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  • COMMUNITY DIVISION SERIVCE BASED POLICY DOCUMENT

    NAIL SURGERY POLICY

    Policy Number: 177 Scope of this Document: Staff wortking within Podiatry

    Services – Mersey Care Community Services Division

    Recommending Committee: N/A Approving Committee: Clinical Standards Group Date Ratified: Novemb er 2019 Next Review Date (by): November 2021 Version Number: 2019 – Version 2 Lead Executive Director: Executive Director of Nursing

    and Operations Lead Author(s): Podiatry Team Leader

    COMMUNITY DIVISION SERVICE BASED POLICY

    DOCUMENT

    2019 – Version 2

    Striving for perfect care and a Just Culture

    Page 1 of 27 177 - Nail surgery policy Version 2 November 2019

  • COMMUNITY DIVISION SERVCE BASED POLICY DOCUMENT

    NAIL SURGERY POLICY Further information about this document:

    Document name 177 - NAIL SURGERY POLICY

    Document summary

    THIS DOCUMENT OUTLINES THE GUIDELINES AND

    PROCEDURES FOR PODIATRY STAFF TOP FOLLOW WHEN COMPLETEING NAIL SURGERY IN A CLINICAL SETTING

    Author(s)

    Contact(s) for further

    information about this document

    Kate Marley Podiatry Team Leader

    Telephone: 0151 295 9457 Email: kate.marley@merseycare.nhs.uk

    Published by

    Copies of this document are available from the Author(s) and

    via the trust’s website

    Mersey Care NHS Foundation Trust V7 Building

    Kings Business Park Prescot

    Merseyside L34 1PJ

    Trust’s Website www.merseycare.nhs.uk

    To be read in conjunction with

    HS4 COSHH PROCEDURE INFECTION PREVENTION AND CONTROL POLICY

    MC01 MENTAL CAPACITY ASSESSMENT LoccSips

    DUREThis document can be made available in a range of alternative formats including various languages, large print and braille etc

    Copyright © Mersey Care NHS Trust, 2015. All Rights Reserved

    Version Control:

    Version History: Consultation Draft,

    Version 1 Clinical policies group 05/12/18

    Version 2 Reviewed and Ratified by Clinical Standards Group 26 Nov-19

    Page 2 of 27 177 - Nail surgery policy Version 2 November 2019

    mailto:kate.marley@merseycare.nhs.ukhttp://www.merseycare.nhs.uk/

  • SUPPORTING STATEMENTS This document should be read in conjunction with the following statements:

    SAFEGUARDING IS EVERYBODY’S BUSINESS All Mersey Care NHS Foundation Trust employees have a statutory duty to safeguard and promote the welfare of children and adults, including: • being alert to the possibility of child / adult abuse and neglect through their observation of abuse, or

    by professional judgement made as a result of information gathered about the child / adult; • knowing how to deal with a disclosure or allegation of child /adult abuse; • undertaking training as appropriate for their role and keeping themselves updated; • being aware of and following the local policies and procedures they need to follow if they have a child

    / adult concern; • ensuring appropriate advice and support is accessed either from managers, Safeguarding

    Ambassadors or the trust’s safeguarding team; • participating in multi-agency working to safeguard the child or adult (if appropriate to your role); • ensuring contemporaneous records are kept at all times and record keeping is in strict adherence to

    Mersey Care NHS Foundation Trust policy and procedures and professional guidelines. Roles, responsibilities and accountabilities, will differ depending on the post you hold within the organisation;

    • ensuring that all staff and their managers discuss and record any safeguarding issues that arise at each supervision session

    EQUALITY AND HUMAN RIGHTS Mersey Care NHS Foundation Trust recognises that some sections of society experience prejudice and discrimination. The Equality Act 2010 specifically recognises the protected characteristics of age, disability, gender, race, religion or belief, sexual orientation and transgender. The Equality Act also requires regard to socio-economic factors including pregnancy /maternity and marriage/civil partnership.

    The trust is committed to equality of opportunity and anti-discriminatory practice both in the provision of services and in our role as a major employer. The trust believes that all people have the right to be treated with dignity and respect and is committed to the elimination of unfair and unlawful discriminatory practices.

    Mersey Care NHS Foundation Trust also is aware of its legal duties under the Human Rights Act 1998. Section 6 of the Human Rights Act requires all public authorities to uphold and promote Human Rights in everything they do. It is unlawful for a public authority to perform any act which contravenes the Human Rights Act.

    Mersey Care NHS Foundation Trust is committed to carrying out its functions and service delivery in line the with a Human Rights based approach and the FREDA principles of Fairness, Respect, Equality Dignity, and Autonomy

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  • Contents

    1. Purpose and Rationale 5

    2. Outcome Focused Aims and Objectives 5

    3. Scope 5

    4. Definitions 6

    5. Duties 6

    6. Process 6

    7. Consultation 12

    8. Training and Support 13

    9. Monitoring 13

    10. Equality and Human Rights Analysis 14

    11. Appendices 19-26

    Appendix 1 nail surgery referral flow chart

    Appendix 2 high-risk conditions

    Appendix 3 At Risk conditions

    Appendix 4 Total contraindications to use of phenol

    Appendix 5 Contraindications letter to GP

    Appendix 6 Pregnancy and breastfeeding

    Appendix 7 Consent to treatment for adults

    Appendix 8 Consent to treatment for children

    Appendix 9 nail surgery information leaflet

    Appendix 10 Nail surgery standard operating procedure

    Appendix 11 Maximum safe dose of LA Appendix 12 LocSIPP Appendix 13 Competency Framework

    Section Page No

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  • 1. PURPOSE AND RATIONALE

    1.1 The documentation included is relevant to the referral, assessment and consent

    to the procedure of nail surgery. It aims to provide standardised practice of nail surgery referrals for the Podiatry Service.

    1.2 To ensure the safe assessment and treatment of patients undergoing nail

    surgery from Mersey Care NHS Foundation Trust community Podiatry Department

    1.3 To ensure all staff are safeguarded in the use of podiatric Chemicals and

    understand COSHH guidelines associated with chemicals

    1.4 To ensure all staff are carrying out Nail surgery in a competent manner with competent clinical skills

    1.5 To ensure that all documents are consistent in format and content

    2. OUTCOME FOCUSED AIMS AND OBJECTIVES

    2.1 This policy is intended to offer guidance to both patients and members of staff during consultation, assessment and treatment of those patients under-going nail surgery

    2.2 The documentation included is relevant to the referral, assessment and consent

    to procedure. It aims to provide standardised practice of nail surgery referral and treatment for the department.

    2.3 As with all patients, they will receive a primary assessment and conservative treatment to help resolve the painful nail condition. Should this not resolve the problem and nail surgery is indicated, a referral for nail surgery will be made.

    2.4 Band 5 Podiatrists should complete the defined Nail Surgery competencies alongside an experienced Band 6 Podiatrist. They should complete 20 sessions before being signed off as competent.

    3. SCOPE

    3.1 This policy applies to all working in the podiatry service at Mersey Care NHS

    Foundation trust who carry out nail surgery, this will include podiatrists and foot care assistants.

    3.2 The procedure involves removal of part or all of a toenail and is the most common surgical procedure for the treatment of ingrowing toenails.

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  • 3.3 Nail surgery is a procedure undertaken by HCPC registered Podiatrists with a

    certificate in local anaesthesia.

    3.4 Registered podiatrists can obtain some medicines from a registered medicines distribution service for supply or administration to patients in the course of their professional practice, the podiatrist needs to be registered with the appropriate annotation on the register: Prescription only medicines (POM’s)

    3.5 The Podiatrist is a Band 6 or Band 7 Clinician assisted by a Band 5 Podiatrist or Foot Care Assistant

    3.6 The procedure should be carried out in a clinical setting across Liverpool and South Sefton sites

    3.7 Only in exceptional circumstances may nail surgery be carried out in a domiciliary setting at the discretion of the Podiatry Team Leader

    3.8 All health care professionals have a responsibility to ensure they work in line with their own professional code of conduct

    4. DEFINITIONS

    Nail Surgery Nail surgery is the removal or part of the toenail. A local anesthetic is used so that there is no pain during the procedure. A chemical is applied to the exposed nail bed to stop the nail from growing back

    O/C Onychocryptosis- Ingrowing toenail CI letter Contra- indications letter

    5. DUTIES

    5.1 Podiatrist: It is the responsibility of the Podiatrist to competently assess, refer and perform nail surgery

    5.2 Podiatry Assistant: It is the responsibility of the foot care assistant to assist the

    podiatrist in under taking the procedure of nail surgery 6. PROCESS

    6.1 Suitability for nail surgery

    6.1.1 All new referrals are received by the Podiatry service based at dovecot health centre, referrals are triaged by the team leaders. The referrals will then be placed onto the ‘assessment waiting’ list and offered an appointment in the appropriate time scale.

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  • 6.1.2 Patients will be assessed as a new patient and a management plan formed to improve or resolve the presenting problem

    6.1.3 During the nail surgery assessment the Podiatrist should consider differential diagnoses, treatment options available and patient wishes. Not all nail pathologies will require surgical intervention as a first line treatment therefore conservative treatment options should be considered.

    6.1.4 All Podiatrists should consider the patient’s general health, any co-morbidities, age, mental capacity and clinical need for the procedure. Podiatrists will use the Nail Surgery Referral Pathway to assist in the referral process (see Appendix 1)

    6.1.5 The risks and benefits of nail surgery must be discussed with the patient

    6.1.6 A Vascular assessment should be undertaken, taking note of the following: • Temperature gradient • Capillary refill time • Varicose Veins present or operated on • Oedema present • Symptoms of intermittent claudication • Rest pain

    6.1.7 Vascular and Neurological assessments should be carried out by palpating foot

    pulses, if required a Doppler should be used. A 10g monofilament should be used to assess for sensory loss

    6.1.8 Consideration of biomechanical needs will be considered to determine if a referral to orthotics will benefit the patient prior to, or post-surgery

    6.1.9 If at the point of assessment conservative management may be appropriate, the Podiatrist will determine a return time for treatment

    6.1.10 If conservative management does not resolve the problem, a referral for nail surgery will be made in line with these guidelines

    6.1.11 If a Podiatrist requires further support in making their decision, they must refer to the Nail Surgery Referral Pathway (see Appendix 1)

    6.1.12 An EMIS assessment template should be run if the patient is being referred for nail surgery

    6.2 Assessing patients with indications or contraindications to nail surgery

    6.2.1 If the patient is high risk, refer to Appendix 2 to inform decision-making and treatment choice.

    6.2.2 If the patient is considered ‘at risk’ due to medical conditions (see Appendix 3), the Community Podiatry Contraindications letter should be sent to the patients GP or

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  • consultant (see Appendix 4). Surgery should be deferred until a response has been received and scanned onto the patients EMIS record

    6.2.3 If the patient falls under ‘Total Contraindications with the use of Phenol’ (see Appendix 5) the Podiatrist will consider conservative management or make a referral for the procedure to be carried out in a hospital setting

    6.2.4 Patients who require nail surgery in a hospital setting must liaise with their GP once the Community Podiatrist has put forward the relevant referral

    6.2.5 If a patient is pregnant or breast-feeding please refer to Appendix 6

    6.2.6 The community podiatry service will only accept nail surgery referrals for routine or low to moderate risk referrals

    6.3 Asthma or Angina

    6.3.1 Patients should be advised to bring any medications for their conditions on the day of the procedure E.G Inhalers or GT sprays so the patient can self-medicate should an attack occur.

    6.3.2 If the patient has unstable Angina then they should be referred to secondary care via the GP.

    6.4 Anaemia

    6.4.1 If this is not controlled then this can prolong post op healing

    6.5 Sickle Cell Anaemia/Thalassaemia

    6.5.1 A tourniquet cannot be used. Liaison with patients GP or consultant should be completed and consider referral to secondary care for procedure

    6.6 Anti-Platelet /anticoagulant therapy

    6.6.1 A CI letter should be sent to the GP and liaison with the anticoagulant clinic is required prior to surgery for patients who are on anticoagulant therapy such as Warfarin and clopidogrel. For patients on warfarin INR levels should be between two and three. For NOAC therapies such as apixaban, edoxaban, rivaroxaban a CI letter should be sent to the GP or anticoagulant team and review manufacturer’s recommendations before undertaking nail surgery

    6.6.2 Patients should be made aware of prolonged post op bleeding and advised appropriately

    6.7 Immunosuppressed

    6.7.1 Patients who are taking immunosuppressant drugs and biologicals will be at risk of developing post op infections due to their immunity potentially being compromised. Auto Immune disorders include RhA, Crohns disease, psoriasis, connective and inflammatory disorders.

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  • 6.7.2 For Patients on biological therapies there is a risk that the nail surgery process can

    increase the risk of vasculitis and possibly lead to gangrene

    6.7.3 For patients who are taking biological medications such as adalimumab, etanercept, infliximab, rituximab liaison with the patients consultant will need to be made as medications may need to be stopped prior to nail surgery

    6.7.4 For patients on DMARDS such as methotrexate and steroids they should be made aware of an increased risk of infection and delayed healing time

    6.7.5 A CI letter should be sent to the GP or consultant prior to treatment and antibiotics considered. If community nail surgery is appropriate then advice should be given to the patient regarding the risk of post op infection and delayed healing.

    6.8 Rheumatoid Arthritis and Connective Tissue Disorders

    6.8.1 Patients who have RhA and connective tissue disorders may suffer with associated complications such as PAD, vasculitis and immunosuppression. If any associated risks are identified at assessment a CI letter will be indicated and liaison with the rheumatologist should be considered. Following assessment and according to the patients disease process they may be more suitable to have the nail surgery in secondary care.

    6.8.2 If the patient is being managed with a biological therapy then the patient may require blood tests to monitor ESR and CRP levels to indicate disease activity. Associated risks of vasculitis should also be considered during assessment

    6.8.3 Patients should be made aware that they are at risk of prolonged healing and at risk of developing infection

    6.9 Diabetes

    6.9.1 A thorough assessment of a patient’s vascular and neurological status should be completed. If the patient’s circulation is compromised then referral to the MDT should be considered for nail surgery in secondary care

    6.9.2 Liaison with the GP will be required to determine the patients Hba1c within the last 3 months. If the HbA1c is below 69 mmols/mol the patient can be deemed suitable for community nail surgery. If the patient’s blood glucose levels are raised then they should be advised that the surgery would be delayed until blood glucose levels are controlled. Consideration should be made as to whether the infected in growing toenail is the cause of the increased HbA1c.Conservative treatment can be offered in the interim.

    6.9.3 Patients should be made aware of the risk of post op infection and delayed healing

    6.10 Epilepsy

    6.10.1 Administration of local anaesthetic can induce a seizure in patients with epilepsy. If a patients seizures are well controlled and they have not had any seizures in the

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  • last 6 months then community nail surgery can be considered. A CI letter should be sent to their GP prior to the surgery

    6.11 Heart conditions

    6.11.1 Patients who have had heart surgery such as coronary artery bypass surgery may be receiving anticoagulant therapy ( see guidance).Endocarditis is inflammation and infection of the heart lining and valves which can cause heart failure e.g a patient who has had rheumatic fever. NICE guidance states that ‘antibiotics should not be given to adults and children with structural cardiac defects at risk of IE when undergoing dental and non-dental interventional procedures’

    6.11.2 A CI letter should be sent to the patients GP

    6.11.3 For patients who have had Rheumatic Fever this can damage the heart valves and poses a risk of endocarditis. Prophylactic antibiotics are no longer advised unless there is active infection or a history of bacterial endocarditis. A CI letter should be sent to the GP prior to surgery.

    6.12 PAD

    6.12.1 A thorough assessment of a patient’s vascular status and history should be taken and if a patient’s circulation is compromised conservative treatment should be offered. If nail surgery is required a referral to secondary care should be made.

    6.13 Raynaud’s/chilblains 6.13.1 Patients with Raynaud’s disease will experience vasospasticity of the digits.

    Conservative treatment should be offered and referral to secondary care considered. Nail surgery should not be completed whilst the disease is active

    6.13.2 If a patient suffers with Raynauds but is static then community nail surgery can be considered. A CI letter should be sent to the GP and the surgery should be completed in warmer months. Nail surgery can be undertaken without the use of phenol in exceptional circumstances and this decision will be made by the clinician performing the procedure

    6.14 Consent

    6.14.1 If there are any concerns over consent the podiatrist should refer to the Mental Capacity Act and complete a Mental Capacity Assessment in line with Mersey Care Foundation Trust policies

    6.14.2 Children under 16 must attend with a biological parent or legal guardian

    6.14.3 At 16 if a child is deemed to be Gilick competent they can consent to the treatment themselves. If the child is not Gilick competent then the person with parental responsibility can consent to treatment.

    6.14.4 At assessment stage if a legal guardian will be present and consenting to treatment, documentation will need to be provided confirming this on the day of the treatment

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  • and scanned onto the patients EMIS record. Failure to provide this will result in the surgery being cancelled

    6.14.5 If the Podiatrist questions the patient’s capacity to consent on the day of surgery the surgery will not be carried out

    6.14.6 The consent form (see Appendix 7) should be completed on EMIS on the day of the procedure and signed by the patient. It should then be scanned on to the patients EMIS record, counter checked by the Podiatrist, printed and a copy given to the patient prior to leaving

    6.15 Referral for Surgery

    6.15.1 If a patient is deemed fit for nail surgery in a community setting and can consent to treatment the nail surgery assessment template needs to be completed on EMIS;

    6.15.2 Podiatrists should ask the following questions and record on the above form:

    • Any previous reaction to anaesthetics • Note if the patient may be pregnant or not applicable • Does the patient suffer from an abnormal reaction to antibiotics • Any serious illness/operations during the past year

    6.15.3 If a patient has had a previous allergy or reaction to anaesthetic this is an absolute contraindication to the patient having a local anaesthetic. A referral to secondary care via the GP will be required.

    6.15.4 Allergies to latex or plaster should be recorded on the assessment template so that appropriate measures can be taken during any treatment of the patient

    6.15.5 If the patient currently has an o/c with infection then the Podiatrist may need to a course of antibiotics from the patients GP.

    6.15.6 The patients pain scale should be recorded at the assessment stage and first nail surgery dressing using the VAS scale (see Appendix 8)

    6.15.7 Once the EMIS nail surgery assessment form is completed patients should be moved to ‘Treatment Waiting’ for their chosen clinic

    6.15.8 Patients referred for nail surgery will be provided with the Nail Surgery Advice Leaflet (see Appendix 9) and the Podiatrist will highlight important information including footwear to bring on the day and travelling arrangements

    6.15.9 The Podiatrist will determine with the patient were the nail surgery procedure should be carried out if the patient has school or work commitments

    6.15.10 The Podiatrist will provide thorough advice on approximate healing times and adhering to post-operative advice. If patients have high risk medical conditions, healing time and possible complications should be explained. Patients will be advised that the information will be provided again on their first re-dressing

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  • appointment. On the day of the redressing appointment the clinician will consider whether the patient requires more frequent dressings

    6.16 Nail Surgery and Children 6.16.1 Nail Surgery can be performed on children of any age in a community setting at the

    Podiatrists discretion

    6.16.2 During the assessment the Podiatrist should take into consideration the mental maturity of the child and comprehension of the procedure and after care

    6.16.3 Nail Surgery on children in the community cannot be carried out without parental/guardian consent

    6.16.4 LA maximum safe dosage on the day should be calculated using the formula and guidance in Appendix 11

    6.16.5 Podiatrists can refuse to treat the child on the day if they query the child’s capacity to understand the procedure about to be undertaken

    6.16.6 The Consent form for children should be completed on the day of the procedure with the person with parental responsibility consenting to treatment

    6.16.7 If a Podiatrist requires the nail surgery to be carried out in a hospital setting then a GP letter should be sent requesting this. The parent or guardian should then be advised that the child will be discharged and they can contact the GP for information on the referral

    6.17 Nail Surgery procedure

    Refer to standard operating procedure for nail Surgery APPENDIX 10

    6.17.1 On the day of the procedure 2 podiatrists will be present or a podiatrist and podiatry assistant

    6.17.2 The patient’s personal details will be checked along with their medical history

    6.17.3 The patient will be reviewed again to see if nail surgery is still required

    6.17.4 All appropriate consent forms will be completed and scanned onto EMIS with both clinicians reviewing the records in accordance with Mersey Care Foundation Trust Policies.

    6.17.5 The nail surgery procedure will be completed as per standard operating procedure for nail surgery

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  • 6.17.6 Once the nail surgery is complete the patient will be given verbal and written post-operative advice

    6.17.7 The patient’s foot/feet will be checked prior to leaving to ensure no bleeding has come through on the dressing

    6.18 Post nail surgery procedure

    6.18.1 Patients will receive one re-dressing appointment with a Podiatrist up to a week post-surgery

    6.18.2 Patients will be provided with further after-care advice at this appointment and advised that they will be discharged from the Podiatry service after eight weeks. Patients who attend for routine Podiatry will revert to their previous return period

    6.18.3 If complications arise or patients require regular follow-up appointments, this will be arranged by the Podiatrist following the procedure or at the first re-dressing appointment

    6.19 Clinical Emergencies

    6.19.1 If a patient faints or loses consciousness lower the couch to prevent any further harm to the patient and try to arouse the patient were possible. Remain with the patient and seek medical attention if required

    6.20 Anaphylaxis

    6.20.1 All clinicians should be up to date with their mandatory training in CPR and anaphylaxis. Adrenalin should be administered intra muscular in the event of anaphylaxis.

    7 CONSULTATION • Band 7 podiatrist • Band 6 podiatrist • Band 6 podiatrist • Band 6 podiatrist • College of Podiatry

    8 TRAINING AND SUPPORT 8.1 All podiatry staff will undergo nail surgery training as part of their BSc Hons Podiatry

    Degree and will have obtained a prescription only medicines certificate to enable them to administer Local anesthetic

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  • 8.2 As a band 5 podiatrist they will perform 20 nail surgery procedures under the guidance

    of a band 6 or 7 podiatrist and complete competency frameworks to support their learning

    8.3 To complete Mandatory Training provided by Mersey Care NHS Foundation Trust

    9 MONITORING 9.1 All podiatrists who perform nail surgery will have an annual audit completed by a

    designated lead clinician to ensure they are meeting the standards of the competency framework

    9.2 All podiatrists will adhere to the regulations by the HCPC and their professional body

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  • 10 Equality and Human Rights Analysis Title: Nail Surgery Policy

    Area covered: nail surgery in a community setting completed by staff of the podiatry department What are the intended outcomes of this work? To provide clear guidance on how to assess and perform nail surgery for all members of staff in the podiatry department Who will be affected? Podiatry Staff and patients Evidence What evidence have you considered? NICE guidelines ( NG19) DOH guidance Evidence based practice for nail surgery Mersey care policies Disability (including learning disability) Sex Race Consider and detail (including the source of any evidence) on difference ethnic groups, nationalities, Roma gypsies, Irish travellers, language barriers. Age Consider and detail (including the source of any evidence) across age ranges on old and younger people. This can include safeguarding, consent and child welfare. Gender reassignment (including transgender) Consider and detail (including the source of any evidence) on transgender and transsexual people. This can include issues such as privacy of data and harassment. Sexual orientation Consider and detail (including the source of any evidence) on heterosexual people as well as lesbian, gay and bi-sexual people. Religion or belief Consider and detail (including the source of any evidence) on people

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  • with different religions, beliefs or no belief. Pregnancy and maternity Consider and detail (including the source of any evidence) on working arrangements, part-time working, infant caring responsibilities. Carers Consider and detail (including the source of any evidence) on part-time working, shift-patterns, general caring responsibilities. Other identified groups Consider and detail and include the source of any evidence on different socio-economic groups, area inequality, income, resident status (migrants) and other groups experiencing disadvantage and barriers to access. Cross Cutting implications to more than 1 protected characteristic Human Rights Is there an impact?

    How this right could be protected?

    Right to life (Article 2) Not engaged

    Right of freedom from inhuman and degrading treatment (Article 3)

    supportive of a HRBA

    Right to liberty (Article 5) supportive of a HRBA

    Right to a fair trial (Article 6) supportive of a HRBA

    Right to private and family life (Article 8)

    supportive of a HRBA

    Right of freedom of religion or belief (Article 9)

    supportive of a HRBA

    Right to freedom of expression Note: this does not include insulting language such as racism (Article 10)

    supportive of a HRBA

    Right freedom from discrimination (Article 14)

    supportive of a HRBA

    Engagement and Involvement detail any engagement and involvement that was completed inputting this together. N/A

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  • Summary of Analysis This highlights specific areas which indicate whether the whole of the document supports the trust to meet general duties of the Equality Act 2010 Advance equality of opportunity Not engaged Promote good relations between groups Not engaged What is the overall impact? Addressing the impact on equalities There needs to be greater consideration re health inequalities and the impact of each individual development /change in relation to the protected characteristics and vulnerable groups This policy has sought to address inequalities Action planning for improvement

    Detail in the action plan below the challenges and opportunities you have identified. Include here any or all of the following, based on your assessment • Plans already under way or in development to address the challenges and priorities

    identified. • Arrangements for continued engagement of stakeholders. • Arrangements for continued monitoring and evaluating the policy for its impact on

    different groups as the policy is implemented (or pilot activity progresses) • Arrangements for embedding findings of the assessment within the wider system,

    OGDs, other agencies, local service providers and regulatory bodies • Arrangements for publishing the assessment and ensuring relevant colleagues are

    informed of the results • Arrangements for making information accessible to staff, patients, service users and

    the public • Arrangements to make sure the assessment contributes to reviews of DH strategic

    equality objectives. For the record Name of persons who carried out this assessment: Kate Marley- Podiatry Team Leader

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  • Date assessment completed: 21/10/2019 Name of responsible Director:

    Lynda Taylor – Associate Director of Nursing and Patient Safety Date assessment was signed: 27 November 2019

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  • See appendix 3

    CI letter to GP appendix 5

    See guidelines appendix 2

    Total contraindications to use of phenol see appendix 4

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  • APPENDIX 2

    Refer to Secondary care

    Medical Condition and Severity

    Considerations:

    Diabetes Type 1&2

    HBA1C above 69mmol/mol

    Peripheral Neuropathy

    Pulses ‘bounding’ (may indicate autonomic neuropathy)

    Poor dietary control (compromised healing)

    PAD

    Co morbidities

    Refer to secondary care

    Rheumatoid Arthritis, Autoimmune diseases, Raynauds

    Active disease

    Biological medications and DMARDS

    HIGH RISK

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  • APPENDIX 3

    Medical Condition:

    Risks

    CI Letter/Hospital Referral When Indicated

    Anaemia Pernicious Anaemia

    Compromised Healing

    CI letter

    Angina (stable or unstable)

    If stable patient to bring GTN spray

    CI letter to GP if stable

    Apixaban Rivaroxaban

    Patient to stop medication 24hrs prior to surgery Patient to commence medication as soon as possible after surgery Patient to be aware they are at higher risk of thrombosis when not taking medication

    CI letter to GP/ anti-coagulant team

    Connective Tissue Disorders (Lupus, Raynaud’s phenomena, systemic sclerosis, scleroderma)

    Peripheral Arterial Disease Peripheral Ischemia Compromised Immune System ‘Flare-up’ of inflammation

    CI letter to GP CI letter to consultant Consider prophylactic antibiotics/CRP and ESR Consider referral to secondary care

    Diabetes Type 1&2

    Compromised Healing Co-morbidities HBA1C (69mmol/mol or below) Vascular status

    CI letter to GP/request HbA1c Consider referral to secondary care

    ‘AT RISK’

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  • Peripheral Neuropathy

    Endocarditis

    Inflammation of the heart endocardium

    CI letter to GP

    Epilepsy

    CI letter to GP

    Fibromyalgia

    Increased inflammation

    Increased pain

    Heart Disease Heart Valve Damage

    Compromised healing Poor peripheral perfusion

    CI letter to GP Consider prophylactic antibiotics

    HIV/Aids

    Compromised immune system

    Refer to secondary care

    Myocardial Infarction

    Defer nail surgery for 6 months post MI

    CI Letter to Cardiologist

    Peripheral Arterial Disease

    Ischemia Compromised healing

    Refer to secondary care

    Rheumatoid Arthritis

    Immunosuppressed due to anti-TNF drugs Compromised healing

    CI letter to GP CI letter to consultant

    Rheumatic Fever (associated Sydenham’s Chorea)

    History of inflammation of the heart muscle Mitral stenosis/hardening of valves

    CI letter to GP Request prophylactic antibiotics

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  • Sickle Cell Trait

    Abnormality of Haemoglobin

    CI letter to patients consultant

    Warfarin patients

    Patients will need INR taking the morning of surgery

    Suggested INR ranges 2-3

    Liaison with anti- coagulant clinic

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  • APPENDIX 4

    Contraindication:

    Affects those with:

    Autonomic Dysreflexia (also known as autonomic hyperreflexia)

    Those with spinal cord injuries

    Complex Regional Pain Disorder (also called reflex sympathetic dystrophy syndrome)

    Creutzfeldt –Jakob Disease (CJD)

    Haemophilia/Von Willebrand’s Syndrome

    Reduced clotting time

    Impending surgery

    Includes those waiting for hip/knee replacements

    Inflammation at injection site

    Ischaemia

    Peripheral Arterial Disease

    Known allergy to local anaesthetic

    Pregnancy/breast feeding

    See appendix 6

    Refusal to consent

    Thalassemia

    Cannot synthesise haemoglobin

    TOTAL CONTRAINDICATIONS TO NAIL SURGERY WITH USE OF PHENOL

    Page 24 of 27 177 - Nail surgery policy Version 2 November 2019

  • APPENDIX 5

    CI Letter To GP Liverpool adjust.doc APPENDIX 6

    APPENDIX 7

    APPENDIX 8

    APPENDIX 9

    APPENDIX 10

    NS sop NOV 18.docx

    APPENDIX 11

    maximum safe dose.docx

    APPENDIX 12

    Page 25 of 27 177 - Nail surgery policy Version 2 November 2019

  • Local standard safety checklist for Na APPENDIX 13

    nail surgery competency framewo

    Page 26 of 27 177 - Nail surgery policy Version 2 November 2019

  • References Baran R, Haneke E: Matricectomy and nail ablation. Hand Clin 18: 693, 2002

    Rounding C, Hulm S: Surgical treatments for ingrowing toenails. Cochrane Database Syst Rev 2: CD001541, 2000

    Weaver T. D., Vy Ton M., and Pham T. V. Ingrowing Toenails: Management Practices and Research Outcomes International Journal of Lower Extremity Wounds, March 1, 2004; 3(1): 22 - 34.

    Boll, O.F. (1945) Surgical correction of ingrowing toenails. Journal of the American Podiatry Association; 35: 8-9. Cited in Ceilly, R.I., and Collison, D.W., (1992) Matricectomy. Journal of Dermatologic Surgery and Oncology; 18: 728-734.

    National Institute for health and Clinical Effectiveness (NICE) guideline 2008 clinical guideline on antibiotic therapy Prophylaxis against Infective Endocarditis.

    http://webarchive.nationalarchives,gov.uk/+/www.dh.gov.uk/publichealth/Sscientificdevelopmentsgeneticsandbioethics/Conset/consentGeneralInfomation/DH_4015950

    https://www.nice.org.uk/guidance/ng19

    https://cks.nice.org/anticoagulantion.oral

    https://pt.info/doctor/precautions for patients with diabetes undergoing surgery

    https://www,nice.org.uk/guidance/cg64

    https://cop.org.uk

    Page 27 of 27 177 - Nail surgery policy Version 2 November 2019

    http://webarchive.nationalarchives,gov.uk/+/www.dh.gov.uk/publichealth/Sscientificdevelopmentsgeneticsandbioethics/Conset/consentGeneralInfomation/DH_4015950http://webarchive.nationalarchives,gov.uk/+/www.dh.gov.uk/publichealth/Sscientificdevelopmentsgeneticsandbioethics/Conset/consentGeneralInfomation/DH_4015950https://www.nice.org.uk/guidance/ng19https://cks.nice.org/anticoagulantion.oralhttps://pt.info/doctor/precautionshttps://www,nice.org.uk/guidance/cg64

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