Clínica médica especializada: norma técnica No. 18-2020-DRACES / Specialized medical clinic: technical standard No. 18-2020-DRACES

DRACES [Departamento de Regulación, Acreditación y Control de Establecimientos de Salud] Este documento tiene como objeto: "la regulación, autorización y control de las clínicas médicas especializadas, en concordancia con el Reglamento para la Regulación, Autorización, Acreditación y Control de Establecimientos de Atención para la Salud, Acuerdo Gubernativo 376-2007." Es de carácter obligatorio, por lo que se aplica en todo el territorio nacional. Contiene además, las definiciones de los conceptos relacionados al tema principal, además de la infraestructura que deberá tener cada clínica, incluidos el equipo y recurso humano y técnico.

Clínica médica general: norma técnica No. 17-2020-DRACES / General medical clinic: technical standard No. 17-2020-DRACES

DRACES [Departamento de Regulación, Acreditación y Control de Establecimientos de Salud] Este documento tiene como objeto: "la Regulación, Autorización y Control de las Clínicas Médicas Generales, en concordancia con el Reglamento para la Regulación, Autorización, Acreditación y Control de Establecimientos de Atención para la Salud, Acuerdo Gubernativo 376-2007." Es de carácter obligatorio, por lo que se aplica en todo el territorio nacional. Contiene además, las definiciones de los conceptos relacionados al tema principal, además de la infraestructura que deberá tener cada clínica, incluidos el equipo y recurso humano y técnico.

Is it safe to re-access sodium bicarbonate bottles for use in minor surgery?

BACKGROUND/PURPOSE: Sodium bicarbonate is added to lidocaine to reduce injection pain. In Canada, it is available in vials exceeding the injection volume 100-fold. These are single-use vials that should be disposed of after one access. Some surgeons re-use vials to reduce waste, potentially causing contamination. This study aims to review the safety of sodium bicarbonate and assess alternatives to current practice. METHODS: Strains of Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, and Burkholderia cepacia were used to assess bacterial growth in vials of sodium bicarbonate. Each pathogen was inoculated into a vial for 14 days at room temperature. At several time points, 1 mL of solution was removed and diluted. One hundred microliters were transferred to blood agar plates and incubated at 35 °C. Colony counts were calculated, averaged and plotted onto a logarithmic graph. RESULTS: Colony counts of all strains fell below observational threshold after 7 days in sodium bicarbonate. CONCLUSIONS: Although all strains were reduced, bacteria can survive in sodium bicarbonate for several days, during which transmission may occur. Sodium bicarbonate vials should be treated as single-dose, as indicated by the manufacturers. To reduce waste, hospital pharmacies can repackage sodium bicarbonate into smaller vials or pre-alkalize lidocaine with sodium bicarbonate.

[Quality perceived by users of minor surgery according to care level and the professionals that carried it out]. / Calidad percibida por usuarios de cirugía menor según nivel asistencial y profesionales que la realizan.

OBJECTIVE: Nowadays minor surgery is performed by di- fferent professionals at primary as well as specialized care. Being a healthcare technology, minor surgery must be assessed in order to achieve an organizational efficiency. User's satisfaction must be one of the quality criteria. That is why an analysis of the quality perceived by users according to where minor surgery takes place and who carries it out is made. METHODS: This study explores, conducting telephone surveys, the satisfaction of a sample of 275 minor surgery patients of two hospitals and three primary healthcare areas of Asturias. The survey is based on the SERVQUAL model adapting the one used by the Spanish Ministry of Health in 1977. A behavior pattern of satisfaction was established in terms of the variables that increase or diminish it. RESULTS: In every item, satisfaction was perceived as good or very good at least in 84% of the survey users and in the majority was over 95%. There was a significant difference in favour of primary care with respect to waiting time (p less than 0,001), explanations received (p=0,002) and security perceived (p=0,015). The more explanatory variables of excellent satisfaction were the sense of security and the staff attention. The kind of professional did not represent a conditioning factor and the level of healthcare only appeared to be so among those who did not feel safe showing to be less satisfied those treated in primary care. CONCLUSIONS: Good quality perceived by users does not seem to be penalized by the fact that minor surgery can be carried out at different healthcare levels or which specialist performs it.

OBJETIVO: La cirugía menor es realizada actualmente por diversos profesionales en atención primaria y especializada. Como tecnología sanitaria debe ser evaluada para conseguir una eficiencia organizacional. La satisfacción del usuario es uno de los criterios de calidad. Por ello se plantea un análisis de la calidad percibida por el usuario según dónde y quién realice cirugía menor. METODOS: Se estudió por encuesta telefónica la satisfacción de una muestra de 275 pacientes de cirugía menor pertenecientes a dos hospitales y tres áreas de atención primaria de Asturias. El cuestionario sigue el modelo SERVQUAL adaptando el utilizado por el Ministerio de Sanidad en 1977. Se establece un modelo de comportamiento de la satisfacción en función de las variables que la incrementan o disminuyen. RESULTADOS: En todos los ítems la satisfacción fue buena o muy buena como mínimo en el 84% de los encuestados y en la mayoría estaba por encima del 95%. Había una diferencia significativa, a favor de atención primaria en tiempo de espera (p menor que 0,001), explicaciones recibidas (p=0,002) y seguridad percibida (p=0,015). Las variables más explicativas de una satisfacción excelente fueron la sensación de seguridad y la atención del personal. El tipo de profesional no apareció como condicionante y el nivel asistencial solo apareció entre los que no se sentían muy seguros, en cuyo caso estaban menos satisfechos los atendidos en atención primaria. CONCLUSIONES: La buena calidad percibida por los usuarios no penaliza el que la cirugía menor sea realizada en ninguno de los niveles asistenciales ni por ninguno de los profesionales que la realizan actualmente.

Developing accreditation for community based surgery: the Irish experience.

Purpose Carrying out minor surgery procedures in the primary care setting is popular with patients, cost effective and delivers at least as good outcomes as those performed in the hospital setting. This paper aims to describe the central role of clinical leadership in developing an accreditation system for general practitioners (GPs) undertaking community-based surgery in the Irish national setting where no mandatory accreditation process currently exists. Design/methodology/approach In all, 24 GPs were recruited to the GP network. Ten pilot standards were developed addressing GPs' experience and training, clinical activity and practice supporting infrastructure and tested, using information and document review, prospective collection of clinical data and a practice inspection visit. Two additional components were incorporated into the project (patient satisfaction survey and self-audit). A multi-modal evaluation was undertaken. A majority of GPs was included at all stages of the project, in line with the principles of action learning. The steering group had a majority of GPs with relevant expertise and representation of all other actors in the minor surgery arena. The GP research network contributed to each stage of the project. The project lead was a GP with minor surgery experience. Quantitative data collected were analysed using Predictive Analytic SoftWare. Krueger's framework analysis approach was used to analyse the qualitative data. Findings A total of 9 GPs achieved all standards at initial review, 14 successfully completed corrective actions and 1 GP did not achieve the required standard. Standards were then amended to reflect findings and a supporting framework was developed. Originality/value The flexibility of the action-learning approach and the clinical leadership design allowed for the development of robust quality standards in a short timeframe.

Safety of community-based minor surgery performed by GPs: an audit in different settings.

BACKGROUND: Minor surgery is a well-established part of family practice, but its safety and cost-effectiveness have been called into question. AIM: To audit the performance of GP minor surgeons in three different settings. DESIGN AND SETTING: A community-based surgery audit of GP minor surgery cases and outcomes from three settings: GPs who carried out minor surgery in their practice funded as enhanced (primary care) services (ESGPs); GPs with a special interest (GPwSIs) who worked independently within a healthcare organisation; and GPs working under acute trust governance (Model 2 GPs). METHOD: An audit form was completed by volunteer GP minor surgeons. Data were collected about areas of interest and aggregated data tables produced. Percentages were calculated with 95% confidence intervals (CIs) and significant differences across the three groups of GPs tested using the χ(2) test. RESULTS: A total of 6138 procedures were conducted, with 41% (2498; 95% CI = 39.5 to 41.9) of GP minor surgery procedures being on the head/face. Nearly all of the samples from a procedure that were expected to be sent to histology were sent (5344; 88.8%; 95% CI = 88.0 to 89.6). Malignant diagnosis was correct in 69% (33; 95% CI = 54.2 to 79.2) of cases for ESGPs, 93% (293; 95% CI = 90.1 to 95.5) for GPwSIs, and 91% (282; 95% CI = 87.2 to 93.6) for Model 2 GPs. Incomplete excision was significantly more frequent for ESGPs (17%; 9; 95% CI = 7.5 to 28.3, P<0.001). Complication rates were very low across all practitioners. CONCLUSION: GP minor surgery is safe and prompt. GPs working within a managed framework performed better. Consideration needs to be given on how better to support less well-supervised GPs.

Testicular biopsy in prepubertal boys: a worthwhile minor surgical procedure?

No consensus exists regarding the precise role of testicular biopsy in prepubertal boys, although it is considered useful for assessing the potential consequences of undescended testes on fertility. Current scientific knowledge indicates that surgeons should broaden indications for this procedure. For example, the use of immunohistochemical markers such as OCT/3-4, TSPY, Kit ligand (SCF) and ALPP (PLAP) has considerably facilitated the detection of germ cell tumour precursors, such as carcinoma in situ and/or gonadoblastoma. These markers are very important for evaluating malignancy risk in undervirilized patients with 46,XY disorders of sexual development. Testicular histology is also of considerable value in the prediction of both fertility potential and risk of cancer in individuals with undescended testes, particularly those with intraabdominal undescended testes. New possibilities for the preservation of fertility after gonadotoxic chemotherapy - even for prepubertal boys - are emerging. Cryopreservation of testicular tissue samples for the preservation of fertility - although still an experimental method at present - is appealing in this context. In our opinion, testicular biopsy in prepubertal boys is a minor procedure that can provide valuable information for predicting the risk of malignancy and fertility, and might be useful in fertility preservation in the near future.

Correlación clínico-patológica en cirugía menor en un área de salud rural / Correlation between clinical and histological diagnosisv in minor surgery in a rural health area

Introducción. La cirugía menor forma parte de las actividades programadas en un número cada vez más creciente de nuestros centros de atención primaria. El objetivo de este trabajo es conocer el grado de correlación entre el diagnóstico clínico previo al proceso de cirugía menor y su concordancia con el resultado de anatomía patológica. Material y método. Para ello realizamos un estudio retrospectivo a partir del Registro de Actividades de Cirugía Menor de un Centro de Salud Rural de la Comarca de Valdejalón de Aragón. Sujetos. Se incluyeron 1.231 pacientes atendidos durante el periodo comprendido entre abril de 1999 y julio del año 2009 a los que se realizaron un total de 1.391 diagnósticos con sus correspondientes actuaciones. Mediciones. Diagnóstico clínico y resultado clínico-patológico. Correlaciones entre ambos Resultados Se remitieron 820 piezas para estudio clínico-patológico (el 59% de las intervenidas). Se valoraron los 11 diagnósticos clínicos y clínico-patológicos principales con los que se construyó una tabla de contingencia. Se obtuvo un coeficiente kappa de 0,638 Conclusiones. Analizados estos resultados y comparándolos con otros trabajos similares realizados en el ámbito de la cirugía menor en atención primaria, podemos afirmar que hay una buena correspondencia entre el diagnóstico clínico inicial y los resultados de anatomía patológica (AU)

Introduction. Minor Surgery is an ever-increasing programmed activity in Primary Health Care Centres. The aim of this paper is to determine the relationship between the clinical diagnosis prior to Minor Surgery and its concordance with the histological results. Material and methods. We carried out a retrospective study using the registered activity log in a Primary Health Care Centre in the region of Valdejalón of Aragón. Subjects. A total of 1231 patients were included between April 1999 and June 2009. A total of 1391 diagnoses were given, together with the corresponding medical care. Measurements. Clinical diagnosis and histological results, and the level of correlation between both. Results. A total of 820 samples were submitted for histological study (59% of the total sample). Eleven of the main clinical and histological diagnoses were evaluated, and a contingency table was prepared. The result of the correlation gave a Kappa coefficient of 0.638. Conclusions. Once the results were analysed and compared to similar studies of Minor Surgery carried out in Primary Care, our results confirm that there is a high correlation between the clinical diagnosis and the histological results (AU)

A baseline audit of referral and treatment delivered to patients in the intermediate minor oral surgery service in Croydon PCT.

INTRODUCTION: Patients attending for primary dental care may require oral surgery procedures beyond the capability of a generalist and thus need to be treated by a dentist with greater expertise. In the United Kingdom, it is increasingly accepted that such care may be provided in primary care settings by specialists or dentists with a special interest. In response to local pressures, an intermediate minor oral surgery (IMOS) service has been established in Croydon, south west London, to provide oral surgery treatment for non-urgent patients on referral. AIM: To audit the appropriateness and quality of oral surgery referrals after triage to an IMOS service in Croydon and to set standards for future audits on this topic. METHODS: An audit tool was developed in line with the local referral guidelines and agreed with local stakeholders. Information on 501 (10%) triaged referrals to IMOS practices over a 24-month period was obtained through the referral management centre. A 10% sample of referrals per month to each practice was calculated and IMOS providers randomly selected the relevant patient records. Using an agreed audit pro forma, information on the indications for referral, treatment provided, and dates relating to patient management, in addition to the age and sex of patients, was collected from the IMOS providers by one investigator. Descriptive analysis of the data was performed. RESULTS: Of the 501 patient records that were examined, 99% of patients were treated in IMOS practices, with only three (less than 1%) patients being referred on to hospital consultant services. The largest proportion (237; 40%) of referrals was for the extraction of teeth considered to have special difficulty, followed by lower third molars (154; 26%). Almost one-third (159; 32%) of patients were referred for more than one procedure. One in eight (72; 13%) teeth removed by the IMOS providers were recorded as a simple extraction without medical complications. CONCLUSIONS: In general, patients were referred appropriately to the primary care oral surgery service in Croydon, with only a minority recorded as receiving simple care that should not have required referral. The clinician-led triage process using a referral management system worked well in selecting appropriate patients for treatment by IMOS providers in primary care and reduced referrals to hospital. Suggested standards for future audits of IMOS referrals have been set.

Primary excision of cutaneous melanoma: does the location of excision matter.

Melanoma is diagnosed more quickly if primarily excised in primary care, but current guidelines discourage this. The reports of all melanomas excised in north-east Scotland between 1991 and 2007 were analysed for adequacy of excision. Reports were analysed blinded as to source. Of primary biopsies performed in primary care, 72.5% were reported as completely excised, compared with 69.7% of those performed in secondary care (P<0.612). The difference remained non-significant following adjustment for important confounders.

[A prospective study to evaluate the safety of minor cutaneous surgery during aspirin treatment].

BACKGROUND: Many patients undergoing cutaneous surgery are treated with aspirin due to its proven advantages. Discontinuation of aspirin prior to surgery is still controversial. We conducted a large-scale, prospective study to evaluate the safety of dermatologic surgery in patients receiving aspirin. OBJECTIVES: The authors' objectives were to evaluate the complication rate in patients undergoing cutaneous surgery while treated with aspirin. METHODS: All patients operated on solely by one plastic surgeon were included in the study. The study group included all patients receiving aspirin during surgery, while the rest of the patients comprised the control group. Demographic data, surgery type and complication rate were collected. Complications were classified as major or minor hematoma, wound infection and dehiscence. Statistical significance was calculated using the Student's t-test and Chi test. RESULTS: During the study period 7259 patients underwent minor cutaneous surgery (without local flaps or skin grafts). A group of 115 patients taking either Plavix (Clopidrogel) or Coumadin (Warfarin) were excluded. The study group consisted of 1088 patients who were taking aspirin regularly while 6056 patients comprised the control group. A statistically significant change was found between the two groups regarding sex, age, background chronic diseases and in the distribution of lesions across the body. No significant change was found regarding the peri-operative complications. CONCLUSIONS: In this large-scale prospective study, dermatologic surgery on patients receiving aspirin was found to be safe, as no statistically different complication rate was found between the study and the control groups. This statement is further emphasized due to the significantly statistically older age, chronic illness rate and the head and neck location of the lesions in the study group.

Effect of surgical training course on performance of minor surgical procedures in family medicine physicians' offices: an observational study.

AIM: To examine the influence of a practical surgical course on the number of minor surgical procedures performed by family physicians. METHODS: We compared the number of minor surgical procedures performed by family physicians in 59 offices in the city of Osijek and surrounding rural area during 12 months before and after the 40-hour practical surgical course held in September 2006 by surgeons and family medicine specialists. Minor surgical procedures taught in the course included management of ingrown toenails, abscesses/comedones, and minor wounds, anesthesia application, disinfection, use and sterilization of surgical instruments, and antibiotic treatment. RESULTS: The number of minor surgical procedures performed in family medicine offices almost doubled (503 vs 906 after the course, P<0.001, Wilcoxon test). The median number of abscesses/comedones treatments per physician increased from 1 to 6 (P<0.001, Wilcoxon test), the number of managed wounds increased from 111 to 217 (P<0.001, Wilcoxon test). The increase in ingrown toenail resections was also significant (from 120 to 186, P=0.004, Wilcoxon test). Fifty percent of physicians did not treat patients surgically, irrespective of the training. We found no association between the number of performed procedures and age, length of employment, or location of the physician's office (urban vs rural). However, we found that male physicians performed more surgical treatments both before and after the course (abscesses/comedones: P<0.001 and P=0.108 respectively; ingrown toenail resections: P=0.008 and P=0.008 respectively; minor wounds: P=0.030 and P<0.001; respectively). CONCLUSION: Practical courses can encourage practitioners to treat the patients surgically in their offices and, thus, increase the number of services offered in primary care. Female physicians should be more encouraged to perform minor surgical procedures in their offices.

A prospective randomised comparison of minor surgery in primary and secondary care. The MiSTIC trial.

OBJECTIVE: To determine whether there is equivalence in the competence of GPs and hospital doctors to perform a range of elective minor surgical procedures, in terms of the safety, quality and cost of care. DESIGN: A prospective randomised controlled equivalence trial was undertaken in consenting patients presenting at general practices and needing minor surgery. SETTING: The study was conducted in the south of England. PARTICIPANTS: Consenting patients presenting at general practices who needed minor surgery in specified categories for whom the recruiting doctor felt able to offer treatment or to be able to refer to a colleague in primary care. INTERVENTIONS: On presentation to their GP, patients were randomised to either treatment within primary care or treatment at their local hospital. Evaluation was by assessment of clinical quality and safety of outcome, supplemented by examination of patient satisfaction and cost-effectiveness. MAIN OUTCOME MEASURES: Two independent observers assessed surgical quality by blinded assessment of wound appearance, between 6 and 8 weeks postsurgery, from photographs of wounds. Other measures included satisfaction with care, safety of surgery in terms of recognition of and appropriate treatment of skin malignancies, and resource use and implications. RESULTS: The 568 patients recruited (284 primary care, 284 hospital) were randomised by 82 GPs. In total, 637 skin procedures plus 17 ingrowing toenail procedures were performed (313 primary care, 341 hospital) by 65 GPs and 60 hospital doctors. Surgical quality was assessed for 273 (87%) primary care and 316 (93%) hospital lesions. Mean visual analogue scale score in hospital was significantly higher than that in primary care [mean difference=5.46 on 100-point scale; 95% confidence interval (CI) 0.925 to 9.99], but the clinical importance of the difference was uncertain. Hospital doctors were better at achieving complete excision of malignancies, with a difference that approached statistical significance [7/16 GP (44%) versus 15/20 hospital (75%), chi(2)=3.65, p=0.056]. The proportion of patients with post-operative complications was similar in both groups. The mean cost for hospital-based minor surgery was 1222.24 pounds and for primary care 449.74 pounds. Using postoperative complications as an outcome, both effectiveness and costs of the alternative interventions are uncertain. Using completeness of excision of malignancy as an outcome, hospital minor surgery becomes more cost-effective. The 705 skin procedures undertaken in this trial generated 491 lesions with a traceable histology report: 36 lesions (7%) from 33 individuals were malignant or premalignant. Chance-corrected agreement (kappa) between GP diagnosis of malignancy and histology was 0.45 (95% CI 0.36 to 0.54) for lesions and 0.41 (95% CI 0.32 to 0.51) for individuals affected by malignancy. Sensitivity of GPs for detection of malignant lesions was 66.7% (95% CI 50.3 to 79.8) for lesions and 63.6% (95% CI 46.7 to 77.8) for individuals affected by malignancy. CONCLUSIONS: The quality of minor surgery carried out in general practice is not as high as that carried out in hospital, using surgical quality as the primary outcome, although the difference is not large. Patients are more satisfied if their procedure is performed in primary care, largely because of convenience. However, there are clear deficiencies in GPs' ability to recognise malignant lesions, and there may be differences in completeness of excision when compared with hospital doctors. The safety of patients is of paramount importance and this study does not demonstrate that minor surgery carried out in primary care is safe as it is currently practised. There are several alternative models of minor surgery provision worthy of consideration, including ones based in primary care that require all excised tissue to be sent for histological examination, or that require further training of GPs to undertake the necessary work. The results of this study suggest that a hospital-based service is more cost-effective. It must be concluded that it is unsafe to leave minor surgery in the hands of doctors who have never been trained to do it. Further work is required to determine GPs' management of a range of skin conditions (including potentially life-threatening malignancies), rather than just their recognition of them. Further economic modelling work is required to look at the potential costs of training sufficient numbers of GPs and GPs with special interests to meet the demand for minor surgery safely in primary care, and of the alternative of transferring minor surgery large-scale to the hospital sector. Different models of provision need thorough testing before widespread introduction.

Normas técnicas básicas para la obtención de la autorización sanitaria de las salas de procedimientos y pabellones de cirugía menor / Basic technical standards for obtaining health authorization procedure rooms and minor surgery

Se denominan Salas de Procedimientos a locales o recintos de establecimientos públicos o privados de salud destinados a efectuar procedimientos de salud, de diagnóstico o terapéuticos, en pacientes ambulatorios, y que no requieren de hospitalización. Estos deberán formar parte de un establecimiento de salud o ser dependencia anexa a consultas de profesionales. Se denomina Pabellón de Cirugía Menor a los locales o recintos destinados a realizar intervenciones quirúrgicas médicas u odontológicas, que no requieren la hospitalización del paciente, al que se le aplica sedación y/o anestesia local. Estos deberán formar parte de un establecimiento de salud o ser dependencia anexa a consultas de profesionales. Ámbito de aplicación: a) Esta Norma Técnica se aplicará a todas las Salas de Procedimientos y Pabellones de Cirugía Menor dependientes del Sistema Público de Salud y establecimientos privados destinados a efectuar procedimientos de salud, de tipo diagnóstico y/o terapéuticos, en pacientes ambulatorios que no requieren de hospitalización. b) Los Consultorios y establecimientos de atención primaria de salud, ya sea dedependencia municipal o pertenecientes a los Servicios de Salud que realicen las actividades descritas en esta norma, independiente de su denominación actual de acuerdo a los Planes y Programas del Ministerio de Salud, tales como Centros de Salud Familiar (CESFAM) o Centros de Salud (CES), deberán obtener su autorización sanitaria de acuerdo a esta norma técnica. c) De acuerdo a las prestaciones que realiza el Establecimiento, esta Norma Técnica podrá ser aplicada en conjunto con las Normas Técnicas Básicas de atención cerrada para Pabellones de Cirugía Menor, Anexos, Servicios de Apoyo y las Normas Técnicas Especificas, según corresponda: Laboratorio Clínico, Imagenología, Esterilización, Farmacia Despacho, Hospitalización Transitoria, Hospitalización psiquiatrica, Sala para estudios funcionales especiales...

A survey of competency-based training of senior house officers in performing minor surgical procedures.

INTRODUCTION: The aim of this survey was to ascertain the level of competency and training of basic surgical trainees (SHOs) in performing incision and drainage of a perianal abscess (a minor surgical procedure). MATERIALS AND METHODS: Questionnaires were sent to SHOs enquiring about preferred methods of incision and drainage and the teaching received to perform this procedure. RESULTS: Of respondent SHOs, 10% did not receive teaching when performing their first incision and drainage and over half did not received any feedback from their trainers. A mere 65% received practical supervision. Use of the curette and de-roofing of the abscess are not routine methods used. In addition, 13% reported inadequate incision and drainage, which required a second procedure. CONCLUSIONS: Competency-based training in minor surgical procedures benefits not only from didactic teaching, immediate supervision and appraisal but also from frequent practise. This was found to be lacking for incision and drainage of perianal abscesses by basic surgical trainees surveyed in the study.