DUAL ROLE WITHIN THE PERIOPERATIVE ENVIRONMENT

• Definitions
• Aims
• Background and indications for standard operating procedure
• Prerequisites
• Roles and responsibilities
• Procedure method
• Escalation process
• Appendices A-H

DEFINITIONS

Back to top

AIMS

The aim of this SOP is to provide guidance and recommendations for safe efficient use of registered Perioperative Scrub Practitioners and unregistered Senior Perioperative Assistants (Scrub) in the Dual Role when Operating Clinicians require intermittent skilled assistance in the absence of an available medical assistant, Surgical Care Practitioner (SCP), SFA or when the assistant is already gainfully employed during the operative stage of a procedure but is unable to provide the necessary assistance at a particular stage of the surgical procedure.

This SOP outlines the extended role of the Perioperative Scrub Practitioner/ Senior Perioperative Assistants (Scrub). It shows the differences between Dual Role responsibilities and those of the Advanced Scrub Practitioner/ Surgical First Assistant (ASP/SFA). Dual Role assistance must be secondary to the responsibilities of the scrub practitioner/ Senior Perioperative Assistants (Scrub) and must be an intermittent role throughout appropriate surgical procedures.

This SOP affects Registered Practitioners who have completed their preceptorship period, acting in the Dual Role with the support of their team leaders and who feel comfortable and competent completing Dual Role responsibilities. These individuals must have completed the relevant Dual Role competencies for registered practitioners(available on the LTHT Operating Theatres and Day Surgery Intranet page) http://lthweb.leedsth.nhs.uk/sites/theatres/themes-for-the-week/key-trainers/key-trainers-1

The SOP also affects Unregistered Senior Perioperative Assistants (Scrub) who have completed additional scrub modules as part of their qualification, accomplished an agreed period of consolidation following completion of their training prior to acting in the Dual Role without being back scrubbed by a registered practitioner with the support of their team leader. They must feel comfortable and competent completing Dual Role responsibilities and always work under the supervision of a registered Perioperative Scrub Practitioner who is in a position to take over including performing the Dual Role if the need arises. These individuals must have completed the relevant Dual Role competencies for unregistered practitioners (available on the LTHT Operating Theatres and Day Surgery Intranet page) http://lthweb.leedsth.nhs.uk/sites/theatres/themes-for-the-week/key-trainers/key-trainers-1

Practitioners must always work within their scope of practice and must state if they feel actions they are being asked to complete are outside of this area. This SOP gives clear guidance on what is to be expected of staff performing the Dual Role and brings these expectations in line with national benchmarks. As clearly stated in the flowcharts showing the decision process to consider prior to acting in the dual role, this role is not a replacement for the need for a surgical assistant. In order to decide if it is appropriate for a member of staff to act in the dual role the flowchart clearly signposts the questions that need asking to make this assessment.

Failure to follow this SOP could result in the instigation of disciplinary procedures.

Back to top

BACKGROUND AND INDICATIONS FOR STANDARD OPERATING PROCEDURE

Lack of availability of junior doctors can result in Operating Clinicians being left with no Medical Assistant for a procedure.

The Perioperative Care Collaborative (PCC 2012) produced a position statement which identified the roles and responsibilities of the Scrub Practitioner acting in the Dual Role.

They stated the required skills, knowledge and competencies to fulfil the Dual Role should be supported by a local policy.

An updated version of the Perioperative Care Collaborative (PCC 2018) states

“In the event, that an employer considers that a dual role is required in minor surgery, then this must only be undertaken by a registered practitioner and the decision should be endorsed by a policy that fully supports this practice and should also be based on a risk assessment of each situation to ensure patient safety.”

LTHT accepts an Unregistered Senior Perioperative Assistant (Scrub) directly supervised by a Dual Role competent Registered Perioperative Scrub Practitioner may act in the Dual Role.

Registered Perioperative Scrub Practitioners manage the intra operative care required and can only act in the Dual Role based on a risk assessment performed by a registered practitioner of each situation thus ensuring patient safety.

Unregistered Senior Perioperative Assistants (Scrub) manage the intra operative care required under the direct supervision of a dual role competent registered practitioner and can only act in the Dual Role based on a risk assessment performed by a registered practitioner of each situation thus ensuring patient safety.
For patient safety there is a need for assurance that unregistered staff undertaking the Dual Role have the necessary skills, knowledge and are competent to do so.

Back to top

PREREQUISITES

Scrub Practitioners undertaking the Dual Role must be a Registered Nurse
registered with the Nursing and Midwifery Council (NMC), an Operating Department
Practitioner (ODP) registered with the Health and Care Professions Council (HCPC), a Registered Nurse Associate registered with the Nursing and Midwifery Council (NMC) or an Unregistered Senior Perioperative Assistant (scrub) who has undergone a nationally recognised Level 3 Perioperative academic qualification including additional scrub modules.
Registered practitioners - must have completed their preceptorship period and preceptorship documentation.
Unregistered practitioners - must have accomplished an agreed period of consolidation, set by their Team Leader, following completion of their training prior to acting in the Dual Role without being back scrubbed by a registered practitioner.
All those undertaking the Dual Role must complete local competency requirements for each
skill they employ. See Appendices.
All Perioperative Scrub Practitioners must work within their Scope of Practice.
The need for the Scrub Practitioner to act in the Dual Role should be agreed during the team brief.
Each use of Dual Role should be risk assessed independently.
Completion of Dual Role competencies must be agreed and reviewed by the Scrub Practitioners Team Leader during the appraisal process.

Back to top

ROLES AND RESPONSIBILITIES

Roles and responsibilities of the Perioperative Scrub Practitioner working in the Dual Role or supervising the Unregistered Senior Perioperative Assistant (scrub) undertaking the Dual Role

Agreement must be made between the registered Perioperative Scrub Practitioner and their Team
Leader prior to embarking on the Dual Role competency training.
Training to undertake the Dual Role must be identified in the Scrub Practitioners appraisal.
Registered Practitioners need to complete the competency training/ documentation booklets covering each individual skill they will perform in the Dual Role.
The Perioperative Scrub Practitioner must consider the safety of the patient if they undertake the Dual Role. If deemed inappropriate, escalate to the Team Leader.
Assess ability to perform all aspects of care without harm to the patient.
Be accountable for their actions and omissions.
The Perioperative Scrub Practitioner must not act outside their competence or training.
Not perform any assistant role that is not covered within this SOP. See Appendices.
Work in the Dual Role under the direct supervision of the Operating Clinician.
Keep a personal logbook of cases when acting in the Dual Role.
The Dual Role is an extension of the Perioperative Scrub Practitioner role and the Perioperative Scrub Practitioner can refuse to perform the Dual Role.

Roles and responsibilities of the Unregistered Senior Perioperative Assistant (scrub) working in the Dual Role

Agreement must be made between the Unregistered Senior Perioperative Assistant (scrub) and their Team Leader prior to embarking on the Dual Role competency training.
Training to undertake the Dual Role must be identified in the Unregistered Senior Perioperative Assistants (scrub) appraisal.
The Unregistered Senior Perioperative Assistant (scrub) must complete the competency training/ documentation booklets covering each individual skill they will perform in the Dual Role. They must only complete and perform those Dual Role competencies designated as suitable for the Unregistered Senior Perioperative Assistant (scrub). See Appendices.
Be accountable for their actions and omissions.
The Unregistered Senior Perioperative Assistant (scrub) must not act outside their competence or training.
Work in the Dual Role under the direct supervision of the Operating Clinician and the supervising Registered Perioperative Scrub Practitioner.
Keep a personal logbook of cases when acting in the Dual Role.
The Dual Role is an extension of the Unregistered Senior Perioperative Assistant (scrub) role and the Unregistered Senior Perioperative Assistant (scrub) can refuse to perform the Dual Role.

Roles and responsibilities of the Operating Clinician
To assist with the training and assessment of the Dual Role competencies.
If a Perioperative Scrub Practitioner or Senior Perioperative Assistant (scrub) is required to carry out Dual Role competencies, the Operating Clinician must check and give adequate notice. This will only be possible if a suitably competent Perioperative Scrub Practitioner or Senior Perioperative Assistant (scrub) is available.
The Operating Clinician must not expect the Perioperative Scrub Practitioner or Senior Perioperative Assistant (scrub) to act outside their level of competence.
The Operating Clinician must not ask the Perioperative Scrub Practitioner or Senior Perioperative Assistant (scrub) to perform any skill not covered by this SOP. See Appendices.
Directly supervise the tasks they ask the Perioperative Scrub Practitioner or Senior Perioperative Assistant (scrub) to perform.
The Operating Clinician must allow the Perioperative Scrub Practitioner or Senior Perioperative Assistant (scrub) time to complete all equipment and Accountable Items checks at appropriate times. This may result in the Operating Clinician having to cease operating at various times during the procedure.
Document in the Surgical Record the use of a Perioperative Scrub Practitioner or Senior Perioperative Assistant (scrub) in the Dual Role and this should be noted on the Accountable Items Record.
If the surgery proceeds to an unanticipated more complicated procedure where the Perioperative Scrub Practitioner or Senior Perioperative Assistant (scrub) is unable to proceed in the Dual Role or is not competent in the necessary skills, arrangements must be in place to summon medical assistance.

Roles and responsibilities of the Theatre Team Leaders
Theatre Team Leaders will agree with staff at appraisal when it is appropriate for an individual to commence training for Dual Role.
Theatre Team Leaders will ensure compliance with the Dual Role SOP for the staff they manage.
Theatre Team Leaders will store completed competence documentation in the staff personal files.
Theatre Team Leaders will keep records of all those staff under their management competent to undertake the dual role.
Theatre Team Leaders will ensure records of competence are registered on ESR

Roles and responsibilities of the Theatre and Anaesthetics Management Team
The Theatre Education Team will review and update the SOP every 3 years.
This SOP and competency documents will be reviewed by the Theatres and Anaesthetics Clinical Governance Group every 3 years.
An audit of compliance with the SOP (see Audit Tool), by Theatre Team Leaders, will be completed prior to review.

Back to top

PROCEDURE METHOD

Detailed step-by step description of Dual Role Procedures

FLOW CHARTS SHOWING THE DECISION PROCESS TO CONSIDER PRIOR TO ACTING IN THE DUAL ROLE

Surgical Skin Preparation of the operative site:
The allergy status of the patient must be checked prior to skin preparation including any known allergies to Chlorhexidine, Iodine or other products. All available reference sources must be checked i.e. eMeds, ppm+ and paper records

Follow manufacturer’s recommendations for suitable application.

Use a dedicated instrument or applicator for skin prep, discarding this instrument or applicator off the sterile field after use. If swabs are used for cleaning, they must be put on the Accountable Items check.

Only dip applicator into the skin prep solution once.

Prep from ‘Clean to Soiled’ area.

Prep from ‘Incision site to Periphery’ in concentric circles.

Use a rubbing motion.

Extend the prepping area enough to accommodate potential extension of incisions, all possible drain sites, and potential conversion from laparoscopic to open procedure.

Prep intact skin prior to open wounds or body orifices.

Discard skin prep sponge immediately after prepping body orifice e.g. anus, vagina, stoma or sinuses, ulcers. These body areas should be prepped last.

Prep umbilicus first when present within the required prepping boundaries to prevent debris from the umbilicus falling on the rest of the prepped area.

Prep delicate areas/ fragile skin with care.

Use separate skin prepping equipment for multi-site surgery, e.g. abdomino-perineal resection.

Document in the patients Care Plan:

Hair removal, method employed and by whom.
Skin prep solution used and by whom.
Skin condition at surgical skin prep site pre and post operatively.
Any reaction to skin prep solution.

Draping of the operative site:

Allow sufficient space to permit careful draping with good aseptic technique.

Allow the skin prep to dry before draping.

Stand back from the operating table to avoid contamination of sterile gown and gloves.

Hold drapes above waist level.

Place drapes closest to operative site first.

Allow distal edge of drapes to fall below level of the operating table.

Discard drapes if a hole found or cover with an additional sterile drape if drape already in place.

Use atraumatic towel clips or adhesive drapes to assist securing drapes in place.

Use an iodophor- impregnated drape if incise drape required, unless patient has an allergy or hypersensitivity to iodine.

Correctly identify potential sources of contamination and take appropriate action to minimise any risks.

Cutting superficial sutures under the direct supervision of the operating clinician:

Follow the operating surgeon’s directions for cutting the sutures.

Use a pair of suture cutting scissors.

Use the tips of the scissors (to ensure you can see what you are cutting).

Hold the scissors correctly (as demonstrated in competency booklet).

Steady your hand.

Remove the cut ends from the surgical field.

Application of suction and irrigation during open surgery under the direct supervision of the operating clinician:

Follow the operating surgeon’s directions for use of suction and irrigation.

Use the appropriate suction tip.

Only use suction under direct vision.

Assisting in intermittent retraction under the direct supervision of the operating surgeon:

Follow the operating surgeon’s directions regarding placement and pressure.

Use the correct instrument, selected by the operating surgeon.

Only carry out retraction under direct vision.

Only carry out retraction when directly supervised.

Ask for help or clarification if you are unsure.

Cleaning of surface wounds and the application of dressings:

Ensure the patient has no allergies or hypersensitivities to the cleaning solution to be used.

Ensure the area has been appropriately cleaned, using the specified cleaning solution.

Use a gentle cleansing motion taking into account the condition of the skin.

Clean from incision site to periphery.

Follow manufacturer’s recommendations for suitable application.

Ensure that dressings are applied before drapes are removed.

Ensure that the sterile field is still intact when applying dressings.

Ensure the dressings selected have the appropriate properties required.

Use interactive dressings (NICE NG125, 2019).

Ensure the dressing selected is the correct size and will cover the wound as instructed by the clinician.

Ensure the patient has no allergies or hypersensitivities to the properties of the dressing before applying.

Document in the patients Care Plan:

Skin condition at surgical site prior to applying dressings.

Type of dressings applied.

Any reaction to cleaning solution or dressings and the actions there taken.

Haemostasis using indirect diathermy or pressure under instruction and direct supervision of the operating clinician:

Operating clinician grasps or touches the patient tissue to be subjected to diathermy.

Operating clinician verbally directs the Scrub Practitioner to provide indirect diathermy to specified instrument.

Scrub Practitioner advises the operating clinician of the coagulation settings.

Scrub Practitioner touches the specified instrument with the active electrode and when prompted activates the coagulation mode (taking care not to touch the patient with the active electrode) until the operating clinician asks them to stop.

If a foot pedal is being used to operate the diathermy, this should be activated by the operating surgeon.

Follow the operating surgeon’s directions for indirect application of surgical diathermy - and always confirm with them prior to activating.

Use the correct instrumentation.

Only activate the coagulation control.

Only activate the diathermy during open surgery.

Only activate under direct supervision of the lead surgeon.

Store the surgical diathermy instruments in the appropriate insulated quiver.

Intraocular Injection

Check if the solution and administration equipment is available and in date. Always ensure that there is back up solution or equipment.

Check the concentration of gas mixture with the surgeon prior to injection

Follow the operating surgeon’s directions regarding when to inject and the rate of injection

Use the correct substance as prescribed by the surgeon

Only carry out injection under direct vision

Only carry out intraocular injection when directly supervised

Scleral Indentation

Only carry out scleral indentation when directly supervised by the Surgeon.

Ensure that your system of orientation and terminology are the same as your surgeon’s. Always confirm before start of surgery if buckling is a planned part of the procedure.

Back to top

ESCALATION PROCESS

Incidents must be reported through Datix and the following people should be informed:

Daytime

• Team Leader
• Deputy Theatre Manager
• Matron
• Head of Nursing
• General Manager
• Clinical Director for area
• Clinical Governance Lead for area
• Trust Risk Management Team

Out of hours

• Duty Site Matron
• Inform DAYTIME ESCALATION list at the earliest opportunity

Back to top

Appendix - A Skills Registered Perioperative Scrub Practitioners may perform when acting in the Dual Role

Surgical skin Preparation and Draping of the operative site
Haemostasis using indirect diathermy or pressure under instruction and direct supervision of the operating clinician
Application of suction and irrigation during open surgery under the direct supervision of the operating clinician
Assisting in intermittent retraction under the direct supervision of the operating surgeon
Cutting superficial sutures under the direct supervision of the operating clinician
Cleaning of surface wounds and the application of dressings
Intraocular Injection
Scleral Indentation

Appendix B - Skills unregistered Senior Perioperative Assistants may perform when acting in the Dual Role and Supervised by a Registered Scrub Practitioners who has completed the Dual Role Competencies necessary to take over if required

Surgical skin Preparation and Draping of the operative site
Application of suction and irrigation during open surgery under the direct supervision of the operating clinician
Assisting in intermittent retraction under the direct supervision of the operating surgeon
Cutting superficial sutures under the direct supervision of the operating clinician
Cleaning of surface wounds and the application of dressings

Appendix C - Skills Registered or Unregistered Scrub Practitioners may not perform when acting in the Dual Role

Direct diathermy 
Camera manipulation during minimally invasive surgery
Skin closure using sutures, staples, steristrips or glue
Cutting of deep sutures

Appendix D

Surgical Skin Prep and Drape - Dual Role - Prep and Drape

Appendix E

Suture Cutting - Dual Role - Cutting of Sutures

Appendix F

Suction and Irrigation - Dual Role - Suction

Appendix G

Retraction - Dual Role - Retraction

Appendix H

Cleaning Wounds and Application of Dressings - Dual Role - Cleaning of Wounds and Application of Dressings

Appendix I

Registered Practitioners only - Assisting with haemostasis - Indirect Application of Surgical Diathermy - Dual Role - Indirect Diathermy

Appendix J

Registered Practitioners only
Intraocular Injection - Dual Role - Intraocular Injection

Appendix K

Registered Practitioners only
Scleral Indentation - Dual Role - Scleral Indentation