OASC | SURGERY

Complications in the ASC

Advice to help avoid complications and how to handle them when they arise.

By Susan L. Worley, Contributing Editor

The best ophthalmic surgical teams are well aware that no amount of diligence or minute attention to detail can guarantee the avoidance of all surgical complications. Yet, developing and honing superior strategies for preventing and managing complications can go a long way toward improving outcomes.

Here, highly skilled surgeons and ASC administrative experts offer their advice on the best approaches to avoiding and handling complications in the surgical center.

Select the Proper Environment

Data from about 1,000 ophthalmic-specific ASCs in the United States suggest that procedures performed in these highly regulated environments keep getting safer. So when it comes to complications directly related to an ophthalmic procedure, most surgeons and surgical staff would prefer to handle these in a surgical center. However, administrators and surgical team members alike agree that systemic medical problems are always best addressed in hospitals.

“A hospital has more resources for addressing major medical complications that arise during surgery — that is, systemic medical complications unrelated to a particular ophthalmic procedure,” says Cathleen McCabe, MD, of The Eye Associates in Bradenton, Fla. “Obviously, any patient at risk for a major medical complication, such as heart attack or stroke, is more appropriately handled in a hospital setting.”

Steve Charles, MD, of the Charles Retina Institute in Tennessee agrees that medical complications, whenever possible, should be handled in a hospital.

“For ocular surgery complications, however, I prefer to be in an ASC environment,” says Dr. Charles, “because you have a full array of equipment at your disposal, a high degree of efficiency, and you tend to have staff members who are used to working with you and are better able to assist you in an emergency.”

Dr. Charles notes that though ASCs specialize in providing high-quality ophthalmic services in cost-effective, high-volume surgical environments, when it comes to controlling costs or increasing volume, ASCs must guard against being too aggressive, as sometimes cutting corners can result in disastrous scenarios.

“Let’s say a surgery center that is focused on controlling costs questions whether it really needs to have an MD anesthesiologist, and ultimately decides to have only nurse anesthetists. And suppose the same ASC decides to accept a particular patient because … well, more than a month has passed since that patient’s heart attack, and after all, the patient really wants to be at an ASC. That patient could wind up having a serious arrhythmia, and then the ASC would be in the position of coping with an emergency situation without a cardiologist or a cardiac unit, and without cardiac enzymes or other necessary resources.”

While experts know that it’s not possible to avoid 100% of systemic complications in an ASC, steps can be taken up front to ensure that patients undergo surgery in the proper environment.

“Pre-op screening phone calls are one of the best ways to ensure that patients undergo surgery in the proper environment,” says Regina Boore, RN, BSN, MS, CASC, a principal at Progressive Surgical Solutions, LLC. “During this pre-operative process, nurses review the history, physical and patient chart, and get on the phone with patients to verify all pertinent information, including current medications and co-morbidities. This is the time to screen for any recent developments that may have occurred since the patient was seen by the physician, or to identify any previously undiscovered problem that must be considered before the patient undergoes surgery.”

Tammy Rorer, RN, LHRM, VP of Accreditation and Regulatory Compliance with Ambulatory Strategies, Inc., who previously served as director of an ASC for 17 years, adds that patients also must undergo careful examination and clearance on the day of surgery.

“It’s not uncommon in an ASC to see patients who arrive on the day of surgery with symptoms or situations that ultimately disqualify them from having a procedure, and may require that they be transported for emergency care,” says Rorer. “We’ve seen patients come in short of breath, or complaining of recent chest pains or fatigue. In these cases, the surgeon and the rest of the team must determine the next appropriate step for the patient.”

Rarely, a medical emergency directly related to an ophthalmic procedure can arise during surgery. For example, a needle inadvertently placed in the optic nerve sheath during a retrobulbar injection can result in central anesthesia, says Dr. McCabe. Such an incident could cause a patient to stop breathing, or even lead to cardiac arrest or death. All ASCs, which are required to have an agreement with a nearby hospital to accept such patients on transfer, must have a well-rehearsed plan to address this situation.

“Surgical teams must be prepared to offer basic life and respiratory support until EMTs arrive to transport the patient,” says Dr. McCabe. She adds that this type of occurrence is rare, and most ophthalmic emergencies are optimally addressed in an ASC.

“Such a wide variety of procedures are performed in hospitals that they generally don’t have the breadth of equipment and depth of expertise in one small, specialized area that exists in an ASC. In an ophthalmic ASC, I have every tool necessary for eye care and I work with a team whose expertise is focused on eye care, whereas someone working in a hospital OR with me likely scrubbed the day before on an abdominal or orthopedic case. It’s also easier to bring new technology to an ASC setting and stay current with cutting edge technology because there are fewer competing interests for limited dollars.”

Guard Against Flaws in Thinking

As counterintuitive as it may seem, consistent success and low complication rates can pose a danger to surgeons and surgical staff, if a pattern of success begins to result in distorted thinking.

“A major danger to watch out for — and this applies to cataract surgery, transplant surgery and glaucoma procedures as well as to retina — is what I call 'the trap of the simple case,'” says Dr. Charles.

When any member of an ASC begins to refer to a procedure as “only a simple procedure” or “only a simple surgery,” notes Dr. Charles, that’s the first sign of trouble. These phrases get tossed around, for example, when a retina surgeon is encouraged to perform procedures in an ASC that’s primarily dedicated to cataract surgery, often in exchange for referrals.

“If the retina surgeon inquires about whether the ASC possesses the appropriate equipment, alarm bells should sound if and when the surgeon is reassured that he or she will only be asked to perform the simple cases — let’s say only the simple vitrectomy cases.”

“Inevitably,” says Dr. Charles, “the retina surgeon will begin to operate, remove the vitreous, and then suddenly discover a small retinal detachment, and end up asking the ASC for gas or laser to repair the retinal tear. That’s when the ASC will remind the surgeon that he or she was only engaged to perform simple cases — that the retina surgeon is in a cataract ASC, which isn’t equipped with laser or gas. That’s the trap of the simple case. If you’re going to perform vitrectomies, there’s no such thing as a simple case. You need to be prepared to have wide-angle visualization, endolaser photocoagulation, SF6, gas, and silicone oil. You need to have a full array of equipment for the most complicated case, even if it appears to be a simple case. I’ve fallen into this trap before, and all surgeons need to guard against it.”

Dr. Charles adds that surgeons and surgical staff likewise must guard against the related complacency trap.

“The CEO of a major airline made a wonderful point when he told me that one of his biggest potential problems was complacent pilots. I asked how his pilots could become complacent, and he said ‘because we have the best engineering, the best maintenance, and the best weather planning so these pilots just assume that everything is always going to go smoothly. Then, when we least expect it, there’s an unusual occurrence — say, an engine fire — and these guys have never seen one before.’

“The same thing can happen with surgery, so it’s important to always be prepared — even for things that only happen rarely.”

Maximize Timeouts & Check Lists

Timeouts and checklists, which Rorer refers to as “hard stops,” are critical safety measures that are indispensible when it comes to preventing the occurrence of complications.

“A timeout is when the entire surgical team — the surgeon, circulating nurse, anesthesia personnel, and surgical scrub — pauses,” says Rorer. “You want to make sure everyone agrees you have the correct patient, that each of you fully understands the procedure for which the patient has given consent, and that you’re performing the intended procedure on the correct site. This type of hard stop is a regulatory requirement because it is your last chance to stop and determine if everything is correct before you proceed.”

Rorer adds that while everyone participates in a timeout, nurses and administrators typically are responsible for making sure they happen.

“One of the reasons a timeout is always a priority is that so much of what we do is repetitious,” says Boore. “We’re always moving at a rapid pace and doing procedures of a relatively short duration. In a typical ophthalmic ASC, even one that includes glaucoma, retina, anterior segment and oculoplastics, the lion’s share of the center’s volume (typically 60% to 80%) is cataract driven. That means 60% to 80% of what you’re doing is essentially the same procedure with the same surgeons. You must stay vigilant when it comes to basic precautions, such as verifying surgical site ID. You can never rest on your laurels or get ahead of yourselves — there must be a constant emphasis not only on efficiency but also on precision.”

Although timeouts are universal, the focus of each one is always a single, unique patient.

“To ensure the safety of the patient,” says Dr. McCabe, “it’s essential to customize timeouts, to address any specific concerns or potential for complication. For example, it’s important to know if a patient is taking a medication that increases his risk for intraoperative floppy iris syndrome, or if the patient has loose zonules that were identified prior to surgery, or a history of another surgery — such as vitrectomy — that may make things move differently in the eye at the time of surgery.”

Just as indispensible as the customized timeout is the surgical checklist.

“Timeouts are standard for all surgeries, across the board — a routine part of the nursing ritual,” says Dr. Charles. “But to achieve optimum process control, the checklist is absolutely essential. Just as in the cockpit, it’s essential for crew resource management. As one person reads the checklist and a second person verifies items on the list, there is a verbal exchange and acknowledgement, a back and forth on each checklist item. This is a far more detailed process than occurs during a typical timeout. It’s about becoming completely familiar with every single detail about that patient. This process also underscores each team member’s role so no one ends up assuming a certain task is someone else’s responsibility.”

Strive for Coordination, Communication, and Continuity

Effective preparation for potential complications and unplanned procedures in an ASC involves repeated clarification of the role of each surgical team member, the use of tools and visual cues that facilitate a high level of communication, and a constant emphasis on skilled teamwork. These aims guide every activity in the ASC, beginning with the orientation of new surgeons.

“When you’re bringing a new surgeon into your center, the key is to establish a relationship between the surgeon and the center before the first day of surgery,” says Rorer. “You want to know what standard procedures the surgeon will be doing, and whether there will be anything new or varied that might require training the staff.”

“After we vet the qualifications of a new surgeon,” says Boore, “we make every effort to have him visit prior to a surgery day to meet the staff and communicate their preferences, as well as their practice patterns, and typical patients and procedures.”

Once team members become acquainted, they must develop methods for coordinating their activities and communicating critical information.

“There should be a huge emphasis on handoff communication, from the preoperative stage to intra-op to post-op,” says Boore. “The safety of the patient, at all times, lies in being able to verify critical elements of patient data and information. If a patient has specific allergies or a history that could pose certain risks, then that information must be communicated every step of the way during the surgical encounter. Visual cues, such as a sign that might hang on an IV poll to indicate that a patient is diabetic, can be an excellent way to help avoid a complication.”

“In our surgery center,” says Dr. McCabe, “we use special color-coded information sheets, which are located at the end of the patient’s bed, to further ensure patient safety. These sheets highlight important details. For example, patients scheduled to have femtosecond laser have orange sheets, while others have white sheets. Each sheet indicates the patient’s name, eye, intraocular lens, and any key points or special considerations that were discussed during a customized timeout. Any surgical team member can glance at the sheet at any time during surgery to obtain a quick, legible record of all critical information.”

Emergency kits that are clearly labeled for particular complications and conveniently located are essential.

“Once something happens,” says Dr. McCabe, “everyone’s blood pressure goes up, and it’s critical that everyone stay focused on the complication. You don’t want staff running around trying to locate needed items. For instance, if something is labeled as a vitrectomy kit, when a posterior capsule ruptures, you have all the tools you need to handle that complication.” She adds that careful inventory management, to ensure that items recently used by another surgeon have been replaced, is equally important.

In addition, technology that assists in communication can be a worth-while investment.

“I’ve found that having a camera that projects the view through the microscope onto screens in the operating room and at the nurses station is a valuable investment,” says Dr. McCabe. “It keeps everybody on the same page during the surgery. If an unusual situation arises, the camera can instantly communicate important needs, such as the need for additional viscoelastic or the need for assistance. It also helps stage patients who are coming up behind the patient undergoing surgery. Everyone is aware of a delay or the need to adjust the schedule.”

Every effort to improve communication leads to better teamwork.

“Some facilities start their day with a team huddle,” says Boore. “During the huddle, there’s typically a rundown of the patients. This is a good way to bring awareness to cases that are likely to be more complicated than others. It’s an opportunity to say ‘I’ll need an iris expander for this case.’ It brings the whole team together so everyone is on the same page.”

Engage in Regular Drills & Rehearsals

ASCs must operate with the understanding that ophthalmic complications — and consequently, unplanned procedures — are going to happen. Accordingly, well-prepared surgical teams understand the value of engaging in a wide range of drills and rehearsals.

“Just as important as fire drills and code blue drills are hands-on drills related to very particular surgical complications in the ophthalmic ASC,” says Rorer. “These should take place regularly and involve surgeons whenever possible. The drills should help each team member understand his role during an unplanned event, and should involve the use of whatever special equipment may be needed to address a particular complication.”

“Exercises involving mock emergency situations allow you to validate that your staff is prepared and fully understand their roles and responsibilities,” says Boore. “Administrators must ensure that all surgical team members know how to manage a particular emergency situation. Drills also should engage your anesthesia staff and surgeons whenever possible. Regular exercises should be devoted to, for example, making sure your crash cart is equipped and supplied to meet the most current Advanced Cardiac Life Support standards. Crash cart equipment also should undergo regular inspection and testing.”

Drills can help surgical team members prepare for every contingency, including the possible incapacitation of a staff member or surgeon. Typically an ASC follows a calendar of drills, many of which are required by Medicare or accrediting agencies, to ensure that all policies and procedures are covered.

Just as important as any drill or exercise, according to both Rorer and Boore, are the team discussions that take place afterward.

“It’s essential for team members to meet after a drill and critique their performance, with the goal of evaluating the drill’s effectiveness,” says Rorer. “This is the time to figure out what might need to be changed or adjusted to ensure that the team is best prepared for necessary action and to help ensure better outcomes.” ■