The ASC Insider

Smart Steps to Take When Adding Retina to Your ASC

A special series sponsored by Alcon

Adding retina to an ASC can be done efficiently and cost effectively if you plan ahead, says Vera Watkins, RN, CNOR, a surgical/clinical nurse specialist and primary scrub nurse at Retina Specialty Institute in Florida.

Pack Light

Ms. Watkins has more than 6 years of experience working in a retina ASC and 20 years of OR experience. Here, she shares her insights to help increase a center's efficiency and improve daily operations.

Keeping costs in check while continuing to provide excellent patient care is one of the most important aspects of her job. Therefore, Ms. Watkins recommends developing a surgical pack with just the bare necessities. "Only include items that are used in every case. When scheduling a case, keep in mind what special supplies need to be opened and make a list of them. Be careful to open only what you need and open the right instrument the first time," she says.

In her ASC, Andrews Institute Surgical Center, the doctor lists the special instrumentation necessary for each case on a patient preference card, as well as the office scheduling form. Ms. Watkins arrives an hour before surgeries are scheduled to begin to review cases with the ASC eye coordinator. "Our eye coordinator will have taken my patient list and pulled the cases ahead of my arrival. She also pulls the packs along with the special items listed on the sheet. When I arrive, we compare my notes to what she has done. We do this to avoid finding ourselves in the middle of a case with people scrambling.

"I also bring the office notes and the OCT scans with me. This way, the surgeon can review the OCT results and focus areas," says Ms. Watkins.

In addition, the eye coordinator has a bin for each patient with a pack in it and anything special from the patient's preference card. Items that are a "maybe" aren't opened until requested during surgery.

Under special equipment, Watkins lists whether the pack needed is a 23- or 25-gauge. "All of our surgeries are small gauge and typically sutureless. We have a pack with the basic drapes and gowns, and the exact number of needles and syringes that we use for ever y case," she says. This also helps to keep inventory low.

Ms. Watkins is a proponent of disposables in the ASC. "I know it might seem less expensive to have reusable supplies, but when you start using the more intricate 23- and 25-gauge instruments, they don't hold up very well and they're difficult to clean. When you open a new forceps for each procedure, you know it's clean and will work perfectly. You can also choose from a wider variety of instruments because you don't need to purchase backups."

Teamwork

"The thing about efficiency is that it's not about how fast you are. It's about preparation and communication as a team," says Watkins. She says most freestanding ophthalmology centers already are team focused and this will aid them in the transition when adding retina.

Watkins recommends that you don't throw a new hire into surgery until a senior team member has mentored them. Staff education and development is a key component.

"The biggest key to efficiency in retina surgery is for every staff member to understand the procedure completely," Ms. Watkins says. "The staff needs to be familiar with the disease process they're treating — that's how they know which instruments to pull. This is especially important with retina surgery. The disease makes a difference in how you set up the machinery, and determines the instruments that will be used during the procedure."

Running the OR

In order to maintain an efficient OR, each team member's role must be clearly defined — in here, there's no room for surprises. "When we schedule a patient in the office, we have a scheduling form for the ASC. It lists the patient's name and includes the CPT and ICD9 codes, so that billing knows exactly what we're planning to do," says Ms. Watkins. "They see the diagnosis and don't have to figure it out from the ops sheet. We write out the procedure and diagnosis as well."

She explains that coding reduces the risk of errors. In addition, the insurance for the patient is verified at the office as well as the surgery center.

Patients arrive 90 minutes prior to surgery. "You have to be very realistic about the time you schedule for a case. For instance, I know we can turn a case over, on average, in 10 minutes and on average we can do a case every 45 minutes," says Watkins. The ASC has one OR and the average caseload is 12 procedures per day.

"If you're considering adding retina to a surgery center, it's cost prohibitive to duplicate high-end equipment such as vitrectomy machines and scopes. If you have your team working the way it should, you can efficiently turn a room over, which means that one OR room works just fine," says Watkins.

She recommends having two nurses at the beginning of each case. "You need someone to help open the case and get your machinery set up and another person prepping the patient," explains Watkins. Five minutes before each case is completed, Ms. Watkins calls for turnover help. The staff members take instruments to the decontamination room; they clean the room and help prep the next case.

Nurses alternate cases so they never cause a delay during the OR turnover. They communicate by radio to keep the anesthesiologist and perioperative holding area abreast of the progression and status of the case. In this way, everyone is tuned in to what's going on with the patient, explains Watkins.

Although many doctors perform their own blocks, Andrews Institute uses an anesthesiologist. "We call the anesthesiologist 5 minutes before the surgeon is finished with a procedure and say it's time to block the next patient. This way, patients have the full effect of the block during the operation but it wears off in time so that when they wake up from sedation, they're cooperative when you get them in the postop room."

Another OR recommendation from Ms. Watkins is to schedule all left eye procedures first and right eyes second — or vice versa. "The less equipment you have to move the better," she explains. "I have a table, a waste can and sharps on both sides of the room and a duplicate stool. The laser is part of the Constellation, so that's a piece of equipment we don't have to move. It's nice if the microscope is ceiling-mounted, so it doesn't need to be moved."

Don't Bite Off More Than you Can Chew

"Starting out, I recommend that you avoid cases such as severe traction detachments or PVR retinal detachments," states Ms. Watkins. "They're complicated, take a long time to perform and require expensive items such as silicone oil and perfluorocarbons. I would recommend scheduling these procedures at the hospital. Instead, schedule epiretinal membranes, macular holes and retinal detachment repairs for the ASC. Let the staff get comfortable with these types of cases before moving on to the more difficult ones."

The bottom line? "Remember that you're part of a team. You must ask yourself every day, how well are we communicating with each other? Have we formed a plan for the day? If the answer is yes, you're on your way to running a successful ASC," concludes Watkins.