Maximizing Efficiency in Your ASC
Doing so brings cost savings and reduces error.
BY VICKEY HAWKINS, COA, AND LARRY E. PATTERSON, M.D.

One important way to optimize revenue is by reducing all phases of the surgical process to their most fundamental elements. This not only eliminates unnecessary drains on revenue, it also reduces the likelihood of error.

In particular, cataract surgeons often work diligently to shear a minute or two off their operating times, only to wait an unreasonable period for their next case to begin. In our ASC we comfortably perform four to five cases per hour in one OR, with an average case time of 5 to 7 minutes. Turn-over, mostly accomplished by our scrub tech and one assistant, averages 4 to 5 minutes (calculated from the time one case is finished to making the incision on the next case).

Here, we'd like to share some of the strategies that have helped us get the most out of our ASC.

Scheduling

Appropriate scheduling is a key part of achieving optimal productivity and effectiveness. Try these strategies:

• Place potentially difficult cases at the end of a morning or afternoon to avoid disruptions or delays in the surgery schedule.
• Schedule like eyes (right and left) together. This can lessen employee time and effort as well as reduce wear on your equipment.
• Use a software program to create customized paperwork for each patient. (We've implemented Microsoft Word's merge program.) Information such as name, operative eye and allergies can be typed into a data box and merged into a 15-page document. These pages include the physician's orders, history and physical, pre- and post-op instructions, and prescriptions for pre-op eye drops.
• Print a patient information card and hang it on the patient's bed. (We hang it at the foot of the bed on an I.V. pole.) This card makes it easy for the physician and staff to see who the patient is, which eye you're operating on, the density of the nucleus, the size of the pupil and the IOL type and power.
• Create customized, detailed forms for the procedures you perform routinely. This lessens the time the circulating nurse has to spend filling out redundant paperwork during the procedure, giving her more time to assist in other duties.

	PHOTOGRAPHER: GARY S. AND VIVIAN CHAPMAN

Before the Day of Surgery

To prevent last minute hang-ups on the day of surgery:

• Have your coordinator review the charts with the surgeon before the day of surgery. The coordinator should also call patients to confirm their appointments, verify and document any changes in the H&P (History & Physical), and review pre-op instructions.
• Have someone confirm and pull all of the implants the day before surgery. Each implant box should be labeled with the patient's name and placed in the proper order in a container that stays in the OR. This will not only save time during and between cases but will also reduce the chance of an assistant grabbing the wrong lens at the last minute.
• Pull all supplies needed for the next day's surgical cases so they're ready to be opened in the morning. (This will also alert you if you're missing needed supplies.)
• Equip small carts to hold all supplies needed for the day; position them next to each stretcher in the pre-op area.

On the Day of Surgery

When setting up in the morning:

• Have the scrub tech and coordinator open and draw up post-op antibiotic injections and intracameral lidocaine and assemble viscoelastics using sterile technique. These can be placed in a sterile Genesis tray, which rests on a cart at the side of the back table. (Make sure the lid remains securely closed until the scrub tech removes what she needs.)
• BSS bottles should be prepared with epinephrine. They can rest on a shelf beneath the Genesis tray, along with sterile water, IOL cartridges and extra viscoelastics. In this arrangement they're easily accessed, but out of the sterile field.

When the patient is being prepped for surgery:

• Let the stretcher double as the operating table, so the patient doesn't have to be moved to another bed.
• Connect the patient to a portable monitor resting on the footplate of the bed. This can stay with the patient at all times.
• Try using sublingual Versed instead of an I.V. or hep-lock on routine cataract patients. (We give it to the patient about 15 to 20 minutes before the procedure.)
• Place an Ocucel sponge, soaked in the preoperative drops, in the superior conjunctival fornix using forceps. This gives a faster, more powerful dilation, and frees up the staff for other duties.
• In the holding area, apply Betadine solution and Xylo-caine gel to the eye and adjust the patient's head and body properly. When the stretcher is rolled into the surgery suite the patient is ready for the final prep, drape and surgery.

In the OR

For efficient surgery:

• Place two boxes of sterile 4 x 4 sponges in a sterile prep tray; partly soak one box with Betadine solution, but leave the other dry. (The tray lid should be kept closed when not in use.) The prep tray can rest on a small metal rolling tray.
  The RN should wear a sterile glove on one hand only. After the circulator helps roll the patient into the room, the RN can lift the tray lid with the non-sterile hand and use her sterile hand to remove a Betadine-soaked sponge to prep. A dry sponge can be used to wipe off the excess Betadine. The entire process takes less than 1 minute.
• Make sure your instrument trays contain only the absolute essentials used on every routine cataract case. Other instruments needed for unforeseen events should be placed on a secondary, sterile Genesis tray. Choice pieces such as capsulorrhexis forceps and extra lid specula can be peel-packed separately; disposable surgical packs should be trimmed down to a bare minimum.
  Not handling excess instruments on your regular cataract trays reduces clean-up time and decreases wear and tear. Reducing additional supplies limits cost, waste and space requirements, as well as saves time.
• If you're considering purchasing a phaco machine, take into account the time and effort required to set up and calibrate it. (We've used Bausch & Lomb's Millennium for almost 6 years and are very satisfied with the quick and simple set-up between cases.)

Discharge

To make sure discharge goes smoothly and post-surgery misunderstandings are minimized:

• Create a position for a discharge specialist. Be sure to pick someone for this position who has excellent communication skills and can relate to older patients.

Following surgery in our ASC, we evaluate the patient's vital signs, transfer the patient into a wheelchair and provide juice to sip on. Then our discharge person escorts the patient out and reviews the post-op instructions with the patient and family in a relaxed atmosphere. (Between patient discharges, she carries on conversations with patients waiting for surgery in the holding area.) In addition to making the process go smoothly, this individual reduces the "assembly line" perception by providing a personal touch.

Changing for the Better

Two final thoughts:

• Implement changes to your routine slowly. Wait until you and your staff have acclimated to one set of changes before streamlining another aspect of the process.
• Never do anything in the name of speed that compromises the quality of patient care you provide. Efficiency will lead to speed, but speed won't lead to efficiency.

Ms. Hawkins is surgical coordinator, and Dr. Patterson is medical director and surgeon, at Eye Centers of Tennessee.