The changes in healthcare delivery over several years have led to increasing provision of surgical services in the primary care setting. It is likely this trend will continue as patient choice and liberation of provision results in more minor surgery and minimal access intervention (MAI) in primary care.
There have, until now, been no specific guidelines for the physical requirements of the facilities in which minor surgery is to be undertaken with regard to infection control, despite the fact that surgical procedures are now one of 15 areas that GPs must register with the CQC. The new guidance from the Healthcare Infection Society attempts to fill this void with simple, practical, evidence-based guidance.
For the purposes of this article, minor surgical procedures are defined as those that can be carried out under local anaesthetic and are superficial. The size of the operative site is usually limited by whether it can be anaesthetized locally. Minimal access interventions are defined as those therapeutic or diagnostic procedures that are not considered major in terms of the operative site.
Finally, the guidance below is for the design of new facilities yet many existing minor surgical facilities do not meet these standards. In such settings, the type of operations undertaken should be considered and if necessary limited in accordance with the guidelines. If possible the facility should be improved over time in accordance with this advice to ensure the safest possible patient experience.
1. Remember that the risk of infection varies
Many minor surgical procedures are currently being undertaken in ‘treatment rooms’ that do not meet the standards for a conventional operating theatre. Despite this the reported incidents of infection are low.
As the delivery of healthcare changes and more procedures are undertaken in primary care, both the risk and consequence of infection could rise if the infection control precautions do not improve to match the increasing complexity of the procedure being undertaken. For example, the consequence of an infected sebaceous cyst wound may be less than that resulting from infection at arthroscopy leading to septic arthritis.
2. Pay attention to ventilation
For minor surgical procedures, natural ventilation is satisfactory. If this is provided by use of a window that opens, a fly screen must be fitted to prevent insects entering the room. The window should also be suitably screened to protect patient privacy. If interventional radiology or minimal access interventions (MAI) (e.g. arthroscopy, laparoscopy, percutaneous interventions) are to be undertaken then mechanical ventilation to achieve 15 air changes per hour should be installed.
3. Use disposable instruments if possible
The rigorous standards of decontamination and cleaning required by specialised sterile supply departments can be difficult to achieve in general practice. Disposable instruments remove the need to apply these standards. All instrument packs should be stored in areas that prevent contamination with dust. Special thought should be given to the type of shelving in this regard. If re-usable instruments must be used (such as endoscopes) there should be separate secure areas for their cleaning, storage and collection. It is not necessary to have a separate laying up area as in a conventional operating theatre but instruments should only be laid up as required and not in advance.
4. Check ceilings, walls, flooring and doors
Ceilings should be non-porous and suspended ceilings should not be fitted in new facilities. Walls should be non-porous and suitable for occasional disinfection. Floors should be strong, durable and disinfected regularly. They should ideally be coved at the edges to aid cleaning, prevent damage and contain spills. Doors should be self-closing, positioned to protect patient privacy and contain vision panels for observation and improving access to the room.
5. Scrub up well
The scrubbing up basin can be within the operating room but must be removed enough so that instruments and the surgical site do not get splashed during hand washing. The scrub up basin should not be used for other purposes and should be fitted with hands free taps. Disposable towels should be used. Clean your hands with a conventional surgical scrub at the start of the list of cases. If the hands of the operator are not visibly dirty, it is permissible to use alcohol hand rub or equivalent between cases.
6. Keep waste secure
The practice should ensure it complies with current guidelines for handling and disposal of clinical waste. It should have secure storage for waste awaiting collection and disposal either inside or outside of the operating room in the form of a lockable bin.
7. Wear sterile gloves and a plastic apron…
For minor surgical procedures the minimum standard is to wear a plastic apron and sterile gloves. If a sterile implant is to be placed, there is risk of significant post-procedure infection, predisposition to infection or minimal access intervention is to be undertaken, full precautions including a sterile gown for each case should be used.
8. …But take off the mask
Minor surgery does not usually require the operator to wear a mask. If a sterile implant is to be placed, or there are conditions making an infection more likely, then a mask should be worn. Face protection is only required if there is a high risk of splashing.
9. Keep your training up to date
Anyone undertaking minor surgery or minimal access intervention has a responsibility to provide evidence of competency in aseptic technique and understanding of the facilities within which they work with regard to infection control. They should be able to provide evidence of both competency in the procedures they undertake and continuing professional development.
10. Measure your outcomes
Essential to healthcare improvement is collection and interpretation of continuous and valid data on performance. Prospective surveillance of post-operative infection will provide the evidence to ensure the continued improvement of minor surgical provision in general practice.
Dr Martyn Diaper is a GP in Winchester and a member of the Safer Care Team at the NHS Institute for Innovation and Improvement