The path to postoperative success is paved long before a patient enters your surgery center. It begins in the clinic during the patient’s evaluation and education, when expectations and possibilities are addressed and the foundation for success — universally defined as happy patients — is laid.

“A happy patient is one whose expectations have been met. So, I first want to identify what the patient is hoping to achieve with surgery,” explains Cathleen M. McCabe, MD, Bradenton, FL.

“Then, I review the tests we’ve performed, evaluate the health of the eye, and determine what is medically appropriate for that patient,” she continues. “Next, and most importantly, I review the patient’s desires along with my clinical findings, and we agree on realistic goals. Success is when we reach those goals.”

Although the path to success can be summarized succinctly, the process is complex and is constantly being refined through experience and advancements in technology. At its core is good communication.

Keep the Lines of Communication Open

“Good communication all the way down the line — between patient and staff, surgeon and staff, surgeon and patient — is a priority,” Bret L. Fisher, MD, of Panama City, FL, says. He adds that documentation of these conversations is equally important.

“Capturing key information accurately requires good internal processes, from the intake form completed by the patient, to the information sheet filled out by a staff member with the patient’s input, to the surgeon’s notes, detailing his or her discussion with the patient,” Dr. Fisher says. “All of that information is then passed to the surgery scheduler, who reconfirms it with the patient before forwarding it to the nursing staff at the surgery center. Information has to flow back and forth seamlessly in a consistent, well-rehearsed way.”

Consistency in messaging also is absolutely essential, Dr. McCabe says. “I’ve honed my conversation to be clear, precise, and logical. I know the exact words I use with patients to explain options and expectations.”

As technology becomes more sophisticated, the need for patients to clearly understand their options becomes more critical, particularly when patients have a preconception of what they want from their surgery. This education begins with the surgeon and is reinforced by staff and educational materials.

“For instance, with today’s lifestyle lenses that give patients a range of vision after cataract surgery, there’s a greater emphasis on retaining excellent distance vision, but there is a trade-off,” Dr. McCabe says. “Even though patients should be independent of eyeglasses for most daily activities, they likely will need reading glasses for some tasks that require good vision up close.

“I explain that to patients, our written material reflects that message, and our counselors use the exact same verbiage, as well. Our message is consistent throughout the patient’s experience.”

In addition to face-to-face discussions, Dr. McCabe also uses printed materials and visual aids to help patients understand and remember what can be an overwhelming amount of information.

“At their consultations, patients receive information about what to expect preoperatively, the day of surgery, and postoperatively,” Dr. McCabe says. “We also present this information in a booklet that we designed to be precise, thorough, and easily understood. The booklet shows pictures of the eye drops patients will be using and a flow chart table, so they can check off each drop as they instill it. The booklet also includes answers to frequently asked questions and a list of dos and don’ts.”

Verify, Verify, Verify

Once a patient enters the surgery center, the team springs into action and “verify” is the watchword, as they match information on the IOL calculation sheet to the patient and the lens.

“You can never verify enough,” says Dawn Clements, RN, CCRN, director of nursing at The Eye Center of North Florida in Panama City, FL. “We use the ORA with VerifEye Lynk (Alcon) and the Verion image-guided system (Alcon) at our facility, along with the LenSx femtosecond laser (Alcon). With the volume of patient data entered into those systems in the clinic, it’s up to those of us in the surgery center to do the final verification to ensure the best outcomes.”

Early in her tenure at The Eye Center of North Florida, Clements instituted a practice that continues today.

“The staff and I arrive about 2 hours before surgery is due to start, so I can review the charts and verify that we have all of the information and tools we need to do the job,” she says. “If there are inconsistencies, I have time to address them before the surgeon and the patients arrive. Although that sounds redundant, advocating for patients is what nursing is all about.”

Although all surgeons adhere to the accepted “time out” procedures to identify the correct patient, surgical site, and procedure, at Dr. McCabe’s surgery center, that process begins at check-in, when a wristband is placed on the same side as the eye that will undergo surgery.

In the preoperative area, the patient’s identifying information is confirmed with the chart, the wristband, and verbally with the patient, and the admitting nurse marks over the appropriate eye.

When Dr. McCabe greets the patient, she also marks over the eye. “That’s three times we’ve marked and confirmed which eye we’ll be operating on,” she says.

Use Visual Cues and Prompts

Surgery days that flow seamlessly are no accident, thanks to visual cues and prompts designed to inform surgeons and staff. Some are new twists on old standbys.

“As long as there have been surgeons, there have been preference cards that list each surgeon’s preferred instruments,” Dr. Fisher says. “That’s a good idea, but a better one is to take photographs of the trays with the instruments for each surgeon. Not only does it show the instruments, but also the order in which they should be arranged. These are valuable references for anyone who’s learning to scrub for surgery or learning to work with a new surgeon.”

In Dr. McCabe’s surgery center, a paper form at the foot of each bed lists all pertinent clinical information for the patient, the cataract, and the implant. The color of the paper form is a visual cue: white indicates patients who will have standard, manual cataract surgery; salmon indicates patients who will have femtosecond laser and a premium lens; and green indicates patients who are part of a clinical study.

Complementing simple, low-tech visual aids are modern electronics, such as video cameras that project images of the operating room or the surgical field onto monitors placed throughout the surgery center.

“At various stations in the surgery center, monitors show the surgery I’m currently performing, or they are switched over to the next operating room as it’s being prepared for the next surgery,” Dr. McCabe explains. “Everybody, whether they’re in the preoperative area, the femtosecond room, or either of our two operating rooms, can see exactly what’s happening and know what the next step is.”

Notes Dr. McCabe, “It’s almost like a ballet.” And, to keep her in step, staff members place signs on the doors of the ORs and the laser room to direct her to the next station. “I just keep rotating around all day to all of those stations in the proper order to accomplish the surgeries that we have scheduled.

“It’s a group effort,” Dr. McCabe continues. “The entire surgery day schedule is posted in a couple of places in the surgery center, so everyone knows where we are in the schedule and what needs to happen next. Those schedules are color-coded, with femtosecond laser cases circled in red, because those will require another step to keep the dance moving.”

Empower Your Staff

Eye surgery has become highly technical and data-driven, and surgeons and ASC staff must have access to all preoperative data, including the surgeon’s notes, on the day of surgery.

“I feel I’m doing the most accurate surgery of my life,” Dr. Fisher says. “But more than ever, I depend on the data generated preoperatively. Having the clinic chart available for reference throughout the process, including in the operating room, is important. If anyone — patient, staff, or surgeon — has a question, the surgeon’s notes are right there for verification.”

In addition, staff members are empowered to question any aspect of the surgical plan.

“At any point in our process, any staff member can flag a chart or a patient and ask for the surgeon’s input if something doesn’t seem to follow our processes,” Dr. Fisher says. “Those inquiries are never a bother or an imposition. We realize there are many opportunities for errors, and we want to minimize those.”

Aim for Precision

“Basically, anything that increases our ability to be more precise contributes to our success,” Dr. McCabe says. “The preoperative testing we perform, particularly to make sure the ocular surface is healthy, helps with the precision of our measurements. A digital marking system improves our ability to orient the eye and a toric lens. Using the femtosecond laser, in my opinion, allows for a high level of precision in executing the surgery, as does intraoperative aberrometry.”

Notes Dr. McCabe, “Precision is part of what enables us to have a predictable postoperative result. When our outcomes are predictable, we can reasonably set patient expectations.”

Monitor Outcomes

“We don’t always know intuitively how well we’re meeting expectations and achieving good outcomes,” explains Dr. McCabe.

“We tend to remember patients who are extremely happy and patients who are unhappy,” she continues, “but we don’t have a good way of monitoring and assessing everyone in the middle, unless we do the work of evaluating 3our outcomes.”

Regularly collecting and monitoring outcomes data confirms that post-op goals are being met and helps to evaluate the effectiveness of any changes made to the process.

“So that’s the final piece,” concludes Dr. McCabe, “circling back and understanding outcomes to see exactly how we’re doing, so we can identify problems and refine our processes further.” ■