelines for Primary Care, has been produced by the National Clinical Programme for HCAI and AMR (antimicrobial resistance) prevention, in collaboration with the ICGP.3 Read it today. All the minutiae of infection control, from the Hepatitis B titre of the surgeon, to safe disposal of clinical waste, must be actively managed. Official guidance should be personalised to your practice. Consider completing the excellent audit tools which are part of this document – improve patient safety AND complete your audit requirement. At a minimum the operating room should have washable flooring, elbow operated taps/liquid soap/alcohol hand gel, personal protective equipment such as gloves (including latex free), masks and aprons. High quality single use disposable instruments are readily available.

Many doctors have completely discontinued “in house” autoclaving of surgical instruments. Doctors who elect to reuse instruments must ensure total compliance with current guidance.3 Please see the section ‘Decontamination of reusable medical devices’ on page 7 (“Infection control – time for a clean sweep?”) for more information.

Histopathology

All specimens excised should be submitted for histological examination. Implement a robust system to ensure that a report is obtained for every specimen; “specimen out – report back”. This system may be electronic or paper, but must be absolutely foolproof. Some colleagues go even further to ensure patient safety. They keep a patient file “live”, until patients in whom a referral was initiated (usually for skin cancer) have actually been seen by a hospital doctor. There is much merit in this enhanced patient safety system.

Audit and minor surgery

Minor surgery provides wonderful opportunities for audit, as highlighted in April 2013’sForum.4 Consider an audit of infection rates, concordance of clinical diagnosis and histology reports, adequacy of consent or patient satisfaction. This verifies quality, while satisfying our Medical Council audit requirements. The ICGP also provide an easy-to-use audit template for infection control – try it out in your practice.

Consent

How “informed” is informed consent? The adequacy of consent may come under intense scrutiny at a later date – MPS has a booklet outlining the essentials of consent.5

The standards of yesteryear may no longer be adequate. Medical literature abounds with cases where consent was deemed inadequate.

The standards of yesteryear may no longer be adequate. Medical literature abounds with cases where consent was deemed inadequate
Consent is also a key part of managing patient expectation. Does your patient know that a joint injection may introduce infection, that a scar may be ugly due to keloid, or that infection is always a possibility? Do your notes unambiguously document that consent was discussed in detail? Consider developing a standard minor surgery “pro-forma”. Augment this with a patient information leaflet (PIL) for the specific procedure undertaken. Such PILs are readily available online. At a minimum, the leaflets should include the nature and purpose of the procedure, alternatives (including no treatment) and more common complications.

MPS recommends obtaining written consent for all procedures, including cryotherapy, joint and soft tissue injections.5 Written informed consent should be obtained prior to the first cryotherapy session; it is prudent to discuss any patient concerns at each subsequent treatment, and document the same. My clinical IT system allows “clinical note templates”, which simplify the otherwise tedious task of writing similar notes repeatedly. Talk to your IT provider.

Minor surgery in primary care is a high quality, locally accessible service provided at modest cost to patients. Like all medical undertakings it has inherent risks. Active risk management of minor surgery is not onerous. Consider the key areas of adequate training, informed consent and rigorous contemporaneous infection control in your practice.

Actively manage your risk:

  • Adequate training
  • Informed consent
  • Rigorous infection control.

Dr Diarmuid Quinlan is a GP based in Cork and MPS clinical risk assessment facilitator.

Case study

A scarring problem Dr S was a city centre GP with a special interest in minor cosmetic surgery. Mr A attended Dr S’s clinic for the removal of a small sebaceous cyst at the corner of his left eye. Various options for its removal were discussed, including a referral to a plastic surgeon.

Mr A was happy to go ahead with the procedure under Dr S the next day. Dr S warned that the removal would result in a facial scar, but Mr A responded that he would rather a scar on his face than the cyst, as it was causing him anxiety. This discussion, which outlined Mr A’s psychological state, was not recorded in Mr A’s medical notes. Neither was any record made of the verbal consent taken.

Dr S removed the cyst using a disposable minor surgical kit and a vertical incision. A sample of the cyst was sent to histology for further examination before Dr S sutured the area and applied a dressing. He advised Mr A to return in one week, or to return sooner if he had any concerns. Mr A was prescribed antibiotics and directed to use these for the next seven days. He did not return for follow-up.

Following the procedure, Mr A was left with a vertical scar together with a small white cyst-like lesion within the scar. Mr A was unhappy with the outcome and was increasingly worried that the scar might have affected his vision. He made a claim against Dr S, alleging that the cyst had been negligently removed.

Expert GP opinion found that Dr S’s medical records were scant and as a result they were critical of the lack of detail outlining the consent taken, the discussion around the possibility of scarring, and Mr A’s underlying psychological issues. Expert opinion was also critical of the fact that Dr S did not chase Mr A when he failed to return for follow-up after seven days.

There was no safety-netting in place. However, ophthalmological opinion found that the removal of the cyst did not affect Mr A’s sight in any way. The case was settled for a small sum.

References
  1. National Clinical Programmes, Mission, Vision and Objectives (July 2011) www.nehb/ie 
  2. NICE Guidelines, Improving outcomes for people with skin tumours including melanoma www.nice.org.uk/guidance/CSGSTIM 
  3. HPSC and HSE, Infection Prevention and Control for Primary Care in Ireland (April 2014) www.hpsc.ie 
  4. Kealy J, Maguire N, Surgical audit for Irish General Practice, ICGP Forum p20-22 (April 2013) www.icgp.ie 
  5. MPS, Consent to Medical Treatment in Ireland: An MPS Guide for Clinicians www.medicalprotection.org
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