The pressure for high efficiency when performing cataract surgery has perhaps never been greater. As surgeons, we want to preserve and improve vision for as many patients as possible. In addition, we now face increased financial pressure to be efficient, as cuts to reimbursements for cataract surgery result in roughly $100 less per case starting this year.

In this article, I provide you tips and techniques that can increase your efficiency in cataract surgery with regard to staffing, paperwork, scheduling, equipment and more.

EFFICIENCY DOES NOT EQUAL SPEED

First, let’s be clear: Efficiency does not equal speed. That is, speed itself will not lead to efficiency. However, efficiency may very well lead to speed.

Efficient surgeons maintain or develop the highest-quality practice. They take the shortest amount of time possible but do not accept unnecessary risks. They actively look for ways to eliminate steps, reduce procedures to their essential elements and strive for an economy of motion, steps and supplies.

What’s more, efficient cataract surgeons look for consistency and repetition. Because most cataract surgeries are very similar, the surgeon should try to do things the exact same way every time. And efficient surgeons are prepared for times when they might need access to something, like an instrument, out of the ordinary.

STAFF AND SURGICAL COORDINATOR

During my surgery day, I handle an average of 20 to 25 cataract cases. Our surgery center is located on another floor in the same building as our office.

Our staff includes two front-office staff, a full-time RN director of nursing, three RNs on our surgery day, two certified registered nurse anesthetists and two scrub technicians.

But the role that perhaps is most critical for efficiency is that of surgical coordinator. This person does far more than schedule surgery. After I evaluate a patient in the office, the surgical coordinator performs a variety of steps to get the patient ready for surgery so that the next time I see the patient is on the patient’s surgical day.

The tasks she performs include preop testing, insurance precertification, discussing refractive lens options with the patient and IOL calculations (although I select the lens). She creates a list of all patients having surgery on that day and assembles all charts. Also, she acts as liaison with the surgery center, so that the center calls the surgical coordinator, not me, with any questions.

What’s more, the surgical coordinator stays in the operating room during surgeries and assists with turnover. She also makes preop and postop calls to the patients. All of this saves me a great deal of time — the surgery center almost never has to talk with me directly.

PREOP PAPERWORK

When it comes to paperwork, one time-saving option is the ability to generate a package of customized paperwork for the patient and the surgery center. In our case, we use the Microsoft Word merge function. Once set up, it is very quick to use for any patient.

This generates 19 pages of custom paperwork that includes the patient’s full name, age, allergies, operative eye, diagnosis and procedure and surgical dates and times. On the day of the patient’s surgical evaluation, the patient receives the informed consent form, allowing him or her to read it before surgery instead of inconveniently presenting it right before the procedure.

On the day before surgery, and preferably 2 or 3 days before surgery, all staff receive a printed schedule for the surgical day with information such as the patient’s name, type of surgery and IOL. It also contains any special information, such as the patient having gotten cold when we operated on the first eye, so we can have an extra blanket ready.

DO TOUGH CASES LAST

On my surgical days, we schedule our complicated cases last, at the end of the day. That might be counter to the idea of doing your complicated cases first, when you are fresh; however, there is a good reason for this tactic.

If you schedule a potentially complicated case at the start of the day, such as an IOL reposition or exchange, and the surgery takes longer than budgeted — perhaps much longer — you risk running far behind for the rest of the day. You and your staff are under stress, and your patients are backing up.

If you feel that you don’t have the stamina to do a full day of patients and then work on a complicated case, schedule that complicated surgery on a day by itself.

Another tip: Do like eyes together so you don’t have to reset the room between patients. Do five or 10 right eyes in a row, and then shift to a series of left eyes.

ROOM WITH A VIEW

One unique feature of our surgery center is our viewing room. From this room, family members can watch their loved one’s cataract surgery through a window and also on a TV screen that shows the procedure.

Permitting family members to watch the surgery not only instills confidence in our practice but also acts as a valuable marketing tool. If family members watch a cataract surgery on their loved one, there’s little doubt they’ll tell others about their experience and perhaps refer them to our practice for cataract surgery or other procedures.

 

 

EQUIP FOR EFFICIENCY

Choose and set up your equipment so that it facilitates efficiency. Here are some tips and techniques:

• Stretchers and recliners. Our practice uses four surgical stretchers and two recliners. Patients lie on the stretchers before surgery and then are rolled into the OR and rolled out after surgery to the same bay. Each stretcher has a footplate that holds a battery-powered monitor. This avoids hooking a patient to a wall monitor and then unhooking and rehooking the patient into another wall monitor in the OR. Nurses position patients’ heads before they are wheeled into the OR, avoiding excess repositioning in the OR. When all beds are filled, patients sit in the recliners until a bed opens. Staff can start some preop preparation like dilating drops while the patients sit in the recliners.
• Information sheet on IV pole. Because we use intravenous fluids in only 10% to 15% of patients, we rarely need to hang fluids or medications from the IV poles on the stretchers. Instead, we use those poles to attach information sheets. That way, everyone can see at a glance vital information such as patient name, age, operative eye, best-corrected vision and so forth. There may also be a notation that says “husband,” for instance, indicating that the husband will watch the surgery from our viewing room. (See “Room with a view”.)
• Medications. Our preop medication regimen includes sublingual midazolam (avoiding any need for an IV), proparacaine and a compounded one-bottle mixture of a dilating agent, NSAID and antibiotic drops. We also use a 5% solution of betadine and 2% tetracaine hydrochloride 0.5%.
• Emergency supplies. In the OR, we have a cart that holds supplies that might be needed in a pinch, such as extra viscoelastic, BSS and gloves. This avoids hunting for these items if an emergency occurs.
• Vitrectomy tray and supplies. Perhaps once a year, I need to perform an unplanned pars plana vitrectomy. It’s for just that complication that we keep a vitrectomy tray and supplies in the OR. Should we need the instruments, we do not have to locate them in some other room. We simply take care of the complication and move on.
• Cataract tray with individually peel-packed instruments. Along those same lines, if an instrument fails or I happen to drop it, in our OR we have an extra cataract tray with instruments that are individually peel-packed. Instead of opening a full cataract tray, you can immediately find just the instrument you need and proceed with the case.
• Extra instruments in file folders. In our OR, we have alphabetized hanging file folders in a plastic container. Each file folder contains extra peel-packed instruments that are not found in a routine cataract tray. Each folder has a tab that says the name of the instruments the file contains, such as cannulas or forceps. If I unexpectedly need an instrument, staff can go to the file folder and get it for me.
• Streamlined custom packs. Although custom packs are highly useful, limit them to contain only the items that you need on each and every case. Don’t include the “what ifs.” If you need an item that’s not in the pack, have it available in the OR and pull it only as needed.
• Alcohol foam scrub. After your initial scrub of the day, you simply can use alcohol foam scrub between cases — you don’t need to scrub at a sink again. This also applies to your scrub tech.

SPEND TIME ON TIMEOUT

If you think the surgical timeout is an efficiency killer, think again. This verbal confirmation prior to incision is a key to both patient safety and efficiency. The 10 or so seconds you spend on it can pay huge dividends.

In our practice, we use a quadruple timeout. It begins with the circulating nurse announcing the timeout. She states the patient’s name, operative eye and the IOL power and model. Second, I look at the sheet on the IV pole and confirm that information.

Third, the scrub technician looks at the implant’s package labeling. Fourth, the surgical coordinator checks the office chart on a computer in the OR. All four individuals have to confirm and agree. More than once, this process has caught a potential error.

QUICK TURNOVER

Another key to efficient cataract surgery is to begin turnover as you work on the current case. If you wait until the OR is completely set up, with the phacoemulsification machine primed and ready before you bring in the next patient, you will waste time and reduce efficiency.

In my OR, the staff uses a back table to set up for the case. Once I insert the IOL, the staff begins to clear that table and place wrapped items readied for the next patient. There is no need to wait for the surgery to be 100% complete before you begin preparing for the next patient.

In fact, I may still be removing the drape as the staff unlocks the stretcher and begins rolling it into the recovery area. If needed, I may help them roll the stretcher.

When we bring in the next patient, we lock the bed, prep and drape the patient and do our timeout. Then, I may make my incision and begin surgery. By then, the phacoemulsification machine is primed and tuned. If not, we simply wait. It’s better to occasionally wait instead of always having the room 100% ready to go before starting the next case.

POSTOP EFFICIENCY

Efficiency should extend into your postop procedures. Because our patients have been minimally sedated, they sit in our recovery area for only about 10 minutes — there is no need for them to remain longer. Postoperatively, we administer betadine, compounded NSAID and antibiotic drops and pilocarpine. We review postop instructions with the family and then send them to get the car as we bring the patient to the front door.

PROFICIENCY IS THE SECRET

For the greatest efficiency in cataract surgery, focus on proficiency, not speed. As you become even more expert at cataract surgery, you will reduce complications and make the most of each surgical day. OM

About the Author

Larry E. Patterson, MD, is a founding partner of Eye Centers of Tennessee and the chief medical editor of Ophthalmology Management. He is also an instrument-rated private pilot. Contact him at: larryp@ecotn.com.