CQC may ask if you have a protocol for minor surgery and joint injections. Please find below an example of a protocol that you may want to adapt for use in your practice.

It is advisable that all practices ensure that the person undertaking any procedure is competent and has the required level of training and is compliant with Infection Control policies and procedures. This is particularly important if the procedures are being undertaken by subcontractors and or locums not directly employed by the Practice.

Example of a Minor Surgery Protocol for General Practice

This policy has been introduced to clarify the process of undertaking minor surgical procedures within General Practice and ensures that they comply with best practice.

It is recommended that all practices also check the requirements in your ICBs Local Enhanced Service document in relation to minor surgery and joint injections.

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The aim is to provide a comprehensive, safe, quality service and minimise the transmission of infections to healthcare professionals and patients.

This policy is based on National Infection Control Policies and RCGP guidance and best practice for minor operations undertaken in primary care.

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Duties and Responsibilities

There should be a named GP and or health professional who can provide evidence of surgical training and updated training and who is responsible for ensuring that the practices minor surgery and joint injection practice meets national and local policy/guidance or best practice.

If supported in the procedure by the Health Care Assistant (HCA) or another nominated member of staff, this person should have completed an enhanced DBS check, infection control and chaperone training, Information Governance and safeguarding training. They should have clear understanding and instruction on their role within minor surgery. All staff involved will have up to date knowledge around the management of an emergency procedure including resuscitation and can provide evidence of having attended annual training.

Every member of staff has a duty of care to prevent healthcare associated infection and all arrangements in the practices should comply with the Health and Safety at Work Act (1974) and the relevant associated legislation.

  • Availability of a suitably competent partner, employee or subcontractor
  • Satisfactory facilities and equipment.
  • Nursing support (or other suitably nominated and trained member of staff)
  • Cleaning of equipment, rooms and infection control compliance
  • Appropriate clinical waste disposal
  • Pathology services
  • Audit
  • Patient information
  • Consent

The GP/health professional will:

  • Maintain their competency around resuscitation and management of emergencies
  • Adhere to strict IC policies and recommendations
  • Regularly update their skills and provide evidence of competency
  • Demonstrate a continuing and sustained level of activity through regular audit
  • Participation in appraisal of minor surgery activity
  • Participation in supportive educational activities
  • Have up to date immunisation cover as per the Green Book chapter 12 (national policy). Occupational Health for GPs and Practice Staff.  Immunisation of healthcare staff

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Operations are normally performed on patients registered at the surgery and referred directly to the Minor Operations’ clinic by one of the GP’s employed at the practice. (the Practice may have a process where they accept referral from other professionals employed within an advanced role.) The patients are informed at the point of referral that the decision to proceed with the operation rests with the GP or health professional and that there is a small chance that they may decide on the day that undertaking the procedure is not feasible or in their best interest.

The practice may consider producing a patient leaflet around what to expect when undergoing a minor surgical procedure including what to do if the patient has concerns following the procedure which is issued to the patient at the point of referral.

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Procedures Undertaken

These will be in-line with DES specifications and fall within the competency of the clinician performing the procedure.

We recommend that clinicians undertaking joint injections in general practice follow the guidelines issued by the Primary Care Rheumatology Society Updated 2017

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Approval, Ratification and Review

The policy should be written and reviewed by both medical and nursing staff and the practice manager. It is recommended that the policy is reviewed every 3 years or earlier in the event of changes to legislation, clinical guidelines, staff changes or best practice.

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All practice staff should be made aware of the policy and a permanent record will be made available on the practice intranet and a hard copy for reference.

Monitoring governance & effectiveness

The monitoring team should consist of a GP, the Practice Manager and the lead for infection control. Other practice staff, such as receptionists, should be encouraged to attend any meetings to enable them to understand and contribute to the issues involved.

Infection Control will be discussed regularly at clinical meetings and actions agreed to improve infection control in the practice in relation to minor surgery procedures.

The practice should have a significant event (SE) system in place, analyses and acts on any near miss, harm or common theme. The learning from these events should be should with all staff with a regular review of actions undertaken and agreed, ensuring these are embedded and changes made as appropriate.

Where practices are undertaking a procedure on behalf of another local practice the practices must ensure they have governance arrangements in place to support audit, assurance and significant event analysis.

It is suggested that an Audit Tool is completed every 12 months and changes made where appropriate to the current policy ensuring that:

  • the Practice is compliant with the Code of Practice for The Health & Social Care Act 2008 .
  • the Practice is compliant with the required staff immunisation programme as per the Green Book Chapter 12; and that records of immunisation are kept and monitored.  Practices may be asked to produce records of staff immunisation during a Care Quality Commission (CQC) inspection.
  • all clinical staff have a yearly mandatory training update on infection control and management of emergencies and those records are kept and monitored.  Practices may be asked to produce records of staff immunisation during a CQC inspection.

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Facilities and Equipment

Ideally there should be a specific non carpeted room used for minor surgery procedures and this will be cleaned in accordance with guidance prior to and after the session. Where there isn’t a dedicated room for minor surgery within the practice the practice is recommended to ensure that the room being used meets minimum requirements:

  • Impervious flooring
  • Hand hygiene facilities
  • Clinical waste bins
  • Dressing trolley or clear countertop area for the laying out of equipment
  • Sharps bin

Adequate and appropriate equipment will be made available for the GP/health professional to undertake the procedures chosen and should also include appropriate equipment for resuscitation. PPE equipment including sterile gloves should be used and staff aware of the guidelines around storage and use of equipment making and Infection Control to undertake the procedure.

Single use instruments will be used where possible and will be disposed of in accordance with current HTM 01-01 decontamination of surgical instruments guidelines. A “Hyfrecator 2000” (or equivalent) is used for cautery and curettage. This is serviced annually as per manufactures guidelines. Where the practice uses reusable instruments or equipment, they must ensure that this equipment is decontaminated as per HTM 01-01 and the manufacturer’s guidance.

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The resuscitation equipment used for minor surgery clinics may belong to the practice, all clinicians in the practice should be familiar with its use and where this is stored. Anaphylactic equipment should be available, and the room equipped with a panic button to attract additional assistance from the wider surgery if required. Resuscitation and anaphylactic protocols should be displayed in the minor surgery room and both the GP/health professional and the ‘assistant’ update their resuscitation training annually.

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Nursing Support

Registered nurses and HCAs can provide care and support to patients undergoing minor surgery. Nurses assisting in minor surgery procedures should be appropriately trained and competent, taking into consideration their professional accountability and the Nursing & Midwifery Council (NMC) guidelines on the scope of professional practice.

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Sterilization and Infection Control

The practice must ensure they comply with the recommendations around infection control (including cleaning of the patient’s skin) and have an updated annual policy in place which is located on the intranet. It is recommended that patients skin is cleaned with 2% Chlorhexidine in 70% alcohol where appropriate for the area of the body being operated on.

1. Sterile packs will be used

2. Disposable single use sterile instruments will be used

Practices would be advised to liaise with their ICB Infection Control lead for further information, guidance and advice on what should be considered prior to undertaking a minor surgery procedure including joint injections.

This is likely to cover:

  • aseptic technique
  • suitability of the environment
  • Decontamination of the room pre and post procedure
  • cleaning of the skin
  • addressing the risk of infection
  • audit and documentation.

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All tissue removed by minor surgery should be sent routinely for histological examination unless there are exceptional reasons for not doing so. Reasons for not sending tissue will be documented in the patient’s notes. The results of these tests will be sent to the operator GP/health professional who will be responsible for ensuring further action is not required. The Practice will decide if patients are routinely informed of their results and will have a policy in place if further action is required.

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Dressing of the Wound

Appropriate dressings which comply with the local wound formulary will be used.

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Post-operative Advice

Practice should provide verbal and written advice to patients, ensuring that the patient understands what action to take in the event of complications.

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Record Keeping

A read-coded entry of the operation undertaken (including any anesthetic, medication and suture material used) will be entered onto the electronic records for each patient.

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Annual audit will be undertaken of the following:

  1. Operations undertaken – number and type of procedures performed.
  2. Diagnostic accuracy – histological confirmation of any tissue removed.
  3. Post-operative complications.
  4. Sharing of SEs if appropriate

Further audits will be undertaken should a need for them be identified.

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Needlestick Injury

All staff should be aware of how to manage a needle stick injury and aware of the practice policy. (Needlestick Injury advice and support to NHS GPs, dentists and healthcare workers, including trainees on 03333 449006. Heales Medical Group).

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Disposal of Waste

The facilities and the procedures for the safe disposal of waste will comply with the current HTM 07-01 management and disposal of healthcare waste guidelines for holding waste prior to collection/disposal. Refer to the practices infection control policy.

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Specialist Services e.g. Vasectomy Clinics

There may be certain factors that need to be in place for those practices where the GP is providing ‘specialist services.

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Ventilation and Smoke Extraction

The minor surgery room should have adequate ventilation and air exchange for patient comfort.

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