Supplement: Diathermy and Service Efficiency
Contents
1. the personal motivation to continually learn how our actions affect our work and efficiency MODULE SUMMARY m Male circumcision scale up will require significant investment in human material and financial resources m It is necessary to rationalize the use and time of available health personnel in order to achieve the desired impact of male circumcision scale up m Different service delivery models including conventional fixed and mobile will need to be employed to reach the set targets 3 Senge PM 1990 The Fifth Discipline The Art and Practice of the Learning Organization Doubleday New York Male Circumcision under Local Anaesthesia 14 Supplement Diathermy and Service Efficiency m Employment of MOVE principles in all of the service delivery models aims to maximize numbers of MCs while maintaining quality m Task shifting task sharing appropriate choice of the surgical method enabling layouts of service sites and use of diathermy and surgical kits are key strategies for enhancing efficiency in MC services Male Circumcision under Local Anaesthesia Supplement Diathermy and Service Efficiency 15 16 Male Circumcision under Local Anaesthesia Supplement Diathermy and Service Efficiency2. conducting material This risk is greatest with monopolar diathermy but whenever diathermy is used care must be taken in positioning on the operating table the choice of operating tables and clinic construction to prevent leakage of current to earth More sophisticated monopolar diathermy machines have safety features incorporated in their design and include automatic switch off if there are any of the following faults earth leakage disconnected grounding plate or poor contact between the grounding plate and skin The grounding plate should be placed so that there is a broad area of contact between the plate and the patient s skin Sometimes it is necessary to shave hairs to ensure good contact If the machine fails to respond when the surgeon activates the current or there is no obvious and immediate visual evidence of coagulation the surgeon should immediately stop applying the current and check all connections and the grounding plate If the surgeon continues to apply current burns may occur where resistance is greatest This is most commonly where the grounding plate is in contact with the body or where the body is in contact with metal In rare circumstances the burn may occur elsewhere in the body Diathermy Tip When using diathermy the surgeon should apply the forceps as precisely as possible The best results will be obtained if the blood vessel is between the diathermy prongs with minimal other tissue and the current acti
3. of different surgical methods for circumcision FORCEPS DORSAL C 8 p zi SLITS ae INDICATOR Surgeon time minutes 6 20 8 45 14 0 Total procedure time 19 20 21 45 27 00 minutes Haemostasis by Diathermy Haemostasis by diathermy stopping the flow of blood by using a machine with a high frequency electrical current that produces coagulation is the standard of care for penile surgery in the United States Reports of harm are rare however training of staff is important It is especially important to ensure that the client is grounded properly and that the machines are modern and do not transmit surges Review section Use and Care for Diathermy Hand Hygiene between MC Cases In most clinical settings an alcohol based handrub should be used for routine hand antisepsis Hands should be washed or treated with a handrub m Before and after direct contact with clients m After removing gloves m Before handling an invasive device for client care whether or not gloves are used m After contact with blood blood products body fluids or excretions mucous membranes non intact skin or wound dressings m After using the toilet normal personal hygiene Task Shifting and Task Sharing Main MC surgical steps m Examination of the genitalia m Surgical site preparation m Injection of local anaesthesia Samkange C 2009 Male Circumcision under Local Anaesthesia Supplement Diather
4. one infection and more infections averted at a lower cost per infection averted over time Reaching 8096 circumcision prevalence in southern and eastern Africa in the coming 3 5 years requires that health authorities service delivery sites and service providers have a different service provision orientation that assures a high number of circumcisions is performed using existing number of providers without compromising quality As programme managers undertake implementation and scale up of MC services they will need to consider a range of factors that will impact efficiency and productivity In male circumcision to prevent HIV AIDS these factors include m Demand creation counseling and testing 1 International Conference on Primary Health Care Alma Ata USSR 6 12 September 1978 At http www who int hpr NPH docs declaration almaata pdf Male Circumcision under Local Anaesthesia Supplement Diathermy and Service Efficiency m Clinical and surgical techniques m Efficient use of staff and training m Efficient use of facility space m Client scheduling and flow Commodities and supply chain management m Cost efficiency DEMAND CREATION AND COUNSELING AND TESTING The service provision in clinical sites is very much dependent on a well planned client flow from the community to access these services Currently programmes are looking at different approaches for increasing awareness about services and inducing service se
5. time the work day can be divided into segments e g three segments of 3 1 2 hours each Clients can be booked for a specific segment and asked to arrive at the starting time for that segment Using segment booking the client s waiting time would usually be a maximum of the duration of the segment i e 3 Y hours Segment booking is preferable to mass daily booking in which clients are asked to all come at the same time at a particular time of the day Male Circumcision under Local Anaesthesia Supplement Diathermy and Service Efficiency Client flow should be coordinated through the facility to avoid congestion and confusion and save client and staff time Client flow should Provide easy access to separate entry and exit points at opposite ends of the clinic ideally Provide a recovery area close to the exit where clients can rest and be monitored as needed Provide an area near the exit point where the client can be given in privacy postoperative counselling an information leaflet about postoperative instructions and complications and a follow up appointment Minimize client contact with hazardous surgical waste COMMODITIES MANAGEMENT AND SUPPLY CHAIN MANAGEMENT SYSTEM The effectiveness of MC programmes will depend on a strong supply chain management system that can ensure that the appropriate commodities and equipment are consistently available The following key components of supply chain management wi
6. Male Circumcision under Local Anaesthesia Supplement Diathermy and Service Efficiency orld Health rganization STATE e KL REN A Wr d FROM THE AMERICAN PEOPLE l ONAL DE D BANK EX NA oz innovating to save lives Maternal and Child Health O piego Integrated Program an affiliate of Johns Hopkins University TABLE OF CONTENTS Section Use of Diathermy for Male Circumcision earning OD COUV OS sci NH 1 BI Pea stack Nar 1 Basic Principles of Diatlieray ue cet ter terree tute tue ete tice etes tubi erae stceaacns 1 Surgical Effects of Diath nny s uen oot tei mte mcr eR Ora urarumnau canteen dus ucl iuns 1 Monopolar and Bipolar Diathermy Circuits nennen 2 Fotentual AdVahtatges a siet tpes Gets sedat tet e eon EE mee eee EEA AEE aede E Re t i SR pe Ee I erue 3 RISKS and ComliplicatlOn xit cot hee E Re ERU EE RR DU MERE C cu Eois ERE e tu TUNE VER cU Ls 3 Module Su fid edo one aoc e cenae eta oisi e t D Rosi iile tv addi m da ie i eme ees 6 Section Efficiency in Male Circumcision Service Delivery Kearning OD COUN GS e m 7 PP OCUICUION I res LR 7 Demand Creation and Counseling and Testing 8 Clinical and Surgical Techrniques uoi nonem geo cete deb tesis co hs oe de tte eun ug Eqs 8 Faemostasis by Di amp Gtlieriy ao tre eerte dpud se eot Ri tee uade pacer v osea ner pl saec deua 9 Hand Hygiene betwee
7. calpel blade and gloves used in an MC operation and then discarded m Instrument set Bundled surgical instruments used in an MC operation may be disposable or reusable m MC kit Combination of consumables pack and an instrument set An MC kit is needed for each MC operation Module Bundled supplies used for infection prevention furnishing operating theatres and managing emergency medical situations These items may be disposable or reusable CLINICAL SUCCESS FACTORS TO ADDRESS EFFICIENCY New service delivery models designed to address efficiency will not work unless the clinical teams who do the work buy in to the new processes Clinical team leaders need to be sensitized to efficient programmes so that they can encourage and promote the mind set changes that are needed to implement new service delivery models for increased efficiency Overall the success in clinical service delivery is not going to be an isolated event Systems thinking needs to happen Systems thinking needs the disciplines of building shared vision mental models team learning and personal mastery to realize its potential Building shared vision fosters a commitment to the long term or public benefit Mental models focus on the openness needed to uncover shortcomings in our present ways of providing services Team learning develops the skills of groups of people to look for the larger picture beyond individual perspectives And personal mastery fosters
8. ciples of Diathermy High frequency alternating current HFAC is passed through the body producing heat within tissues to coagulate bleeding vessels and cut through tissue Main electricity supply of 240v 50 or 60 Hz produces intense muscle and nerve activation resulting in painful muscular contractions and shock When this normal alternating current passes through a diathermy machine it is converted to HFAC ranging from 300 kHz to 3 MHz which produces minimal or no effects on muscles and nerves Surgical Effects of Diathermy Coagulation The heating effect dries out cells in the wall of the blood vessels and they contract which results in haemostastatic function of diathermy Even though diathermy is used to coagulate blood vessels to stop bleeding its use should be limited to vessels with a diameter of 5 mm and below All vessels larger than 5 mm diameter should be ligated Cutting A high quantity of heat is generated between the electrode and the tissue which vaporizes the body cells Male Circumcision under Local Anaesthesia Supplement Diathermy and Service Efficiency Fulguration In this mode very high voltage power is used to produce an electrical arc effect that causes skin charring or carbonization These effects are seen over a wide area when operating in contact with a probe Hence its application is for very superficial or protrusive lesions such as skin tags and to destroy growths in the rectum or bladder Fulgurat
9. current runs from the machine to one of the two prongs of a diathermy forceps through the tissue grasped between the prongs and then back to the machine through the other prong The use of the bipolar configuration does not require the use of plates because the current does not flow through the body of the patient client Figure2 Bipolar Circuit Potential Advantages The greatest benefit of using diathermy in male circumcision is the significantly reduced procedure time Potentially there are savings on the cost of sutures in the long term Fewer instruments are used reducing the cost of reprocessing Risks and Complication Can interfere with pacemaker functions Arcing can occur with metal instruments and implants Superficial burns if used with alcohol based skin preparation Burns if plate is not properly applied Channeling effect if used on viscous with narrow pedicle e g penis testis Monopolar diathermy should not be used for infant circumcision because the point of maximal electrical resistance may be at the base of the penis particularly if the penis is under any traction with risk of coagulation and loss of the whole penis Male Circumcision under Local Anaesthesia Supplement Diathermy and Service Efficiency Precautions Care has to be taken to ensure that the patient is not in contact with any metal or conducting material as there is a risk of earth leakage and burns at the point of contact with the
10. ed by a well trained provider is a useful safe and time saving tool Male Circumcision under Local Anaesthesia Supplement Diathermy and Service Efficiency SECTION EFFICIENCY IN MALE CIRCUMCISION SERVICE DELIVERY LEARNING OBJECTIVES INTRODUCTION m Discuss the rationale for adopting efficient models of providing MC services m List different considerations models for efficient MC service delivery m Explain key strategies to increase efficiency in MC services Improving the efficiency of health care delivery has been the epicenter for many developing and developed countries especially after primary health care was endorsed as a strategy for service delivery in 1978 Efficient health care assures that resources are used appropriately target audiences are served equally and equitably and impacts of services are maximized at both the individual and public level This topic has become especially critical for programs reaching a significant number of men for circumcision in a short period of time Improving efficiency has the benefits of allowing greater public health impact with a tremendous reduction in service cost All the models show that rapid expansion of male circumcision coverage will result in earlier and larger effects on HIV incidence An expert review group concluded that rapid initial scale up produces direct and indirect effects earlier and is considerably more cost effective with fewer circumcisions required to avert
11. eking using different approaches Communication strategies and approaches by PSI and collaboration with community service organizations by Jhpiego Tanzania are two examples Male circumcision is primarily performed for the purpose of HIV prevention making counselling and testing a key component and entry point for the service However providing counselling and testing for a large number of clients has presented itself as a rate limiting in scale up so far Innovating approaches to overcome this challenge is becoming more important than it has ever been CLINICAL AND SURGICAL TECHNIQUES Surgical techniques As discussed in Module 5 three surgical techniques are widely used for adults adolescent MC forceps guided dorsal slit and sleeve resection These techniques are generally equivalent in terms of safety but vary in the time required to complete the procedure In some countries programme reports suggested that forceps guided is the fastest compared to the dorsal and or sleeve techniques As MC services are scaled up operations research will need to evaluate these surgical techniques to ensure that safety is Male Circumcision under Local Anaesthesia 8 Supplement Diathermy and Service Efficiency maintained while efficiency is improved While more specialized providers are encouraged to be proficient in their preferred method scale up and task sharing benefit from standardizing the circumcision method Table 1 Sample comparison
12. ile field e The active electrode tip should be easy to clean securely placed and be single use e When not in use the active electrode should be placed in a clean well insulated holster e Following the completion of the surgery the single use active electrode tip should be discarded into a sharps bin e The dispersive electrode should be removed carefully to avoid denuding the surface of the skin e The patient s skin integrity should be evaluated and documented before and after diathermy unit use e Following removal of the electrode if the skin appears to be damaged appropriate adverse events procedure should apply Male Circumcision under Local Anaesthesia Supplement Diathermy and Service Efficiency 5 MODULE SUMMARY Employment of efficiency principles in all of the service delivery models aims to maximize the numbers of MCs while maintaining quality Task shifting task sharing appropriate choice of the surgical method enabling layouts of service sites and use of diathermy and surgical kits are key strategies for enhancing efficiency in MC services The male circumcision techniques described in this reference manual can all be undertaken safely without diathermy equipment and any surgeon undertaking male circumcision should be adept at stopping bleeding with or without diathermy Diathermy has the advantage of decreasing haemostasis time during surgery thereby shortening the procedure time Diathermy us
13. ion has NO application in MC surgery Monopolar and Bipolar Diathermy Circuits There are several electrode configurations or combinations Commonly in surgical practice we use monopolar and bipolar configurations Monopolar Diathermy With monopolar diathermy the current runs from the machine through a diathermy forceps through the tissue held by the forceps then through the patient s body to a grounding plate placed elsewhere on the body and then back to the machine Only one side of the generator output is connected to the active electrode or surgical instrument which may take different shapes blade loop ball or needle The heating effect is inversely proportional to the surface area of the electrode therefore the smaller the electrode the larger the diathermy effect The other side of the generator output is connected to a large patient plate This plate can be either reusable or disposable These plates may be placed on body parts that have a relatively bigger bulk of tissue and are adequately vascularized such as the buttocks abdomen posterior aspect of the thigh and mid and lower back The plates should have full contact with the skin and be placed on the same side of the body and close to the body parts where the Monopolar procedure is occurring Figure 1 Monopolar Circuit Male Circumcision under Local Anaesthesia Supplement Diathermy and Service Efficiency Bipolar Diathermy In bipolar diathermy the
14. ll need to be in place Forecasting continuous anticipation of future MC supply needs Procurement an efficient system for obtaining MC commodities bundled into sterilized sets packs kits Distribution getting MC supplies where they are needed on time in multiple locations and settings Storage ensuring the quality and safety of MC commodities and their packaging while making them available for distribution Stock in hand keeping track of the quantities of usable MC commodities that are currently available at the MC service delivery site excluding items that are expired or no longer usable Disposal management ensuring that protocols for safe handling and disposal of waste are established and practiced at the MC service delivery site with special attention given to handling and disposal of biohazardous and infectious wastes e g MC commodities soiled with blood and body fluids BUNDLING OF MC COMMODITIES Commodities needed to perform a single MC may be disposable or reusable They vary by surgical technique and whether or not diathermy is used Bundling of these commodities contributes to improved efficiency It is Male Circumcision under Local Anaesthesia Supplement Diathermy and Service Efficiency 13 important to bundle all MC commodities and equipment well in advance of the scheduled procedures MC commodities may be bundled as follows Consumables pack Bundled consumable materials e g gauze needles s
15. my and Service Efficiency m Marking m Placement of forceps except for sleeve technique m Surgical removal of skin m Haemostasis stopping the bleeding m Placement of mattress sutures m Placement of simple interrupted sutures m Dressing of surgical wound A surgeon does not need to perform all of the main steps in MC surgery listed above To increase the efficiency of MC service delivery some of these steps can be shared or shifted Decisions about which steps are shared and which are shifted will need to be made based on staff realities national laws regulations and individual skills Task shifting or shifting tasks from doctors to clinical officers and nurses Use of highly trained non physician providers to complete all steps of MC surgery Task sharing Assigning less complex tasks to lower credentialed but highly trained health care cadres For both task shifting and task sharing a highly experienced provider must supervise and mentor the less experienced providers so that risks to the MC client are minimized EFFICIENT USE OF FACILITY SPACE CONVENTIONAL AND MODIFIED SURGICAL APPROACHES 10 In the conventional surgical approach below typically one surgeon circumcision provider assisted by one nurse performs all steps of the MC procedure for one client One surgeon circumcision provider working with one assistant only allows an average of eight to 10 MCs per day Male Circumcision under Local Anae
16. n MC Cases ssssssssseseseeesee eene nennen enne 9 Task Shifting and Task Sharing sedie e dde ec Pto Ro ERE qu Eres hee er e x ea bneri s Ded Enti Eun 9 Efficient Use of Facility Space Conventional and Modified Surgical Approaches 10 eliept schedalindg and FIO sai oio aos e a e ha fatal aged ia bene mate ees ede 12 Commodities Management and Supply Chain Management System uusss 13 Bundling of MC Commodities 5 rere rennes ens Let epe ete i ex ores pan d dude dus eee end gea 13 Clinical Success Factors to Address Efficiency ssssse 14 Mod le Summae a e Neca ea ee ny ihe torsade Gas E iets Ea Sada 14 SECTION USE OF DIATHERMY FOR MALE CIRCUMCISION LEARNING OBJECTIVES DEFINITION m Define diathermy m Discuss the basic principles of diathermy m Describe monopolar and bipolar diathermy m List the benefits and risks of using diathermy m List the dos and don ts of using diathermy Diathermy is the use of high frequency alternating current to produce heat The name diathermy is derived from the Greek words dia through and therme heat The heat produced within tissues causes coagulation of bleeding vessels and also cuts through tissues Diathermy is therefore used for different surgical interventions ranging from minor procedures e g male circumcision to major procedures e g transurethral resection of the prostate TURP Basic Prin
17. sthesia Supplement Diathermy and Service Efficiency Figure 3 Conventional Surgical Setup Surgeon Client Assistant Assistant This conventional surgical layout and staff to client ratio can be modified to support task sharing and task shifting in the context of rapid scale up of MC services In the modified model m Four MCs are performed simultaneously m A team of providers does the procedures m Floor space is laid out as four surgical bays that are separated for privacy m Asingle surgeon moves from bay to bay removing the foreskin and performing mattress suturing for each of four MC clients m Asingle float nurse moves from bay to bay administering anaesthesia and doing simple sutures for each of the four MC clients m Four surgical bay nurses one assigned to each bay remain in place to prep drape and assist in surgery for a single MC client Male Circumcision under Local Anaesthesia Supplement Diathermy and Service Efficiency 11 Figure 4 Modified Use of Surgical Space Surgeon Client Assistant Assistant CLIENT SCHEDULING AND FLOW 12 Client scheduling has a major impact on efficiency For some communities and facilities segment booking may work better than individual booking In communities where individual appointments are frequently not kept efficiency may be severely hampered by periods of minimum activity that are followed by periods of overwhelming catch up To save staff and client
18. ted metal prosthesis Areas distal to a tourniquets Scar tissue Hairy surfaces e The electrode should be positioned as close to the operative site as possible The dispersive electrode should be connected to the diathermy unit prior to draping to ensure adequate contact The dispersive electrode and its connection to the diathermy unit should be checked if Any tension is applied to the dispersive electrode cable The surgical team repositions the patient s pressure points areas The dispersive electrode cable should not be wrapped around metal objects Incomplete adhesion of a dispersive electrode may be caused by moisture Dispersive electrodes that have been removed from a patient s skin should be discarded or cleaned A new dispersive plate should be used if repositioning is required e Dispersive electrodes should not be used on children suffering from epidermolysis bullosa e The power setting should be confirmed verbally between the operator and the user before activation e The power settings are determined in conjunction with the manufacturer s written recommendations patient size and type of procedure e ltis the responsibility of the surgeon to activate the active electrode e Check the entire diathermy unit circuit if the operator requests continual increase in power to identify any incomplete circuitry e The active electrode should be disconnected from the diathermy unit and replaced if it drops below the ster
19. vated for the shortest time needed to ensure haemostasis If too much tissue is grasped diathermy will not stop the bleeding because the burn is too diffuse Prolonged diathermy causing large black burns should be avoided as these may result in infection increased postoperative pain and scar tissue formation Particular care must be taken near the frenulum because the urethra is near to the surface and there is a risk of creating a fistula by burning through to the urethra Diathermy should also be used with caution close to the skin and mucosal edges as transmitted heat may cause burns Male Circumcision under Local Anaesthesia Supplement Diathermy and Service Efficiency m Diathermy can be used to stop bleeding from small blood vessels but for larger vessels it is safer to apply an artery forceps and tie or under run as described above DOS AND DON TS The diathermy unit should be protected from spills The dispersive electrode should be the appropriate size for the patient s weight An electrode should never be cut to size minimum surface area to avoid overheating is 69 sq cm Only those active electrodes recommended by the manufacturer should be used After the patient is positioned on the operating table the dispersive electrode should be placed on a clean dry intact skin surface over a large well perfused muscle mass e The dispersive electrode should not be placed over Bony prominences Animplan
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