Improving Life in the ASC

A leader shares 20 tips to make outpatient surgery faster, safer and less stressful.

BY LARRY E. PATTERSON, MD

Ambulatory surgical centers grow in importance to ophthalmologists each year, and they're going to be especially critical to our survival under any sort of healthcare reform that gets passed. Since the clearly stated goal of reform proposals is to bring down costs, we'll need to find more and more efficiencies in the ASC to boost their profitability, or at least to hold the line when the reimbursement cuts inevitably arrive.

As president of the Outpatient Ophthalmic Surgery Society (OOSS), I'm privileged to participate in many programs that aim to help our members do exactly that. Earlier this year, the society hosted a symposium in Orlando that brought together a diverse group of ASC administrators, physicians, techs, nurses and other stakeholders. In this issue, we'll kick off a three-part series of highlights from the symposium, which was made possible by the support of Alcon Surgical.

We begin with a potpourri of things you can do, in and out of the ASC, to improve its performance. Virtually everything in the advice that follows are things I've been doing for more than 10 years, so these are time-tested pearls. Many of these may already be staples of your own ASC, but there's usually another tweak or point of view that can make them a little more helpful.

1. Have a surgery coordinator. Let's start with one of the most basic, but most critical, pearls. Unless you're just doing a really small volume of cases, you need someone to take care of all the details so that you can focus just on seeing patients and doing surgery. This person is your liaison between the ASC and the patient/caregivers, and is entrusted with responsibility to get everyone — doctor, support staff, patient, family members — where they need to be, when they need to be there.

2. Turn patients into ASC advocates. ASCs are still a fairly new concept to patients, since the public's perception has long held that surgery happens at a hospital, end of story. When explaining our surgical facility to patients, I stress three main advantages: “First of all, it's a whole lot less expensive,” I'll tell them. “It's basically 75% more expensive to have your surgery done in a hospital.” The second point is the greater convenience of an ASC for everyone involved. “If you go to the hospital,” I explain, “you've got to have a day of pre-registration, and that can take hours, and there's often lab work that might not be needed that adds to the delay.”

The final thing I tell them is how much safer an ASC procedure is. “The lady in the bed next to you is also having a cataract, not her infected gall bladder removed,” I'll say. And then I'll explain that we have a veteran staff of eye doctors and nurses especially trained to handle any emergency, and that having the same surgical staff work together day in and day out is better than a hospital staff of floaters who don't gain the same level of shared experience and teamwork.

3. Personalize the paperwork. No one likes to feel anonymous, least of all surgical patients. So we use the merge function of Microsoft Word and other programs to customize all our patient education handouts. My surgery coordinator puts in the patient's name, age, eye we're operating on, and a few details about the case. Once she puts those in, about 15 pages are generated, including the informed consent documents with the patient's name at the bottom. Everything is personalized for them. Even my operative report is already pre-printed with as much information as possible, with check boxes to be marked off at the conclusion of the case.

4. Personalize the schedule. The surgical schedule should also be as personalized as possible, with notes about the case that everyone needs to know. For example, maybe the patient had some issues during their first procedure. They were too cold, or the lid speculum really hurt, or any sort of issue that we can know so that we're all on the same page. There are a lot of people — the front office person, the nurses in PACU, the circulating RN, the CRNAs, the doctors, and the surgery coordinators. If everyone has the same schedule that tells us that Miss Sally Sue Jo Brown is having this issue, or we're concerned about that problem, we're all on the same page.

5. Schedule like eyes together. Most of us are now operating temporally, so we usually switch the room around when we go from right-eye to left-eye procedures. Set your schedule accordingly. You may want to start at the beginning of the day's cases and do all right eyes, and then do left eyes for a while. We usually start in the middle of the schedule and put a right and a left eye next to each other, and then just proceed either way from there. It doesn't always work out perfectly, but for the most part we do a bunch of right eyes and then we do a bunch of left eyes, then switch again as needed.

6. Don't schedule operating times. It seems logical to schedule procedures and tell patients exactly when their surgery will be, right? Greater precision is a noble goal. You can do that internally, but don't broadcast it to the patient. When you start trying to commit to when they're supposed to be there and when you'll be operating, you're likely to create anxiety because if you fall behind they think something's wrong. Even if you're ahead of time, they may think something's wrong.

All the patient needs to know is what time to arrive. If they ask what time we'll be operating, we say, “Just as soon as we have everything ready for you.” Give them a specific cut-off time for breakfast. We used to just say “NPO after midnight,” but if the anesthetist says they can go eight hours, then tell them. We have people get up at 3:00 a.m. so they can eat breakfast because they're not having surgery until 11 o'clock the next morning. Believe it or not, this is a huge thing with some people.

7. Do difficult cases last. I can't emphasize this too much. A lot of doctors say, “I want to do the bad ones first to get them over with.” That's only going to mess up your whole day because you don't know if it's going to be a 10-minute difficult case, or an hour-and-a-half difficult case. You have just made the whole staff and all the patients in the waiting room wonder, “What's wrong?“ You've put everyone under a lot of unnecessary stress. If you say, “Well, I'm just too tired at the end of the day to do that difficult case,” then cut back on your caseload. Something's wrong. I do 20 to 25 cases in a typical day, and I'm fine by the end to tackle the challenging case. If you're not, don't do so many.

8. Review the charts. Sit down with your coordinator some time before the day of surgery with the stack of surgical charts and go through them one by one. It takes me about an hour or so to go through 20 charts just one last time. Make sure you've got the right implant. Make sure you've got the right eye. It's worth it. About once a month when we're going through this review, we see something that makes us say, “Oh! That's really good we caught that. That was nice to know!” We also have a rather long checklist for each chart.

9. Operate on the stretcher. If you're not doing this, you really want an ASC where your stretcher is the operating table. When I was first doing this hardly anyone else was, and now it's becoming commonplace. We even put the monitor on the top of the footplate at the end of the bed, which is really nice. You just hook them up once. We don't have any monitors in our OR at all. Why? Because they're always on the bed with the patient. We have four beds and four monitors.

10. Use oral sedation. This is always fun for generating controversy: we hardly ever use IVs. Probably about one out of 25 patients get an IV. Our CRNAs love it. They encourage it. They would love to try to talk more doctors into doing it. Five to 10 mg of liquid sublingual Versed works really well. If you've got someone who is really nervous, put in an IV. It's not a problem. On rare occasions, we have someone who's just not doing well during surgery, so we just stop the surgery and start an IV. But that's really rare, only about once every few years.

11. Use drug cocktails. More and more surgeons are administering a prepared mixture of different drops together. Take your dilating agents, NSAIDs and antibiotics and mix them all up, drop in a sponge, and then use forceps to place it in the cul de sac. We usually use the lower cul de sac now. You'll get a stronger dilation that takes effect much faster that way. And the staff is not going around constantly putting in drops. It's just a one-time task.

12. Prep in the PACU. Right before the patient goes into surgery, we put in one more drop of proparacaine so that the betadine won't sting. We put the betadine in before they go back because betadine takes time to work and we've all come to the agreement that it's the most important thing we can do to avoid infection. So, we do that ahead of time. We then use a drop of viscous tetracaine, which is so much easier than lido-caine jelly or the other drops. After you've tried this once, your nurses won't want to do anything else. The actual skin prep, however, is still done in the OR, immediately before draping the patient.

13. Expect the unexpected. We get all our instruments and supplies ready ahead of time for the morning or the afternoon series, including an extra cart that's got the “just in case” stuff also, including our special vitrectomy tray. I'd like to say I don't personally do any vitrectomies, but I'm human and I've got to assume that this is the day I might need to do one. So I have everything ready that I'll need to do a pars plana vitrectomy. That really blows people away sometimes, because I have no formal retina training. “What's he doing — a pars plana vitrectomy?” I assure you, Skip Nichamin convinced me of this years ago: it's safer to do a pars plana vitrectomy than an anterior vitrectomy in these circumstances. Regardless, we have everything ready to go so that if we do encounter vitreous, it's not a crisis.

14. Streamline your trays. My nurses came up with the idea to use just one tray for prepping the patient. In this tray, we have two containers: a sterile set of betadine-soaked 4x4s and a set of dry ones. She puts one glove on one hand, grabs a couple wet 4x4s, preps the patient really well, then throws that aside, takes the dry one off the top, dries the skin, puts the lid back on the tray and uses the same set-up all day long. I guarantee you, there's absolutely no reason to believe this is not safe. We've been doing it for years and never had a problem, and you're not wasting so much stuff. It's not just a cost consideration, it's the environment too. I hate procedures that require opening up massive prep trays multiple times throughout the day. This works really well and your nurses will love it.

We use the same philosophy for all our trays: streamline them as much as possible. We use just what we need on each case. They're very, very small. There are a few additional things we might need, and if we do, we've got them peel-packed and organized and can grab them as needed. We have an entire fourth tray that's peel-packed individually, so if we drop something we needed and only had one of, like a phaco handpiece, we've got a spare ready to go. We alternate between tabletop autoclaves. We've got custom packs that only have what we need. We have one pack of Weck-cels per case. If you have two packs because you might need them sometime, that's just wasteful.

15. Use alcohol foam scrub. A full 10-minute scrub between each case doesn't improve sterilization any, it just slows you down. After our first scrub, we use alcohol foam all day. It's easier, it's cheaper, it's quicker and it works really well. You don't rub your hands raw all day long. I was taught this by a general surgeon over 20 years ago — after a couple of minutes with a scrub brush, you are just removing deeper layers of your own epithelium.

16. Play music. Whether you pick something soothing or something energetic, have some music in the background to lighten the mood. We now have XM radio, which is great because we can go to different channels all day long, plus it's commercial free to keep distractions to a minimum. The only sad thing I'm finding is that as I get older, my cataract patients are beginning to enjoy the same music I enjoy.

17. Use Weck-assisted draping. This is a neat way to pull the eyelid back, by using a Weck-cel, then stick the drape down to the exposed lid margins and lashes. I then cut a slit in the drape to get to the eye. You can do it by yourself. You don't need anyone else to help you. We have an oxygen tube on the stretcher that supports the drape off of the patient's face, while simultaneously providing fresh oxygen.

18. Allow family viewing. We have a viewing room for the family that allows them to look into the surgical suite, which is a really nice public relations boost for the practice. It involves the patient's family in the process and takes away their anxiety. They can see how efficiently the case is proceeding and how confidently our surgical staff functions. Most viewers are extremely impressed with what they've seen.

19. Begin turnover during the case. A lot of people wait until the end of the case to begin turnover. We begin it right during the case, and as soon as the implant has been inserted, we clear the back table, place the pack on it for the next case, and it just sits there until we get ready to go. As soon as we finish — I mean, as soon as we finish — the stretcher starts to move, and we're removing the tape and things like that. The doctor can be part of the team. You can help with room turnover, by pushing the patient stretcher, changing the foot pedals from the right to the left, whatever it takes.

The coordinator assists in turning over the room, but the most important thing in all of this is that the room does not have to be completely set up. You don't have to have the scrub nurse standing there with her hands together saying, “Okay, now I'm ready.” We never have things completely ready. When the patient comes into the room, we're still getting set up. If we're not set up when I'm ready, then we'll wait a minute or two to catch up but it doesn't make sense to waste time otherwise.

20. Be open to new ideas. Never assume your idea is the right way. We had a CRNA a couple years ago who was shocked because we asked him, “Hey, what do you think about how we're doing this? You got any ideas?” He'd never been asked that before. Not all the good ideas should come from you. OM

Larry Patterson, MD, practices in Crossville, Tenn. He is the President of OOSS and the Chief Medical Editor of Ophthalmology Management He can be reached at larryp@ecotn.com