There’s been a lot of recent chatter about office-based surgery (OBS). As an educator, it feels only natural for me to share my beginning experiences regarding this addition to our practice. OBS is the safe integration of a cataract surgery suite into your clinic, offering improved efficiency over hospital and even ASC care. From consultation to follow-up, the entire process can be achieved in one convenient location, with as little as 750 extra square feet needed to make the transition.

Adding a cataract surgery suite to our clinic was a natural extension of the procedures we were already doing in the laser suite, which include excimer and femtosecond laser surgery, intracorneal ring segments and pterygium surgery. All of these are comfortably performed under topical anesthesia with an oral diazepam. Being able to offer lens-based procedures such as cataract surgery, refractive lens exchange and phakic intraocular lenses in a similarly comfortable setting for patients made sense. We enlisted the help of iOR Partners, a company dedicated to the development of turnkey OBS suites.

SUPPORT AND TRAINING

We chose iOR as our partner in creating our office-based surgical suite because of the company’s focus on and familiarity with ophthalmology. Instrumentation, sterilization practices and ventilation are the same as you would find in a hospital or ASC. The main difference is that you have complete control over which equipment and instrumentation you use, without having to go through the extensive approval process of a large center.

Our current staff were trained by the iOR team, who provided a targeted curriculum with a staged approach. For example, the technicians were given didactic training, followed by active observation, shadowing and RN-supervised intraoperative training. They were also trained in providing preoperative and postoperative counseling and preparation.

OF ANESTHESIA AND A SOOTHING ENVIRONMENT

Currently, we limit our cases to Class A anesthesia, which includes oral and topical anesthetics, but monitored IV Class B anesthesia, which utilizes anesthesia support and an RN, can also be administered in a clinical setting.

For the surgeon, it’s very important to keep in mind the power of “verbal anesthesia” and “set the stage” with a calm atmosphere to create an environment in which the patient is — and feels — safe. I have personally seen variations in IV sedation in which it is almost as if the patient did not have any anesthesia and therefore is stone-cold awake, to the other extreme where they are completely disinhibited and moving.

One oral diazepam, an optimized ambience and serene communication can be very effective without the downside of postoperative grogginess with extended recovery or intraoperative disinhibition. Furthermore, with Class A sedation, patients do not have to be without food (NPO) prior to surgery. If the oral diazepam is not sufficient, we administer a sublingual MKO Melt (Imprimis Rx, Harrow Health Inc.), which consists of 3 mg of midazolam, 25 mg of ketamine hydrochloride and 2 mg of ondansetron.

Our staff create a very soothing environment to support oral sedation. A calm preoperative experience maintains tranquility and cooperation during the procedure. This can be accomplished in a quiet, peaceful and supportive atmosphere (including how we, as a team, communicate with each other).

In our clinic, we play classical music, though we are willing to modify our choice to suit the patient; however, we find that a lower volume of music is important to prevent overstimulation. Muddana et al’s study published in April 2021 supports the impact of music on reducing anxiety during phacoemulsification cataract surgery. Blood pressure and self-reported anxiety were both reduced in the patients exposed to music, pre-, peri- and postoperatively.

Designing an office-based surgery suite

by Yair Keshet

For ophthalmologists considering adding an office-based surgery (OBS) suite to their clinics, the outlook is bright to pursue what may have once seemed a moonshot vision. The cost of building an OBS is significantly less than an ASC due to a lower level of complexity and can be implemented in a fraction of the time; in our experience, an OBS may take 6 months to a year, while an ASC will take closer to 18 months to 24 months from inception. Still, an OBS requires expertise to do it right.

“It is critical to have a deep understanding of the space requirements, surgical equipment, staff training, accreditation, the entire billing process and how to set up efficient processes,” says Tony Burns, co-founder of iOR Partners, a company that develops ophthalmic OBS suites. “It all starts with space planning and design to ensure it is set up with the right accreditation requirements, safety standards and compliance protocols for implementation and long-term success.”

With the right planning and design, OBS can provide an optimal surgical experience for the patient, surgeon and staff.

FOR THE PATIENT

In order to build a reputation and brand that reflects their standard of care, ophthalmologists invest significant resources to create a comfortable environment in a convenient location. An OBS can be designed as part and parcel of the environment the physician has cultivated for their patients. From consultation to post-op, physicians want a positive and cohesive patient experience, which means every decision in the design phase is mindful of how the space is perceived and inhabited.

Controlling and calibrating the mood of the preop area and operating room to comfort the patient is a critical component in OBS design. The furnishings, artwork, daylight, artificial lighting, finishes, HVAC and more can be selected to increase the comfort level of patients, which in turn has a significant affect on their decision-making process on whether to proceed with a recommended surgery. Access to views, music, soothing colors, wood tones or other design details have been shown to lower anxiety before surgery, according to research by Laursen et al, Ni et al and Augustin et al.

FOR THE SURGEON AND STAFF

Designing an OBS suite gives the surgeon the opportunity to tailor the operating space to their own needs and preferences. This should be a highly collaborative process between the qualified design professional and the surgeon and consider the needs of all associated staff. A design professional will typically ask at the outset:

• What instruments are stocked
• Where instruments are kept
• What type of lighting is preferred
• What the physician wants the patient to hear and see
• Where and how operating physicians and patients enter and leave the surgical suite
• What is the ideal postoperative discharge — one that allows for patient privacy and comfort
• Whether the practice needs a connected office or an entirely separate lobby desk and waiting area

Of course, ophthalmic-specific accreditation requirements must be met, but they do not prescribe the exact makeup of the space or every last detail. OBS goes beyond the safety requirement to provide the optimal environment for the surgeon, staff and patient.

FOR ACCREDITATION

An OBS suite functions under the same governing body structure as an ASC. Guidelines for operational procedures, record keeping, reporting, emergency care, required spaces, supplies and equipment must be considered during the design process. Operating rooms are defined by categories largely relating to the type of anesthesia used — Class A, B and C — all of which have different levels of standards. While ASCs must adhere to accreditation standards across multiple specialties, some standards do not apply to ophthalmic surgery. An OBS suite can be right-sized for the specific procedures being performed, which makes it much less expensive to build and occupies less leased or purchased space.

In addition to national regulations, OBS has to follow building code, fire code, state and local codes, plus CDC and OSHA operating requirements. The design professional will need to understand all of the above standards and their intricacies and relations.

ADDITIONAL CONSIDERATIONS

When considering OBS for your practice, start by answering the following questions:

• Do I have the space? At minimum, 750 square feet is required for a Class B operating suite. Space that is unencumbered by structural columns, piping or other building services is best, but a room that is at least 15 feet wide and longer in length meets the requirement. Feasibility will depend on the available space’s relation to entrances, adjacent medical suite offices, available plumbing, heating and cooling and proximity to exterior walls.
• How long will it take? From initial feasibility to completion is a process that might take 3 to 6 months, but complications can certainly add time.
• How much will it cost? Urban locations are typically more expensive to build out. We typically find that OBS fitout can cost between $90 and $150 per square foot.
• Where can I learn more? A good first place to check on the feasibility is with your state’s department of health. Different states have varied laws on the outpatient environment, so it is best to work with an expert in ophthalmic OBS suites.

For doctors thinking about expanding their offices for OBS, now may be an ideal time to act. The future of OBS is bright, as technological improvements continue to mean that more advanced procedures can increasingly be handled by smaller facilities with greater success and equal or better safety to other outpatient options. To determine if OBS is feasible for your practice, gaining a more complete understanding of the certification process, state laws, the logistics of billing and working closely with a design professional versed in these issues are the right first steps.

Yair Keshet is a registered architect in New York and Pennsylvania and is a co-founding principal at Lovett Keshet Studio, a firm based in Gladwyne, Pa., that delivers medical office and OBS suite design services among other specialties.

PATIENT SELECTION

From a patient’s perspective, the greatest barriers to undergoing surgery are fear and access. OBS addresses these barriers and many others. For example, healthy patients don’t necessarily need formal medical consultations, including labs, electrocardiograms and chest radiography prior to cataract surgery. These tasks require a lot of time and energy from the patient, particularly if their situation does not call for that degree of medical testing. In addition, with access to OBS, patients don’t have to travel to a medical center or ASC.

Of course, patient care is never one-size-fits-all. In general, the patients best suited to OBS are American Society of Anesthesiologists I and II — meaning healthy or with only mild systemic disease, respectively. I would also recommend screening out patients who are uncomfortable at the slit-lamp in the exam room (ie, “squeezers”) or those who have anxious personalities. They need to be able to cope with only oral sedation. For early OBS cases, it may also be prudent to select cataracts that are not complex.

SAFETY

In 2016, Ianchulev et al published a large retrospective study of more than 21,000 cataract surgeries on over 13,000 patients, average age of approximately 73 years, at a Kaiser OBS office in Denver from 2011 to 2014. The investigators found that only 0.55% of cases experienced intraoperative adverse events (AEs). Postoperative AEs included corneal edema (0.53%), retinal tear or detachment (0.14%) and secondary surgical intervention (0.70%) within 6 months.

The rate of these AEs are in line with other studies on cataract surgery performed in traditional settings such as the ASC/hospital. The investigators found no cases of endophthalmitis.

With regard to emergencies, iOR trained our staff in emergency protocols. If a complication requiring a vitrectomy occurs, such as a dropped lens, we have relationships with vitreoretinal surgeons nearby and can stage the procedure accordingly.

FINANCIAL IMPACT

Patient safety and quality of care always come first, of course. But a definite benefit of OBS over an ASC is autonomy. You can schedule your surgeries in a manner that suits you, even doing consultations and operations on the same day. OBS is covered by Medicare, Medicare Advantage and commercial insurance.

An additional benefit: We skip the added expenditure of transit to and from the OR, delay and block-time, allowing for greater efficiency.

CONCLUSION

OBS has offered my patients and myself the freedom to make a choice about how we want to engage in eye surgery. As the population ages and the demand for cataract surgery increases, we can now accommodate carefully screened patients efficiently in a calm, serene atmosphere within our own clinic. OM

About the Author

Michelle K. Rhee, MD, practices at New York Eye Specialists, New York City, and is the medical director at the Eye-Bank for Sight Restoration and associate clinical professor at Icahn School of Medicine at Mount Sinai, New York City. Email her at drmichellerhee@gmail.com.

Dr. Rhee reports no relevant financial disclosures.