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PubMed1994

Quality of minor surgery by general practitioners in 1990 and 1991.

BACKGROUND: The 1990 contract for general practitioners encouraged them to undertake minor surgical procedures in their practices. AIM: A study was undertaken to determine whether the subsequent expansion of general practitioner minor surgery activity was accompanied by changes in quality of care. METHOD: Data were analysed relating to minor operations conducted in 22 practices during April-June 1990 and April-June 1991. RESULTS: The volume of general practitioner minor surgery increased by 41% between the two study periods. Waiting time, accuracy of diagnosis, use of histology, adequacy of excision, complications and the need for corrective treatment in hospital did not change significantly between the two periods. CONCLUSION: The findings do not support suggestions that the expansion of general practitioner minor surgery activity following the 1990 contract has been associated with an erosion of quality of care.

Clinical Competence↗
PubMed2003

A simple and safe nomogram for the management of oral anticoagulation prior to minor surgery.

In 80 consecutive, anticoagulated patients scheduled for minor surgery, we reduced warfarin daily dosage by 50% on days 4, 3 and 2 before the surgery, restoring the original dose the day immediately before surgery. The evening after surgery, patients took a double warfarin dose, and then the usual maintenance dose was reintroduced. The mean International Normalized Ratio (INR) value assessed 1 week before surgery was 2.63 (range 1.88-3.87); it decreased at the moment of performing surgery to 1.68 (range 1.42-2.20; P < 0.05 with respect to the preoperative value), and returned to 2.43 7 days after (range 1.96-3.51, P = ns with respect to the preoperative value). No significant difference was found comparing prothrombin fragment 1.2 (F1.2) levels 1 week before surgery and on the morning of surgery (0.49 ng/ml vs 0.67 ng/ml, P = ns), suggesting that no activation of blood coagulation had taken place following the reduction of anticoagulant therapy. Patients developed neither major nor minor bleeding, nor thromboembolism during the procedures or up to 1 month after surgery. In our experience, this method for the management of anticoagulation before minor surgery has been shown to be safe and useful, avoiding the cumbersome shift to either intravenous or subcutaneous heparin.

Administration, Oral↗
PubMed1993

Minor surgery by general practitioners under the 1990 contract: effects on hospital workload.

OBJECTIVE: To determine the extent to which minor surgery undertaken by general practitioners after the introduction of the 1990 contract substituted for hospital outpatient workload. DESIGN: Before and after observational study. SETTING: Four English family health services authorities. SUBJECTS: Patients in 22 practice populations who were operated on by their general practitioner or referred to hospital for minor surgery during April to June 1990 or April to June 1991. MAIN OUTCOME MEASURES: Numbers of minor surgical procedures undertaken in general practice and in hospital, numbers of referrals to hospitals for conditions treatable by a minor surgical procedure, and the mix of diagnoses and procedures undertaken in each setting. RESULTS: General practitioners claimed reimbursement for 600 minor surgical procedures during April to June 1990 and for 847 during April to June 1991, an increase of 41%. Referrals to hospital for comparable conditions showed no compensatory decrease (385 during April to June 1990 and 388 during April to June 1991, 95% confidence interval for change in referrals -51 to 57), and the number of hospital procedures resulting from those referrals also remained constant (187 in the first period, 189 in the second, 95% confidence interval for change in procedures -36 to 40). The mix of procedures did not change significantly from one study period to the next in either setting. CONCLUSIONS: Many or all of the additional patients receiving minor surgery under the terms of the 1990 contract may not have previously been referred to hospital. General practitioners seem not to have systematically shifted towards treating the more trivial cases. The overall increase in minor surgical activity may reflect an improvement in accessibility of care or changes in patients' perceptions and attitudes.

Contract Services↗
PubMed1998

Minor surgery in general practice--setting the standards.

BACKGROUND: A self-assessment tool was trialled to set a baseline for control of infection in general practice and to assess the nature and adequacy of infection control precautions in primary care settings with particular reference to minor surgery. METHODS: A request for volunteers was included in a flier sent out periodically by the Communicable Disease Unit to all general practices in the county (n = 114). Eleven practices (9.6 per cent) volunteered to take part and an audit of infection control precautions was undertaken with the practice nurse and/or manager. RESULTS: Of the 11 general practices audited, nine did not have a written policy for control of infection, did not have a separate, dedicated room for minor surgery, did not use protective clothing appropriately, used terry towels for hand-drying and reprocessed single-use only items. Ten used inappropriate methods to decontaminate heat labile items, seven did not record sterilizer processing cycles and five did not comply with HTM 2010 with regard to sterilizer maintenance. Following the survey, minimum infection control requirements have been developed for future applications to provide extended minor surgery within general practice and these will be monitored at subsequent surgery inspection visits and through audit. CONCLUSIONS: Results suggest that there is little room for complacency with regard to standards of infection control in general practice. In view of the increasing shift towards primary care based minor surgery it would be helpful if minimum standards were to be agreed nationally.

England↗
PubMedDate not supplied

The 1990 GP contract: modelling variation in minor surgery provision.

Logistic regression was used to determine the extent to which general medical practices undertake the maximum amount of minor surgery activity allowed for in the GP contract. Data on activity for 89 practices in the Grampian region of Scotland was available for two consecutive financial years: 1992-93 and 1993-94. Comparison of the regression models developed in each year showed that rural location and practice size were consistently associated with the maximization of minor surgery activity under the terms of 1990 GP Contract. In 1993-94 practices with a greater proportion of deprived patients were also more likely to be 'maximizers'. Quantitative modelling allows the performance of GPs to be assessed and also helps to identify factors which are a barrier to service development. It seems likely that, in Grampian, GPs who were able to exploit fully the provisions of their contract were those whose patients had the greatest capacity to benefit from minor surgery. Currently the GP contract is nationally negotiated, but in the future local negotiated remuneration is likely to become widespread. Modelling will have an important role in the design and monitoring of incentive structures, and help to ensure that service provision equates to local needs.

Contract Services↗
PubMed1995

Postural control after propofol anaesthesia in minor surgery.

There is, not only from an economic perspective, a continuous search for surgical and anaesthetic procedures that allow out-patient surgery to be conducted. Reliable estimators of the patient's street fitness are of the utmost importance. Balancing capacity is one aspect that should be considered. Clinical methods like Romberg's are subjective and imprecise. Dynamic posturography comprises a movable support surface and visual surround that are either stable or referenced to the patient's sway, with eyes open or closed. In this study the recovery from propofol anaesthesia was studied in 8 patients who underwent surgery for minor microlaryngoscopic procedures. Dynamic posturography who performed before, and 2 and 4 h after cessation of anaesthesia. All patients who were awake had normal balancing ability already at 2 h after anaesthesia. Further studies may supply additional information of other aspects of discharge after anaesthesia.

Adult↗
PubMed2001

Outcome after minor surgery in children.

Major complications and death are rare events, but cases are reported even in connection with minor surgery. Most of the patients for 'minor' surgery are currently treated as day cases and during the hospital stay only the immediate or intermediate outcome is seen. The results of the evaluations on the late outcome at home can be surprising.

Journal Article↗
PubMed1999

'Stab and Split': a 'bloodless' and 'scarless' skin incision technique for minor surgery.

The 'stab and split' skin incision technique was applied to children requiring minor surgery. A small stab incision was made on a skin crease and split open with mosquito forceps. After the surgical procedure was completed, the wound was closed in layers with a subcuticular suture to the skin. In all cases, splitting caused virtually no blood loss because subcutaneous veins were left intact, and the wounds healed well, especially in infants. 'Stab and split' is an effective alternative incision technique for minor surgery in younger children.

Child↗
PubMed2004

The median effective dose of nefopam and morphine administered intravenously for postoperative pain after minor surgery: a prospective randomized double-blinded isobolographic study of their analgesic action.

UNLABELLED: The aim of this study was to characterize the nature of analgesic interaction between nefopam and morphine administered i.v. for postoperative pain after minor surgery. To do so, we defined the median effective analgesic dose (ED(50)) for each drug and also the median ED(50) of their combination and compared them using the isobolographic method. Determination of median effective doses was performed by the up-and-down sequential drug administration in a two-stage study. First, in a prospective, randomized, double-blinded study, we enrolled 60 patients with mild to moderate pain after minor surgery; this was followed by an open study enrolling 30 patients. The end-point was a pain score less than 3 on a Numerical Pain Scale (0-10). Initial doses were 16 mg in group N, 5 mg in group M, and 7.5 mg of N combined with 2.5 mg of M in group N+M. The testing interval was 2 mg in group N, 1 mg in group M, and 1.5 mg of N combined with 0.5 mg of M in group N+M. ED(50) (95% confidence interval) was 5 mg (4-6 mg) for morphine, 18 mg (16-18 mg) for nefopam, and 4 mg (3.5-4.5 mg) with 12 mg (10.5-13.5 mg) for the combination of morphine and nefopam administered at a 3:1 dose ratio. Isobolographic analysis demonstrated a significant infra-additive interaction. The incidence of side effects did not differ significantly among morphine, nefopam, and their combination. These findings suggest that the combination of nefopam and morphine does not offer any advantage compared to each drug administered i.v. or alone after minor surgery. This study is the first to define the ED(50) of nefopam and morphine in postoperative patients. In conclusion, the addition of nefopam has a morphine-sparing effect, but the combination is infra-additive. IMPLICATIONS: Pharmacologic interaction between nefopam and morphine shows infra-additivity but their combination may be clinically useful as morphine consumption is decreased in postoperative patients.

Adult↗
PubMed1987

Constraints on the performance of minor surgery by family physicians: study of a 'mock' skin biopsy procedure.

Despite the availability of a procedure room equipped for the performance of common surgery procedures, physicians in a family medicine training programme have reported that minor surgery training objectives are not being accomplished. To examine this issue, the frequency of minor surgery procedures was audited among 357 randomly selected medical records. The frequency of documented sigmoidoscopy in this group of active patients over the age of 50 years was 4.8%. A similar low frequency for the performance of skin biopsy was also observed. All 15 senior residents participated in an attitude survey and a timed exercise in which they sought to find the necessary items for performance of a skin biopsy. In a questionnaire the group agreed that sigmoidoscopy and skin biopsies were procedures appropriate for their family practice goals. In their offices, these residents required over nine minutes to partially locate equipment chosen for skin biopsy. The attitude survey revealed few constraints other than insufficient time to perform indicated elective procedures. Further study of procedure room utilization and family physicians' office surgery skills is recommended.

Attitude of Health Personnel↗
PubMed1986

Metabolic changes in the non-insulin-dependent diabetic undergoing minor surgery: effect of glucose-insulin-potassium infusion.

We have compared the metabolic response to minor surgery in the non-insulin dependent diabetic patient with that in the non-diabetic, using transurethral surgery under general anaesthesia as a model. Preoperative blood glucose and 3-hydroxybutyrate concentrations were higher in the diabetic patients, but the response to surgery did not differ. The postoperative cortisol response was lower in the diabetic patients. Glucose insulin potassium infusion (GIK) resulted in lower plasma nonesterified fatty acid, and blood 3-hydroxybutyrate and glycerol concentrations, with markedly higher serum insulin levels compared to patients managed with a 'no insulin' regimen. Blood glucose however was not significantly different except at 2 h postoperatively. Blood metabolite and serum insulin concentrations in the diabetic patients were closer to those in non-diabetic patients in the group not given insulin, than in those given GIK. Rather than rendering the diabetic patient the same as the non-diabetic, GIK produces a further abnormal state which is probably of little benefit. We conclude that there is no indication for the use of insulin in the well or moderately well-controlled non-insulin dependent diabetic patient undergoing minor surgery, provided that glucose containing fluids are not given.

Aged↗
PubMed1994

Propofol infusion anaesthesia and immune response in minor surgery.

This study was set up to evaluate the effects of propofol infusion anaesthesia on immunological function in minor surgery. Twenty-seven patients (median age 51 years, ASA 1-2) scheduled for minor breast surgery were randomly assigned to two groups. Anaesthesia was induced in group 1 with propofol 2.5 mg.kg-1 and maintained with propofol 12 mg.kg-1 x h-1 and 30% O2 in air, whereas in group 2 anaesthesia was induced with thiopentone 4 mg.kg-1 and maintained with 70% N2O in O2. Fentanyl and vecuronium were used in both groups. The percentages of T cells (p < 0.001), B cells (p < 0.01) and memory T cells increased (p < 0.01) in both groups. T helper cell percentages increased in the propofol but not in the thiopentone group (p < 0.05). The percentages of natural killer cells decreased from pre-induction values in both groups (p < 0.001). No changes were seen in lymphocyte proliferative responses. Minor breast surgery under propofol or conventional combined anaesthesia had only minor effects on the immune response. The higher percentage of T helper cells after propofol anaesthesia compared to conventional combined anaesthesia is beneficial, but its clinical importance remains to be determined.

Adult↗
PubMed2003

Teaching and learning about skills in minor surgery.

The aim of this study was to assess the feasibility of a scenario-based approach to learning minor surgery skills. After learning component technical skills for ellipse excision and wound closure, nurses were provided with an opportunity to integrate these skills with communication skills and contextual factors in a quasi-clinical environment. Feasibility was assessed using observation of procedures and a group interview with participants, simulated patients and tutors. The scenario-based approach to teaching and learning about technical and communication skills proved feasible and was valued by participants in this course on minor surgery. Although all participants expressed anxiety about integrating skills in the quasi-clinical setting, they valued the opportunity to undergo a formative assessment prior to working in supervised settings with real patients. Learners valued highly the opportunity to reflect on their performance and to receive feedback on technical and communication skills. Future courses should include focused teaching on communication skills prior to the scenario-based exercise. Limitations of the study centre on the small numbers of participants and the novelty of the course. Repeating the evaluations on a subsequent course will provide insight into the ways in which nurses acquire and integrate new skills.

Clinical Competence↗
PubMed1988

Insulin treatment of the insulin-dependent diabetic patient undergoing minor surgery. Continuous intravenous infusion compared with subcutaneous administration.

In a prospective randomised study in 20 insulin-dependent diabetics who had minor surgery under general anaesthesia we compared the metabolic responses to intravenous glucose-insulin-potassium infusion with those who had conventional subcutaneous insulin administration. The former treatment resulted in lower blood glucose levels both during the infusion period (p less than 0.05) as well as the entire observation period (operative, first and second postoperative days; p less than 0.01). More blood glucose values were within the intended range of 5 to 10 mmol/litre in the glucose-insulin-potassium as compared to the conventional group (48% versus 24%; p less than 0.01). The levels of lactate, 3-hydroxybutyrate, glycerol, alanine, glucagon, insulin and growth hormone did not differ between the two groups. The infusion regimen resulted in better glycaemic control both peri-and postoperatively than the conventional subcutaneous insulin regimen in insulin-dependent diabetic patients who have minor surgery.

Adult↗
PubMed1994

General versus regional anaesthesia and platelet aggregation in minor surgery.

In order to evaluate the impact of minor surgery on platelet aggregability and the effect of anaesthesia on this parameter, we allocated 14 otherwise healthy men for inguinal herniotomy to either general anaesthesia (n = 7) or lumbar epidural anaesthesia (n = 7). Platelet aggregation threshold to adenosine diphosphate (ADP-threshold) was measured before and after anaesthesia, prior to surgery, at the end of surgery and during the following hours as well as on the first post-operative morning. General anaesthesia did not affect ADP-threshold while epidural analgesia itself induced a significant increase. During and soon after surgery the ADP-threshold increased in those receiving general anaesthesia while in those receiving epidural analgesia the ADP-threshold returned to pre-operative levels. On the first post-operative morning both groups showed a significantly lower ADP-threshold as compared to the pre-operative level. Surgery induced an increase in 3'5' cyclic-adenosine monophosphate (cAMP). This adrenergic response was attenuated by epidural analgesia.

Adenosine Diphosphate↗
PubMed2000

What is the optimal dose of glucose administration during minor surgery under sevoflurane anesthesia?

PURPOSE: We attempted to identify the optimal infusion rate of glucose to maintain an appropriate usage of energy sources during minor surgery after an overnight fast. METHODS: Forty patients scheduled for tympanoplasty or skin grafting under sevoflurane anesthesia were assigned to four groups. The patients received a 2-h infusion of either saline or glucose at a rate of 0.1, 0.2, or 0.3 g.kg(-1).h(-1). Blood samples were collected before the induction of anesthesia, and at 1 and 2 h after the start of the saline or glucose infusion. Plasma glucose, free fatty acid, beta-hydroxybutyrate, acetoacetate, and immunoreactive insulin were measured. RESULTS: Plasma glucose concentration increased dose-dependently. Immunoreactive insulin levels increased in the groups receiving 0.2 or 0.3 g.kg(-1).h(-1) of glucose infusion. Free fatty acid and ketone bodies did not increase in any glucose infusion groups. The arterial ketone body ratio increased to over 1.00 in the groups receiving 0.2 or 0.3 g.kg(-1).h(-1) of glucose infusion. Glycorrhea was observed only in the group receiving 0.3 g.kg(-1).h(-1) of glucose. CONCLUSION: The smaller doses of glucose (0.1-0.2 g.kg(-1).h(-1)) prevented lipolysis and hyperglycemia during minor surgery.

Journal Article↗