CLINICAL USE OF PHENOL FOR NAIL SURGERY BY PODIATRISTS

Version number: Name and title of originator/lead author Contact details of originator/author Name of Lead Executive Director/Manager * Ratified by (include ratification date): Date issued: Review date Expiry date: (9 months after review date) One Christine Hurley Professional and Service Lead Podiatry Tel: 01225 831660. E-mail christine.hurley@banes-pct.nhs.uk Stella Doble Divisional Director of Adult Services Community Healthcare Services Committee September 2009 September 2009 September 2011 June 2012 Target audience No Podiatry staff No No

Applicable to (shade appropriate box) Community Healthcare Staff Public Health staff Commissioning staff Yes Yes Yes

This document can only be considered valid when viewed via the Trusts website. If this document is printed into hard copy or saved to another location it is your responsibility to check that the version number on your copy matches that of the one on-line. * note for documents that apply to both Commissioning and Community Healthcare staff these must be ratified by the appropriate committee/group within Commissioning and Community Healthcare Services.

Title:

Clinical Use of Phenol for Nail Surgery by Podiatrists Version: Date of Issue: Sept 2009 Date of Review: Sept 2011

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CONSULTATION PROCESS
Key individuals involved in developing this document (main authors) Name Christine Hurley Designation Professional and Service Lead Podiatry

Circulated to the following groups for ratification Name of Group Clinical Standards & Patient Safety Group Policy Approval Group Circulated to the following groups for ratification Name of Group Community Healthcare Service Committee Date September 2009 Date Feb 09 April 09

VERSION CONTROL Version No 1 Updated By Christine Hurley Updated On August 2009 Description of Changes

Title:

Clinical Use of Phenol for Nail Surgery by Podiatrists Version: Date of Issue: Sept 2009 Date of Review: Sept 2011

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Section

INDEX Consultation Process and Version Control Index

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2 3 4 4 4 5 5 5 5 6 6 6 6

1 2 3 4 5 6 7 8 9 10 11 A

Introduction Background What is Phenol? Clinical Situations where Phenol is used? Clinical Criteria of Patient What is the Key Health Hazard? Exclusions Spillages First Aid Record Keeping Extracts APPENDICES Protocol for Podiatry Nail Surgery

Title:

Clinical Use of Phenol for Nail Surgery by Podiatrists Version: Date of Issue: Sept 2009 Date of Review: Sept 2011

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INTRODUCTION

Phenol (liquid 80% salivation) is used to chemically cauterise following surgical nail removal to ensure the matrix of the nail is destroyed and does not re-grow. 2.0 BACKGROUND

Phenol is highly toxic and all those working with it must exercise care in its handling. In June 2000, the Health and Safety Executive HSE issued a Chemical Hazard Alert. Guidance was given to prevent exposure to Phenol by any route and where ever possible use a different substance. Exposure of Phenol within the B&NES Podiatry Department is very low in total only 40mls of Phenol used per year on 160 patients approx. Exposure per patient is 3 minutes. See Appendix 1 Key points on use of Phenol within B&NES Podiatry Department: 1. Liquefied Phenol should be stored in a cool place in a lockable pharmacy cupboard. Bottles must be returned to pharmacy for disposal. 2. Staff must read the B&NES Podiatry Nail Surgery procedure 3. Staff must be aware of the risk associated with the use of Phenol 4. Staff carrying out procedures must wear impermeable gloves, protective face wear and long cuffed gloves 5. Ensure good room ventilation 6. The Phenol bottle must be open for as little time possible only opened immediately before use and closed between applications 7. Phenol must be stored in the medicines cupboard. Bottles must be returned to pharmacy for disposal 8. If accidentally spilt dilute with Alcohol (Chlorhexidine will suffice) 9. Method of application an instrument called Blacks file is dipped into a very small amount of Phenol approx 0.25 ml and then rubbed into the area where the nail has been removed. This takes 3 minutes and the area of lesion should become blanched. The area is then diluted with alcohol. 3.0 WHAT IS PHENOL?

Phenol was first isolated from coal tar in 1834 and named carbolic acid. It is a colourless-to-white solid, the commercial product is liquid that has a sweet acrid odour. It is a caustic agent that produces damage to the epidermis.

Title:

Clinical Use of Phenol for Nail Surgery by Podiatrists Version: Date of Issue: Sept 2009 Date of Review: Sept 2011

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CLINICAL SITUATION WHEN PHENOL IS USED Phenol is used for the clinical cauterization of a nail bed following removal of the toe nail to prevent re-growth of the nail. Staff authorised to use: HPC Podiatrist with degree/diploma qualification in podiatry. HPC Podiatrist with a certificate of competency in nail surgery

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CLINICAL CRITERIA OF PATIENT Patient undergoing nail avulsions require nail bed removal to prevent regrowth of the nail. Phenolisation of the nail bed is the least invasive and most effective way to undergo this procedure. Patients must present with an acute or chronic nail condition where application of Phenol to the nail bed would offer a cure.

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WHAT IS THE KEY HEALTH HAZARD? Phenol is corrosive which can burn or irritate the skin. General side effects such as nausea, vomiting, paralysis, coma or burning of the gastrointestinal tract are only seen after ingestion. Phenol is readily absorbed through the skin or when inhaled. Inhalation of vapour over a prolonged period may cause digestive, nervous, skin, kidney and liver disorders. Animal studies have shown many signs of acute poisoning appear when Phenol enters the systemic circulation through absorption or ingestion. The use of Phenol has been shown to be very safe and no systemic complications have been reported within the use of Phenol in nail matricectomies. The amounts used in nail surgery procedures are very small and no side effects have been noted by practitioners. References BDH database for hazard data information (known as EM Science database) 4th June 2001. www.emiscience.com Boberg JS, Fredrericksen MS, Harton, FM, Scientific analysis of Phenol nail surgery Journal of the America Podiatric Medical Association 2002; 92 (10): 575-579

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EXCLUSIONS None but note extreme caution:

Title:

Diabetes mellitus Rheumatoid Arthritis Peripheral vascular disease Elderly patients

Clinical Use of Phenol for Nail Surgery by Podiatrists Version: Date of Issue: Sept 2009 Date of Review: Sept 2011

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SPILLAGES Ventilate area Mark the area and warn all persons present Dont allow spillage to enter water courses Wear Nitrile gloves. Wear eye/face protection Dilute with alcohol (Chlorhexidine in 70% 1mls) Absorb in sand or inert substance/material

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FIRST AID Inhalation remove to fresh air and rest. If exposure is significant get immediate medical attention. Ingestion do not induce vomiting: give plenty of sips of water. Get immediate medical attention. Eye contact irrigate for at least 15 minutes. Get immediate medical attention. Skin wash with Chlorhexidine then with soap/cleanser rinse with plenty of water if significant get immediate medical attention. Document time of application and nature of incident. Follow PCT Adverse Event Policy.

If needing emergency ambulance transfer to A&E state Phenol contact/ingestion as reason. Accompany to A&E.

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RECORD KEEPING Record patients name, age and number in nail surgery register. Record contact time in clinical records. Record batch number in nail surgery register. Record expiry date in nail surgery register. Monitor use and risk assess for significant change of use and exposure time

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EXTRACTS

Extracts taken from: Phenol and the H&S Guidance, J. Gordon Burrow, MIOSH, FChS Podiatry New August 2001 And Phenolisation nail matrix avulsions: historical profile and literature review L. Cook B AppSc (podiatry) Podiatry New September 2008

Title:

Clinical Use of Phenol for Nail Surgery by Podiatrists Version: Date of Issue: Sept 2009 Date of Review: Sept 2011

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APPENDIX A PROTOCOL FOR PODIATRY NAIL SURGERY

It is the responsibility of the registered Podiatrist to be competent in this procedure.

Indication for Use Painful nail pathologies i.e. onychocryptosis, onychogryphosis

Purpose To provide a cure for problematic/painful nail pathologies, with no complications.

Environment Nail Surgery will take place in a suitable environment. An adequate sized treatment room, adequate lighting and ventilation is essential. Floors and ceiling should be washable. Emergency equipment and assistance needs to be available.

Equipment Pre-packed sterile nail surgery instruments with tourniquet Phenol 80% Beaver chisel blades, size 61 + 62 Chlorhexidine 0.5% Dressing pack to create sterile area Post operative dressings to include Sorbsan and Inadine Sterile gauze Tubigauze Size 12 and 01 Adrenaline Sterile gloves Eye/face protection Apron Sharps bin Resus mask

Pre nail surgery information must have been given to ensure informed consent prior to procedure. Written consent must be obtained in accordance with the Trust Consent Policy.

Title:

Clinical Use of Phenol for Nail Surgery by Podiatrists Version: Date of Issue: Sept 2009 Date of Review: Sept 2011

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PROCEDURE Before the procedure commences anaesthesia of operation site must be achieved. Wash hands. Open sterile pack on top of clean trolley surface/or onto sterile trolley surface. Ensure all personnel protective equipment for procedure is worn. Apply sterile drape over operating site, isolating specified toes(s).

RATIONALE To ensure patient is confident and pain-free during procedure. See Administration of Local Anaesthetic policy. To create a safe sterile field for instruments and to prevent cross infection. To protect staff and patients from hazards in the procedure and prevent infection. To maintain safe clean clinical environment during operation, so preventing cross infection. To exanguinate toe in order to create a bloodless field in which to work, prevent cross infection of blood products and maintain concentration of Phenol BP. Separation needed to aid avulsion, and prevent soft tissue tears, especially thick fibrous Partial Nail Avulsions and Total Nail Avulsions. To enable complete removal of nail section.

Apply sterile digital tourniquet to specified toe(s) and hold in situ. with forceps. Apply from distal to proximal aspect of toe.

Separate nail from bed for procedure if required.

For Partial Nail Avulsion make a longitudinal incision of the nail plate as far as possible with Thwaites nail nippers. Complete incision down to the nail matrix with beaver chisel ensuring incision is complete. Clamp section being removed with forceps and turn forceps medially towards centre of toe. Check all structure of nail removed and check operation site for loose debris. Check free edge with black file.

Aid gentle removal of complete nail section including fibrous sheath.

Check Phenol - it should be free of debris and colourless. Apply Phenol to operation site for a total of 3 minutes. Disturb site using a black file. Ensure there are changes in the tissue matrix (tissue blanches and becomes softer). During phenolisation ensure area is dried out and fresh Phenol applied as Phenol may become contaminated.
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Presence of the frond effect at the base of the removed nail indicates a complete removal. To ensure all nail removed, thus preventing re-growth. To ensure the Phenol is not contaminated or has had its effectiveness impaired. Ensure concentration of the Phenol and complete destruction of the nail matrix. Cautery of the blood vessels may also be achieved, thus preventing excessive post operative bleeding.

Clinical Use of Phenol for Nail Surgery by Podiatrists Version: Date of Issue: Sept 2009 Date of Review: Sept 2011

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PROCEDURE After the process, dry the area, flush out with chlorhexidine and dry again. Remove esmarch bandage while keeping digit covered.

RATIONALE To remove excess Phenol and dilute any that may remain. To prevent contamination of blood and prevent alarming patient should the wound have a tendency to bleed. Ensure circulation has returned to the digit.

Check to see if digit returns to previous colour and warmth. Dress with appropriate primary dressing Alginate if moderate/severe bleeding occurs Tuille Dressing if little or no bleeding occurs. Secondary dressings should be low adherent dressing and sterile gauze, and enough to prevent strike through, and allow patient comfort. Advice to be given re elevation of the foot and limited mobility. If strike through occurs, apply extra secondary dressing. Do not allow patient to leave unless bleeding from wound has resolved. Elevate limb, apply pressure if necessary. Post operative advice sheet to be given with written explanation of procedure, anaesthetic given and dressing applied.

To control blood loss from the wound and reduce any adherence of secondary dressing. To avoid giving patient alarm, should bleeding occur limited mobility and foot elevation will reduce occurrence of bleeding and swelling, aiding healing.

Ensure patient has fully recovered from procedure and the wound will not continue to bleed excessively at home.

Written documentation given to patient can be forwarded to a GP should any out of hours emergency arise. Patient can follow advice to facilitate recovery.

Procedure must be carried out in accordance with the following Trust policies: Health and Safety Risk Management Infection Control

Post Operative Procedure: The patient will return to clinic 1 to 2 days post operatively for a wound and dressing review. The patient will be given written and verbal advice on changing the dressing. Further appointments will be given to check wound healing until the patient can be considered healed.
Title: Clinical Use of Phenol for Nail Surgery by Podiatrists Version: Date of Issue: Sept 2009 Date of Review: Sept 2011 Page 9 of 10

Outcome: The nail pathology is resolved with no post operative complication of infection or regrowth. This procedure will be audited for occurrence of growth.

References: Atlas and Text of Forefoot Surgery Neales Common Foot Disorders Pages 65 85 Pages 353 356

Title:

Clinical Use of Phenol for Nail Surgery by Podiatrists Version: Date of Issue: Sept 2009 Date of Review: Sept 2011

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