Management Essentials

ASC Efficiency — A Real Production

By Farrell “Toby” Tyson, MD, FACS

An ASC should be synchronized to run like a choreographed dance. The performance has multiple acts, and requires the involvement of several talented individuals. Just like any well-run production, if executed properly, your operating room day should appear effortless to the untrained eye.

Casting

Assembling the proper talent doesn't occur overnight. As the star of your production, you need to surround yourself with the appropriate cast. Your OR manager has to be on the same page as you. He needs to understand that his importance is not based on the number of people he supervises, but with the outcomes and efficiency that his OR can produce. He needs to set the tone in the pre- and postop areas, as you will seldom be present in those areas.

Anesthesia providers can be a big bottleneck in performing cataract surgery. Most anesthesia providers come from the hospital environment where cases can last hours and turnover is not as important. An effective anesthesia provider is one who can be a force multiplier. He will help start IVs, take a leadership role in the preand postop area and not be afraid to push stretchers. If your provider feels his only job is anesthesia and paperwork, look elsewhere.

Upgrading your staff is a gradual process, but you will be well on the road to achieving your goals once your staff leaders have bought into your mission and work ethic. Remember, the OR environment is cramped and busy; you need good staff, not a lot of staff.

Scheduling appears in the first act of your cataract surgery day. This requires forethought. First, consider scheduling all of your right eyes first and all your left eyes following. This reduces the confusion of which eye is being operated on and you only have to change around the room once a day. Place all your complex cases at the end of the day so that you are not rushed and your normal patient flow is not upset. Timing of arrivals should be worked out based on how long it takes to perform a case and the speed of your autoclaves. These time studies may elucidate the need for more surgical trays and autoclaves so that the surgeon is not left waiting.

On With the Show

Act two is equated with the preoperative period. This needs to be as simplified as possible. Complete as much paperwork as possible prior to the surgical day. Also, keep the eyedrop regimens simple. Some surgeons give prescriptions for dilating and preop drops prior to surgery so the patient arrives dilated. Another good method is to use a compounding pharmacy to premix your dilating, NSAID and antibiotics into one bottle to simplify the dropping in the preop area.

Patients should be placed on a surgery stretcher from the start. This minimizes the relocating of patients. The patient should be connected to the monitor, which is mounted to the bed. This can be done with quick and reusable wrist clips. At this point, one of your anesthesia providers should be reviewing the patient's health history and also starting IVs and managing flow. This reduces the need for an extra RN in the preop area.

Act three is the surgery itself, and it is clearly the surgeon's responsibility. Confirming the lens, operative eye and patient name are all part of the “time out” that you must participate in. This does not mean that the patient cannot already be prepped and draped in anticipation of your presence. Surgical efficiency is reached by minimizing your time in the eye. That does not mean rushing. It does mean limiting the number of extraneous instruments and movements necessary to remove the cataract. One does not need two tubes of viscoelastic, a CTR and trypan blue to get through every case.

The surgeon should also be willing to play a lesser role when necessary. You may help out by draping a patient or moving the patient to the postop area. This helps efficiency and shows your staff that there is no job too little even for the surgeon.

The final act takes place in the postoperative area. Large amounts of information need to be conveyed in a short period of time here. This may be expedited by having preprinted instructions with pictures of the postop medication bottles and a schedule. This helps reduce confusion, as most patients will not remember everything that is discussed. Your choice of anesthesia can also delay discharge, causing a backup. Topical agents, blocks or propofol allow for quick discharge, whereas fentanyl can result in a longer postoperative stay.

Having a well-orchestrated surgery day not only reduces stress, error and fatigue, it will also help decrease staff turnover. Since we are unable to increase our insurance reimbursements, we must rely on increased efficiencies to have a successful run. OM

Farrell C. Tyson, MD, FACS, is a refractive cataract/glaucoma eye surgeon at the Cape Coral Eye Center in Florida. He may be reached at tysonfc@hotmail.com.