Orchestrating Cataract Surgery

Your surgical staff must work in harmony — and follow your lead. Experts explain how to set the tempo.

BY LESLIE GOLDBERG, ASSOCIATE EDITOR

The concert hall is quiet as the audience anticipates the performance. All eyes in the orchestra pit turn to the conductor, who must activate his players only at the moment when needed and silence them with equal precision. The individual musicians, seasoned professionals one and all, know the piece by heart but still must work effortlessly as a group, anticipating each other's moves, to create the magic of the symphony.

In many ways, the same dynamic is necessary to create the perfect cataract surgery outcome — a strong group, set in a controlled environment, working with familiar tools to create magic for their expectant patients. To find out what makes some of ophthalmology's best philharmonics excel, we asked several maestros for advice.

The doctors interviewed for this article agree that a cohesive staff appears to be the greatest common denominator among successful and efficient ORs. In addition, saving time between procedures appears to be a much more popular idea than trying to cut time during a procedure. Below are valuable tips from colleagues that you should consider implementing in order to improve OR efficiency and provide better patient outcomes.

Practice Makes Perfect

A tourist in New York stops a passerby and asks, "How do I get to Carnegie Hall?" goes an old joke. "Practice!" he replies with a wink. Cataract surgery is no different, our experts say.

Your staff must be proficient in their own roles and those of their colleagues. "Cross training OR staff has been paramount to increasing our efficiency," says Marcia Conley, RN, director of nursing at Cataract & Laser Center, LLC, located in Crossville, Tenn. and headed up by Dr. Larry Patterson. "While each of us is more proficient in certain areas, we all have a basic knowledge of all aspects of the OR dynamic."

Ms. Conley also stresses the importance of communication. "The OR staff works together as a team; a well-oiled machine with each part knowing its place and function." She says that each person is willing to help out and do whatever is needed should the need arise.

Kerry Solomon, MD, of South Carolina has increased OR efficiency by sitting down with his staff and educating them about the surgeries and demonstrating surgical techniques used in prior cases, much like football teams do after the game to hone their skills. "We've reviewed videos and emphasized in our OR, like our office, the importance of our customer service," says Dr. Solomon.

Boston's Bonnie Henderson, MD, says in the clinic, proper staff education is the key to efficiency with preoperative cataract surgery patients. "Technicians must be aware of symptoms associated with cataracts. Additionally, if the technicians believe that a patient may need cataract surgery, they must know that all preoperative testing must be done before drops have been placed. This saves time for the patient and provides important information for the surgeon to discuss the possible lens choices. It also saves the patient from having to return for a separate visit to complete preoperative testing." Lastly, a knowledgeable technician can start the discussion of the type of IOLs that are available.

Her surgical scheduling staff must be knowledgeable with regards to preoperative preparation for surgery, answer patients' questions regarding the specifics of surgery and be able to address questions regarding postoperative activities and concerns.

Mark Rosenberg, CEO of Phoenix's Barnet Dulaney Perkins Eye Center, says that a majority of the efficiencies must be physician driven. "Surgeons need to know what the term 'efficient' means to them. Does it mean you are more profitable? Are you taking on more cases in the same period of time? Are you using less staff? The only way to get an OR efficient is if the surgeon takes ownership of the process and takes a hand in making it more efficient."

He says it is important for the surgeon to meet with his staff at the end of the day and review whether they have met their efficiency goals, and if not, discuss why. This is how to improve the process.

Setting the Tempo

Richard Ruckman, MD, of east Texas, feels that the greatest opportunity for efficiency — both in time and money — is the process of safely and efficiently moving a patient through the surgery center.

"The key is standardized communication," says Dr. Ruckman. "Everyone from check-in to postop has to have the same basic information. We use a summary sheet that lists the patients in the expected order using one of the preprinted name labels, which saves writing and reduces the chance of error."

Additional information on these sheets includes the type of IOL and additional procedures such as pterygium removal or LRI, which may require extra consent documents and instruments. Dr. Ruckman will also include information on how the patient did with the first eye, which may alert him to a need for extra sedation.

What is just as important is what is not on the sheet, says Dr. Ruckman. "The more that the information is transcribed, the more chance for error; therefore, we do not list IOL powers or axis of LRIs. Instead, at the 'time out,' we look at the original chart documents. The summary sheet is available in all areas of the ASC, and at the end of the day a master copy goes to billing to confirm that all charges for the day have been captured."

Uday Devgan, MD, a partner at the Specialty Surgical Center in Beverly Hills, schedules his more complex cases toward the end of the day so he doesn't feel rushed. "This relieves you of the pressure of feeling like you are falling behind."

He says it is very important to avoid the "rush" mindset and have more of an "efficiency" mindset. "What made me feel rushed in the beginning of my career was that I would schedule surgery from 7:30 am until 12:30 pm and then I had to rush to clinic by 1 pm to see patients. Now on the days that I operate, I only operate. There's no clinic, and the pressure is removed."

Time Signature

Dr. Henderson follows the adage "less is more" in surgery. "I believe in using just a few instruments and minimizing movements in and out of the eye. This makes the surgery more efficient and shortens the preparation — and hence the turnover time — between surgeries."

Dr. Devgan concurs. "Realizing one minute of time between cases is easier to achieve than saving one minute of time during a case. Rush equals complications. It is much easier to ask, 'How can I shave off time between cases'?"

Dr. Devgan says that more time is spent turning the OR over and getting the next patient in than is spent doing the cataract surgery. He has one room with three trays and sterilizers. "All my trays are identical," says Dr. Devgan. "So while I'm using one tray, one is sterilizing and one is cooling down. This way I am never waiting for the instruments."

His goal is to minimize everything. "My normal tray is 4×8 inches and holds five to six instruments, because that's all I need for a routine case. If it's a more complex case, I have everything available pre-sterilized in peel-packs in the OR."

If he uses one OR room, he can use two circulators. "The circulator gets the tables, drapes them and gets the instruments ready for the next procedure. The tables are on wheels, so with two tables and two scrubs you are ready to move on to the next case once the patient and the used table are moved out," says Dr. Devgan.

In Dr. Devgan's old ASC, he had one phaco machine to split between two OR rooms. The problem was he had to shut down the phaco machine and then restart it when he went into the next room. His solution: "I went to a store and bought a computer uninterruptible power supply (UPS) device with a battery and plugged the phaco into the UPS, which was plugged into the wall socket. This way when I unplugged the unit from the electrical socket, I still had 15 minutes of power left. I would just wheel it out and plug it in the next room — thus eliminating any down time. I also stored the battery in the base of the machine so that it didn't take up any space."

Robert Weinstock, MD, director of cataract and refractive surgery at The Eye Institute of West Florida, recommends having a primary scrub and a secondary scrub whose job is to help open and prepare for a case. Once the case begins, the secondary scrub should move to the next OR room and assist with that setup. Additionally, he says that all OR rooms should have backup and extra instruments in case one is dropped. In his operating rooms, extra viscoelastic and vitrectomy sets are also available. Lastly, he tries to keep all patients who are having their left eyes operated on in one room and all right eye cataract cases in another room.

Finely Tuned Instruments

There are other simple preoperative and intraoperative steps that can be taken with the OR setting and instruments to increase surgical efficiency as well.

Dr. Solomon uses surgical beds that convert from a chair to a bed to minimize moving his patients. Another benefit of this is that his patients are less intimidated by not having to move onto a stretcher.

Dr. Weinstock recommends that, in the preop holding area, patient's heads should be taped to the bed, the bed should be at the proper height and the patient should be double-checked for good dilation. He also has a primary lens, backup lens and sulcus lens ready and in a bin at the foot of the bed.

Dr. Devgan says that the average cataract surgeon in the U.S. (who has been in practice 10+ years) likely does about a 15-minute cataract surgery. "At the end of the day, it's not the speed of the case which makes the difference; rather, it is the outcome. Your patients would rather have you spend a few extra minutes to ensure a safe surgery with good results." He stresses that speed does not equal quality. "The goal should be efficiency — no wasted movements, no extra manipulations, minimizing phaco time/energy to protect the corneal endothelium, less inflammation and less trauma.' In Figure 1, Dr. Devgan shows the typical percentage breakdown for routine cataract surgery.

To increase efficiency intraoperatively, Dr. Devgan uses the following instruments: for the capsulorhexis, he does not use a cystotome. He has designed a forceps with sharp tips which can do it all in one step (open the capsule, grab the capsule edge and start the capsulorhexis). In addition, his fixation ring holds the eye still and also has markings in clock hours (30-degree segments) to act as a guide for LRIs. His chopper/multi-tool does all kinds of chopping, plus is designed to lift the incision, fixate the eye, dial in an IOL and act as an iris push-pull.

The Barnet Dulaney Perkins Eye Center performs approximately 12,000 cataract surgeries a year. Mr. Rosenberg says that Alcon's Infinity phaco machine has improved the efficiency of their OR by assisting surgeons in cutting through dense cataracts faster and has significantly decreased the number of vitrectomies performed in their OR. He emphasizes that to reach these numbers takes a combination of well-prepared charts and paperwork, an efficient staff and a highly skilled surgeon.

Mr. Rosenberg cautions, however, that there are a significant number of new guidelines being introduced by Medicare as well as infectious disease controls that will create inefficiencies in the OR. "In many ORs, techs will open up a custom pack while the surgeon is finishing up the previous case. Now you can't do that," says Mr. Rosenberg. "You can't open the new case until you've completely turned over the room. Initially, this will be an efficiency challenge that practices will need to adapt to."

Anesthesia — Allegro Style

The doctors interviewed for this article all seem to believe in using minimally invasive anesthesia. Dr. Solomon has moved to using oral sedation in his OR. He prefers oral sedation to IV because of the decreased prep time and says his patients have been very accepting of the change.

Dr. Henderson believes using topical anesthesia greatly improves patient outcomes and efficiency. "With topical anesthesia, there is no risk of hemorrhages, posterior pressure from the injected volume of anesthetic medication and no risk of postoperative ptosis," she says. "Also, topical anesthesia relieves the preoperative delays of waiting for the anesthesiologist to medicate the patient for the injection and of waiting for the injection to diffuse sufficiently before starting the surgery."

Dr. Ruckman provides all of his patients with IV access through a saline lock. He says that most of his patients will receive Versed in the preop area as this provides a consistent level of anxiolysis without excessive sedation. If additional sedation or pain relief is needed in the OR, the IV is immediately available. "This is actually a cost savings, since the saline lock is relatively inexpensive compared to stopping the rhythm of the ASC, even for a few minutes, to provide extra sedation to a patient," says Dr. Ruckman.

Dr. Devgan does not want his patients to be knocked out for long periods of time. "The less traumatic we can make the surgery the better, so we have switched to a very brief-acting anesthesia." He likes short-acting synthetic opioid analgesic drugs. This enables him to send his patients home more quickly.

Grace Notes

Dr. Solomon emphasizes the importance of treating patients appropriately. The staff reviews everything from how to greet patients to how to deliver instructions at postop. He says that this has increased patient satisfaction and helped with efficiency.

"Providing written postop instructions for patients and their postop medication treatments shortens the amount of time nursing staff needs to spend with patients," says Dr. Solomon. "These instructions include postop do's and don'ts, what to call us for, and what to expect. This helps better prepare patients, alleviate concerns and streamline things for the nursing staff."

Dr. Devgan says it is important to have great relationships with your patients, especially because the procedure is so short. "I hold my patient's hand before surgery and assure them that I am doing all the driving and all they need to do is relax. I don't give too many instructions and I talk to every patient before surgery. Our practice calls them later that day and I give every one of my patients my cell phone number. I find that I get very few calls, but this goes a long way in assuring them that I am available to meet their needs."

Devote some time and attention to adopting some of these OR pearls and efficiencies into your practice as they will help to ensure that you and your staff are performing optimally and providing your patients with the best care available. OM