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Vitreoretinal surgery in the ASC: How progressive doctors and facilities are making it work.
By Eddie F. Kadrmas, M.D., Ph.D., Plymouth, Mass.

Over the past 20 years, however, vitreoretinal surgery has changed dramatically. Today, instrumentation is simpler, more compact, easier to use and more effective. New techniques have made surgery faster and safer and produce better results. We can now perform some procedures in 30 minutes, and even the most complicated ones often take less than 2 hours.

Because of these changes, a new trend is taking shape -- one that would have been unthinkable to many surgeons in the past. Retinal surgery is moving out of the hospital into ambulatory surgery centers (ASCs).

I've helped develop successful retinal facilities in two ambulatory surgery centers in Massachusetts. These facilities provide the highest standard of care, use the best equipment technology can offer, and still maintain costs at a level that keeps operations "running in the black." Today, I rarely perform retinal surgery in the hospital.

I'm convinced that ambulatory surgery centers will become the standard of retinal surgical care in the not-too-distant future. On the following pages, I share some of my experiences and discuss the implications of this trend. I also offer advice for developing your own ASC retinal facility, should you choose to do so.

Advantages of an ASC

Today, technology and techniques have advanced to the point that staying in a hospital setting is an option, not a necessity. At the same time, performing retinal surgery in an ASC has many advantages:

The surgeon has the "home court advantage." At an ASC you can work with well-trained staff who are familiar with the nuances of retinal surgery. Yes, I've worked with superb OR staff members in hospital settings. However, most hospitals don't have dedicated ophthalmology personnel with extensive retinal surgery experience. Working in hospitals, I often needed to bring an assistant from the office to help direct the proceedings. Even in an eye hospital, I was sometimes faced with new and different staff members from case to case.

When operating in an ASC, you're in control. You can pick your staff and train them so you know that they'll perform up to your level of expectations. And, you can work with the same people every time.

It allows greater efficiency and faster turnaround time. Having a nearby OR and a competent, well-trained staff leads to more efficient use of your time, as well as more efficient use of the OR suite and the ASC staff. This has other benefits:

• Quicker surgery is better for the patient. It decreases the possibility of intraoperative complications. It leads to fewer postoperative complications, such as cataract formation, and it results in faster recovery times.
• More productive use of the facility and staff benefits both your practice and the ASC.
• Using an ASC also allows you to manage your workload more effectively.

When the ASC is adjacent to your clinical space, as it is in my practice, individual productivity is maximized even further. I can perform surgery for one part of the day and devote the remainder to examining patients. I don't have downtime.

Patients are more comfortable. A hospital can be a pretty austere environment. In contrast, I've often had patients at an ASC tell me that they feel like they're truly receiving personal care -- from the friendly reception they receive when they walk in the door to their post-op coffee and muffin.

It makes quality care available locally. Don't underestimate the impact of making this kind of treatment easily available to the patient:

• Patients love the convenience of having surgery at a facility that's close to their homes, family and friends.
• Local surgery makes patients feel as if the surgeon is part of their community. This makes the experience less impersonal and frightening.
• Once patients realize that they don't have to go to a large city or hospital to have these procedures, most won't consider other options.
• By performing retina surgery locally, you're providing a major service to your patients, further bolstering the comprehensive ophthalmology practice of today.

The day-to-day difference

The difference in my daily schedule now (compared to when I performed surgery in the hospital) is dramatic. Scheduling at a hospital was always problematic, primarily for two reasons:

• When I had to travel to the hospital, commuting could eat up a lot of time, especially with traffic being unpredictable. The physical proximity of the ASC eliminates this problem altogether.
• Hospitals don't care about how long you spend waiting for an OR to open up. It was always "hurry up and wait" -- and the wait was too long. Also, if I didn't have the first case in the morning, my exact OR time couldn't be predicted with any accuracy. Many hours when I could have been seeing patients in clinic were wasted while I waited to get into the OR.

The overall effect on my schedule was to make surgery time-consuming and inflexible, and to make it difficult to schedule the rest of my day.

Today, in contrast, scheduling is easy and consistent. I usually schedule surgery 1 day a week in each of my two offices. We "batch" all similar, nonemergency cases together the same way successful cataract ASCs do because this is a cost-effective way to use staff. Also, putting similar cases back-to-back enhances the flow in the OR as the staff and surgeon "get into the groove."

In one ASC, I usually set aside all or part of the morning for surgery, depending on the number of cases. I can handle two to four cases over the course of the morning, depending on the type. If I have fewer cases on any given day, I schedule clinic time. Following surgery and a brief lunch break, I can see patients immediately.

In my second office, it works out better for me to see patients in the morning and perform surgery in the afternoon. If only a few cases are scheduled, patients or laser surgery can follow.

Responding to urgent cases

Operating in an ASC also makes a big difference when a case must be handled quickly. In the hospital, my experience (and that of other surgeons I know) has always been that ophthalmologists and their patients aren't a priority. I found it almost impossible to get an urgent case booked at a local hospital with a definite start time at a reasonable hour. Almost any other surgical emergency would be given precedence.

In contrast, when you work in an ASC, you can schedule an urgent case in the middle of the day or at the end, depending on the ASC cataract schedule. Clinic patients can be rearranged before and after the case as necessary.

A few days ago, for example, I had an emergency to deal with at my Dartmouth office. I was able to complete my regular day of seeing patients, and -- virtually the minute I was through -- my staff had the extra patient ready for me to start the operation.

This works because the ASC is located in the same facility as our clinic. I control everything in this setting, including my schedule, with few outside forces getting in the way.

A recipe for success

If you're interested in making the move to an ASC, here are some steps you can take to make the process a smooth one.

First, do the math. Examine your patient population base and decide whether the number of cases you perform warrants setting up a retina suite. We initially figured that it would take about two cases per week for us to make this work. We knew that our profit margin wouldn't be huge, but it would pay for our staff and equipment over a 1- to 2-year period.

How many cases will your practice need to make this worthwhile? It depends on your overhead costs in general and how expensive your tastes are in terms of new equipment.

It also depends on your motivation. Unfortunately, doing retina in an ASC is not a way to get rich or turn a huge profit. It is, however, a way to improve your lifestyle, decrease the hassles and headaches associated with surgery and take better care of your patients.

The important thing is to manage it so that it doesn't end up costing you money. (This shouldn't be a problem if you're a cost-conscious individual.)

Consider joining an existing, successful, cataract-surgery-based ASC. You can set up your own surgery center if you have the liquid assets, but for most surgeons this is too expensive and impractical. In my experience, the best approach is to work with an existing surgery center and incorporate retina as one of its services.

To make this happen, you, the facility administrator and those who have financial interest in the center must all agree on common goals -- such as the development of a high-quality program that will provide local care for patients in a cost-effective manner.

An already successful ASC of this kind has several strengths that will work to your advantage:

• A successful cataract center will have "been around the block a few times" and will know how to manage cases in a cost-effective manner.
• The cataract surgery environment can be easily adapted for retina surgery.
• The ASC staff is probably already geared toward maximizing efficiency.

(If you own an ASC, and you're wondering whether it would be profitable for you to add vitreoretinal surgery to the services you offer, see "Should You Add Posterior Surgery to Your ASC?".)

Choose your instrumentation judiciously. The basic set-up for a retina case has a lot in common with the setup for cataract surgery. For the most part, microscopes can be shared, as can patient gurneys or reclining chairs. Other basic instruments are also common to both surgeries.

Here are some strategies to help save money at the outset:

• It's true that we retinal surgeons like our "toys." However, most of us will admit that we don't need a whole suitcase of instruments to perform 99% of our retinal cases. For that reason, in the early stages of developing your retina program, I'd suggest picking out only the instruments that you really need. The rest can come later.
• The major expense to the ASC will undoubtedly be purchasing a posterior segment system. However, you can save money if the unit is capable of both anterior and posterior segment surgery. This will make the system more versatile so it fits the overall needs of the ASC. (Some ASCs may already own a system capable of both types of surgery, which will make the addition of retinal surgery even easier.)
• If the price of a new system is too much for the budget, don't forget about pre-owned/refurbished units. These can be purchased from the manufacturer, complete with warranty.
• Your practice may already have a laser that can be shared with the ASC. If not, consider investing in a portable solid- state laser. These lasers are small and easily used in the OR. They're perfect for office use, as well as convenient for taking to a satellite office.
• Your practice may already own some of the instruments that you'll need, and others are relatively inexpensive. You probably have a cryopexy unit in your office, for example. You may need a diathermy unit, but this shouldn't be a major expense. Likewise, once a basic inventory of scleral buckle elements is purchased, the cost per case is minimal.
• Whenever possible, select instruments that are reusable and autoclavable.
• Whenever possible, purchase "disposable" supplies that can be reused (with appropriate safeguards). For instance, laser probes and light pipes can be gas sterilized. If properly cared for, these fiber-optic instruments can be used in multiple cases.
• Spend time training your staff for their roles in the various types of retinal cases. This is a major factor in developing an effective retina team. (Retina procedures will be foreign to some OR staff, but for others it will be a natural transformation.)

Don't forget the importance of having a quality anesthesia staff as well.

• Think each procedure through carefully to avoid wasted time and maximize your surgical efficiency. Often procedures take too long just because the surgeon didn't bother to come up with a definite game plan.

Staying on track

To make this work, you and the people in charge of the ASC must make a conscious decision that success is important, both for you and your patients. Then, if you and your staff are well prepared and you've thought the whole process through, all should go smoothly. However, don't expect to achieve maximum efficiency immediately -- this will develop over a few months.

	Because he operates in an ASC, Dr. Kardmas works with the same staff -- trained by him -- every time.

Also, to make sure you don't get sidetracked by unforeseen problems, reassess how you're doing at regular intervals:

• evaluate operating times and turnaround time
• track cost per case
• use patient satisfaction surveys to "fine-tune" your performance.

A change for the better

I believe the move from hospital to ASC is a natural, evolutionary process. Yes, change can be difficult, and it makes sense to question it. But once I experienced what it was like to operate in my own facility, it was clear to me that all other options were second best.

When retinal surgery is performed in an ASC setting, everyone benefits -- the surgeon, the practice, and especially the patient. And in the long run, that's what counts.

Eddie F. Kadrmas, M.D., Ph.D. is a vitreoretinal surgeon in private practice at the Post and O'Connor Eye Centers in Plymouth, Mass., and at Eye Health Vision Centers in North Dartmouth, Mass. He's a clinical instructor in ophthalmology at the Massachusetts Eye and Ear Infirmary and Harvard Medical School in Boston.

Staffing Your ASC
Each of the ASCs at which I perform retinal surgery have about a dozen people on staff. For our retinal procedures, we use existing staff members who are already experienced in eye care. These individuals are trained to perform multiple roles as part of the retina team, which gives us flexibility in case of illness or vacations. We always have staff members available to do cases. Dr. Kadrmas and members of his team at the Plymouth Laser and Surgical Center. All staff members perform both retinal and nonretinal duties at the center; many are cross-trained to manage multiple roles. Usually, we have three team members who help to support the surgeon during any given retinal procedure: A first assistant. The first assistant is perhaps the most important team member besides the surgeon because this person is directly involved in the case. He or she must have "good hands" in order to help with the operation. I have either a trained surgical technician or registered nurse/surgical assistant fill this role, depending on which of the two centers I'm working in. A circulating nurse. The circulating nurse is responsible for patient preparation, as well as helping the case move along through set-up and takedown. (Both the first assistant and the circulator are responsible for turning the room around and instrument cleaning/sterilization between cases.) Dr. Kadrmas with one of his surgical teams at the Greater New Bedford Laser and Surgicenter in North Dartmouth, Mass.. A nurse anesthetist. In my facilities the anesthetist, in addition to managing the anesthesia, is also responsible for performing the peribulbar block prior to the procedure. The anesthetist handles this while I'm dictating and talking to the patient's family, which facilitates case turnaround. In one ASC, we subcontract the certified registered nurse anesthetist to work on the retinal cases. (These individuals do their own billing, so they're not a part of the expense for a given case.) In the other ASC, we use employed (part-time) anesthetists who also have other responsibilities in the practice, such as preoperative screening. The anesthetists in both practices have been specially trained for ophthalmic surgery. -- Eddie F. Kadrmas, M.D., Ph.D.