Stepping Up Efficiency

High-volume cataract and refractive surgeons offer tips for maximizing efficiency.

BY RENÉ LUTHE, SENIOR ASSOCIATE EDITOR

Becoming a high-volume ocular surgery practice, whether cataract or refractive, requires not only attention to the latest techniques, but also considered use of the latest technology and the understanding that each movement can contribute to the success of your day. In this article, busy cataract and refractive surgeons share their tips for streamlining their routines while maintaining high-quality results for their patients. We will begin with the cataract realm.

No Substitution for Focus

According to I. Howard Fine, M.D., of Eugene, Ore., and Johnny Gayton, M.D., of Warner Robins, Ga., nothing takes the place of good old-fashioned conscientiousness in cataract surgery — even if this sounds counter-intuitive for the efficiency-minded. A desire for speed could be a surgeon's worst enemy. "Efficiency cannot be gained from speed," warns Dr. Fine. "Speed causes you to make mistakes." He finds it much more beneficial to focus on delivering the best possible vision to the patient. "Patients know they are getting the best of care, no matter how long it may take," he says. This knowledge on the part of patients has kept his practice busy, despite, he says, other surgeons coming in to observe their cataract extractions, which tends to slow procedure times somewhat.

Try Everything

After focus, familiarity and flexibility make cataract procedures more efficient, these experts claim. Companies send Dr. Fine new instruments, lenses and devices to try all the time, he says — and he does. "It's critical, for efficiency, to know the ins and outs of all these things, so you'll know the types of patients they work best for," he explains. While some doctors resist learning new techniques for years, Dr. Fine believes this reluctance is in neither the best interest of a smooth-running practice nor the patient. His practice has all the major phaco units, and his commitment to custom care means he may use four different machines in a single day.

Dr. Gayton also contends that familiarity with a large cataract armamentarium is critical for efficiency. "For instance, use a lens that you are very comfortable with delivering so that you can be sure you're not going to damage it and have to take it out, because that takes time," he says. "Anything that lengthens the time of the operation is not only going to reduce your efficiency for the whole day, it's going to increase the likelihood of a complication on that particular patient."

Dr. Fine agrees. "Complications are what slows down efficiency," he says.

Flexibility extends to cataract-extraction techniques as well. "I'm not married to any particular style of cataract surgery," Dr. Gayton says. "I think it's whatever that particular eye is telling you it needs to have the cataract removed." He describes himself as a "WEW man — whatever works!" Dr. Gayton believes that watching videos of other surgeons performing various cataract-extraction techniques helps him to hone his own technique and perform more efficiently. However, one of the most beneficial things he has tried comes not from medicine, but from his athletic training.

"I am a competitive athlete, a weight lifter, and one of the things that's been successful for me in athletics as well as surgery is to do it in my mind first," he says. He believes visualization is very helpful for younger surgeons. "The truth is, if you think something through before you go to sleep at night, it enables you to imprint it on your brain, and when you're faced with the situation in real life, you're better able to handle it," Dr. Gayton explains.

Technique Tips

Despite his versatile approach to cataract surgery, Dr. Gayton does have some techniques that he has found that help him stay on schedule. Should he find an epinucleus shell after removing the nucleus, he reaches for a J cannula. "I irrigate under the anterior capsulorrhexis with the J cannula, and a lot of times that brings the epinucleus right out so it's easy to take," he says. "I've been doing that trick for many years and I've had a few people adopt it."

He also recommends hydrodissecting cortex more thoroughly to eliminate struggling with sub-incisional cortex. Bitoric IOLs, which have become more common in his practice, have their own considerations. He assigns staff members to remind him that the lens is a toric so that he does not forget to adjust the axis. "Then, secondly, when I do my irrigation/aspiration of viscoelastic, after I position the lens, I do that very gently, so as not to disturb the position so you don't have to keep rotating that lens to try and keep it in position," he explains.

For the OR

Dr. Fine reports that his patients remain on the same bed throughout the extraction process. "That's pre-procedure, during and post-procedure," he says. Less getting the patient up and leading him or her from spot to spot results in significant time savings, his practice has found. Additionally, the patient is hooked up to the same monitor throughout, so staff does not use time changing monitoring equipment and can gauge the patient's condition throughout.

Many of his practice's procedures for more efficient patient turnover come from staff, Dr. Fine says. Dr. Gayton concurs with the importance of staff input. "I think it's important to surround yourself with good people because a chain is only as strong as its weakest link," he says. "I stress to my staff that they do not work for me — they work with me and we work together as a team. I can't emphasize that enough: You have to have the team working together."

Another OR factor that influences efficiency is the readiness of instruments. Both Drs. Fine and Gayton say they have multiple trays of instruments prepared. "There is no waiting around for staff to autoclave the instruments," Fine says. Having multiple ORs also helps keep patient flow moving. Dr. Fine's practice has one room dedicated to right eyes and a second dedicated to left eyes. Dr. Gayton also moves between two rooms, enabling him to work on one patient while staff prepares the next patient in the other OR.

As for when to schedule those difficult cases, Dr. Gayton does not advocate a get-them-over-with-first approach. "I've heard people say, 'Well, I'm going to do my difficult cases when I'm fresher,'" he says. However, his practice reviewed their surgical times and found their complication rates were the same for early surgeries as they were for later ones. "We just found that it interfered with our schedule less if we did them [complicated cases] at the end of the day," Dr. Gayton explained. "That way, if the case takes an inordinate length of time, it hasn't gotten me behind with all my other cases."

Take Cues From Your Patients

Patient reactions to cataract surgery can also affect surgical efficiency, something that practices focusing on the technical aspects of surgery may overlook. Dr. Fine recommends an attentive talk with patients to reassure them that their visual outcome is important to the surgeon. Dr. Gayton claims that it is worthwhile to note patient reactions and change plan accordingly. "If a person shows you that he or she is real anxious and isn't going to be cooperative in the holding area, go ahead and convert from a topical case into a block there," he says. Alternately, "If they show you during the case that they are very anxious and they're going to be difficult during that case — well, there's an old Southern saying: You don't learn a thing the second time a mule kicks you. If a patient has already shown you he is going to be difficult during the first eye, he's going to be even worse on the second. So block him for the second procedure so he doesn't disrupt your schedule and you can get the best results you can for him. If a person displays a lot of anxiety and an inability to cooperate on the first eye, believe him."

Refractive Practice Considerations

For high-volume refractive practices, new technology, such as laser keratomes, have provided both challenges and benefits to efficiency. Daniel S. Durrie, M.D., of Overland Park, Kan., acknowledges that his femtosecond laser did require a learning curve for staff training when he began working with it more than 5 years ago — as well as refiguring patient flow. Because he has excimer laser models whose beds do not move to go under the keratome, he keeps the IntraLase FS (Advanced Medical Optics, Santa Ana, Calif.) in another room. Despite this extra step of moving the patients from place to place as he creates flaps and then performs the ablation, Dr. Durrie is certain the laser keratome ultimately makes refractive surgeons more efficient. "Since we have introduced blade-free LASIK, we're seeing fewer complications, we don't have to cancel cases, we're seeing more accuracy, less enhancements," he says. "So I think it is a very good investment if you're taking fewer patients back to the operating room for enhancements or problems."

Mitchell A. Jackson, M.D., of Lake Villa, Ill., uses a mechanical microkeratome both in his private practice and at a high-volume LASIK Plus Center. "I find them extremely efficient," he says. Because he can place the microkeratome beside any model excimer laser, there is no need to move patients from room to room. "I think with the laser keratome, you have to factor in the staff learning the computer that programs everything into the laser keratome," Dr. Jackson says. "But you don't have the time and worry of the staff putting together the pieces of a mechanical microkeratome. So once past the learing curve, the time between the two microkeratomes is probably equal."

Electronic medical records are another way that technology creates more efficient ORs. Dr. Durrie reports that all his refractive protocols are on EMRs. "I think that a lot of doctors have EMRs in their offices, but not in their laser centers," he says. "They are absolutely fabulous in the laser center, because they enable you to avoid a lot of the writing that the nurses have to do and give you a lot of doublechecks." In his ORs, there are computer screens beside each excimer laser and laser keratome that the staff use simultaneously. The patient's topography is on the screen when he comes in to perform the procedure. "If I need to re-check the refraction, if I need to do anything, it's right there," Dr. Durrie says. He feels that going paperless in the OR has been an enormous advantage for his practice.

Organizing Patients

Methods of arranging cases can also contribute to staying on schedule. Dr. Durrie says that his staff likes to throw a short case into the mix periodically. "We usually have four patients per hour scheduled and we like to have one that's either a one-eye case or conductive keratoplasty (CK, Refractec, Irvine, Calif.) or another type of surgery just in case you need a quick one to catch up," he says.

Dr. Jackson organizes his cases similarly when he is at the LASIK Plus Center. In his private practice, however, where there is only one laser, he groups his primary LASIK cases and his enhancement cases separately. "All the patients are in the waiting room talking to each other," he says. "I don't like it when the enhancements talk to the primary LASIKs. Because an enhancement is not the end of the world, but a patient out there will make it sound like it is the end of the world and screw up the mindset of the people who are having LASIK for the first time." He will do one-eye LASIK cases or a PRK case to keep to his schedule in this environment.

Another way of organizing patients that promotes efficiency, according to Dr. Jackson, is grouping cases by laser platform. He says he will perform three or four procedures on one laser, then switch. Within each laser platform, cases can be grouped by procedure — PRK, enhancement, one-eye LASIK. All equipment is kept on one cart that is wheeled from one laser to another. He acknowledges that sometimes grouping treatments by laser platform cannot be helped, that it may be determined by patients demanding certain times for surgery, but says that such grouping greatly helps efficiency.

Having a portable slit lamp in the laser suite also keeps things moving, Dr. Jackson reports. In his private practice, he does not have the room for this, but at the LASIK Plus Center he does, and patient flow definitely benefits. "When the slit lamp is in the laser room, they get off the laser and I look at them right there and they go," he says. "The next patient comes in. That saves you time if you're trying to do from 10 to 12 eyes per hour. It's impossible otherwise."

Watch the Time

Old-fashioned clock watching can also be useful in staying on schedule. The whole staff needs to be mindful of how much should be accomplished by a specific time, according to Dr. Durrie. "If you start at 8 a.m. and it's now 8:30, you should be finishing the second case," he says. "If it's 9 o'clock, you should be finishing the fourth. If you're not, everyone looks around and says, 'We've got to hurry up or we're not going to finish on time.'" The first hour is particularly important, Dr. Durrie says, because if you are behind at its close, it will be difficult to catch up and remain on schedule for the remainder of the day. "You don't want staff to watch the clock too much, but on the other hand, it's nice to have a little metronome to see how we're doing."

He emphasizes that it is not just the staff who must be mindful of the surgical schedule. "If we have the patient ready to start at 8 a.m., it's important that the doctor be there too and ready to go." While it may be easy to fall into the habit of behaving as if the surgeon has the prerogative of keeping others waiting, it is good for neither productivity nor morale. "If I stroll in 10 minutes after the patient is ready, we've lost 10 minutes and the staff is glaring at me," Dr. Durrie says. "They were ready and I wasn't. I have seen a lot of physicians really get into this habit and they get slower and slower as the years go by and complain to the staff, 'Why are we so behind?'"

The Right Combination

A high-volume ocular surgery practice requires more than just the latest devices or an obsession with time. At his practice, Dr. Fine says, "Patients know that they are getting the best of care, no matter how long it may take." Dr. Gayton concurs. "The better you are, the more efficient your day is going to be." OM