As reimbursements for cataract surgery shrink and other economic factors impact our practices, we need to maximize surgical efficiency so our ASCs can thrive.

Device manufacturers continue to roll out advanced surgical technologies that optimize visual outcomes from refractive cataract surgery but also streamline coordination, patient flow and execution of procedures. They take our ASCs to a new level of efficiency.

In this article, I will highlight some of the technologies that we have implemented in our practice that have reduced treatment time, enhanced workflow and maximized productivity. I’ll also share the successful strategies we have in place to streamline our patient flow.

INNOVATIVE TECHNOLOGY

When we perform 50 procedures per day, the minutes we save add up quickly. By adding new technologies that shave time from these procedures, we can treat more patients each day — boosting revenue — or finish our day earlier and send staff home, which reduces staff costs.

One example of a recent addition we made that has paid immediate dividends in our practice is the ALLY Adaptive Cataract Treatment System (Lensar Inc.), which combines innovative imaging and a dual-pulse femtosecond laser in one unit. It has shortened the femtosecond portion of the cataract procedures from an average of 2.5 minutes to approximately 45 seconds. Its imaging system determines the lens density, quickly creating complex fragmentation patterns and incisions.

We keep the small, compact unit in the operating room, performing an entire femtosecond laser-assisted cataract procedure in one sterile environment. Therefore, we do not need to move the patient from room to room or even bed to bed for the femtosecond laser and phacoemulsification. It frees up a room and expedites patient flow.

In addition, ALLY integrates with a variety of biometers. We use it with the Cassini Corneal Shape Analyzer (i-Optics), IOLMaster 700 (Zeiss), OPD-Scan III (Nidek) or Aladdin system (Topcon Healthcare). Consequently, our multiple satellite clinics can run different systems without being restricted to one manufacturer.

The preoperative biometry feeds and drives the laser for iris registration to address cyclotorsion. It lays down limbal relaxing incisions in appropriate locations or places capsulorhexis tags for precise alignment of toric IOLs. These features save time — I do not need to perform additional diagnostic tests on a dedicated device to position the laser, and there’s no need to mark the eye before surgery. The data aligns approximately 97% of the time with my ORA intraoperative aberrometer (Alcon). Using the ORA as an error check increases our accuracy in achieving targeted outcomes and expedites cases, reducing the number of times needed to return to the operating room for touchups or revisions.

The miLOOP microinterventional lens fragmentation device from Zeiss is very complementary to the ALLY system. With this technology, I can efficiently pre-section a dense cataract, expending less energy in the eye and enabling quick removal of the cataract.^1,2 As a result, our case times are shorter and on average reduce phaco energy used by 34%. It also increases safety because the phaco energy is being used at the iris plane or above, so we are not close to the capsular bag. Because we use less energy, the corneas are clear, the patient heals faster, and visual recovery is quicker. This results in happier patients, leading to word-of-mouth recommendations and referrals from optometrists.

In addition, in a high-volume, fast-paced cataract surgery environment, instrument trays are turned over quickly. To increase our efficiency, we found it necessary to invest in autoclaves that can keep up by running a full cycle in a short amount of time. We have found larger autoclaves require longer cycle times because they heat a large reservoir of water to steam point. In contrast, newer autoclaves may have a gallon reservoir but only heat a cup of water to steam point to run the cycle. Therefore, cycles are completed more quickly. Without rapid sterilization, our ASC would require many more instrument trays.

STREAMLINING PATIENT FLOW

In addition to investing in technology, our practice has also employed successful strategies to streamline our patient flow, which I will discuss below.

Preoperative preparation

In the preoperative area, patients are already on stretchers with mounted anesthesia monitoring and the oxygen tank below. When the patient rolls into the operating room, the nasal cannula is already in place, with oxygen flowing, and the electrocardiogram is connected, so we’re not wasting time in the operating room setting up the patient. This is in contrast to having wall-mounted equipment in the pre/post-op area and operating rooms requiring multiple connecting and disconnecting of leads and air cannulas.

Operative setup

Many operating rooms rotate the positions of the microscope base, the phaco tower and the instrument table/stand based on which eye is being operated on. This can be a very time- and labor-intensive activity if it is happening several times a day. In our facility, after the patient has been positioned, the microscope base remains in the same location on one side of the bed. We place the phacoemulsification system at the head of the bed with the instrument table to the right of it. The only piece of equipment moving throughout the surgical day is the surgeon’s chair and operative pedals.

Strategic scheduling

We operate on all right eyes in the morning and left eyes in the afternoon, so we need to change the chair and pedals only once a day. In addition to maximizing efficiency, scheduling patients in this manner enhances safety. When patients arrive for surgery, we ask them which eye is being treated. If a patient expects surgery on the left eye in the morning, we know there’s a problem and can investigate it.

In contrast, when a practice uses one room for right eyes and another room for left eyes, if a patient is delayed, the surgical staff must wait for the correct room to be available for the next patient. Conversely, our system allows continuity even when the schedule is disrupted.

Optimizing staff

When hiring staff, we seek people who are eager to work as an active part of a team. For example, our anesthesia providers need to do whatever is necessary to keep our schedule on track, potentially helping to prep patients, wheeling patients where they need to go or performing other necessary tasks.

Our operating staff are mature veteran employees with meticulous, detail-oriented personalities who can multitask and provide care efficiently. It is a fine balancing act to find staff with all of those characteristics. We perform approximately six to eight cases per hour in two rooms in our fast-paced ASC. Some personality types may be comfortable in this environment, but others may be overwhelmed and function better elsewhere in the organization.

A carefully choreographed procedure may move quickly and appear effortless, but it is a symphony where everyone gets into a groove and becomes comfortable with the pace. In addition, when our staff finish the day at a reasonable time, it boosts their job satisfaction.

Displaying procedures on video

To keep all surgical staff members in sync during a case, we display procedures on video monitors installed in every room. Consequently, the scrub tech knows when to hand me instruments and the anesthesia provider knows whether to provide additional anesthesia as I proceed with a case. If the surgeon looking through the microscope is the only one who can see the procedure, staff do not know what is happening and it is harder for them to keep pace.

Training tech-savvy staff

Many of our scrub techs are also clinic techs, so they are very knowledgeable about both areas. They get to know patients during their workups and develop a personal connection with them.

We also believe in continual education in our practice and constantly learn new procedures and techniques. Because we consult with industry on FDA clinical trials, we are always using new technologies. When change is standard, it is not feared.

Our more experienced staff are always training newer staff. Even if we only need two scrub technicians, we always have at least four who are trained, so we have backup available.

Building an efficiency mindset from the top down

Physicians need to model an efficiency mindset in the operating room. For example, in some facilities where I have worked, physicians treated the operating room as a social environment, chatting and relaxing with their staff. However, they cannot turn over the operating room quickly to get to the next case. It also sends a message to the rest of the staff that this attitude is acceptable.

Physicians are free to operate as they choose, but we need to keep in mind that reimbursements for cataract surgery and 90 days of postoperative care continue to drop. To generate the revenue we require and operate a successful ASC, we need to maximize our day, work efficiently and perform clean surgery with outstanding outcomes. We do not want dissatisfied patients who return with complaints.

CONCLUSION

If ASCs do not take steps to make cataract surgeries more cost-effective, it will no longer make financial sense to perform them in an ASC. This is already occurring in some other ophthalmic specialties, where the time, effort and number of staff required for cases is becoming less viable unless centers can run multiple surgical suites and turn over rooms quickly enough.

I think we will see a paradigm shift in operating rooms. In addition to striving for high-quality outcomes, I think surgeons will increasingly emphasize time-efficient procedures. Staff members who enjoy that pace will remain, but those who do not will seek other career options. OM

REFERENCES

1. Ianchulev T, Chang DF, Koo E, et al. Microinterventionalendocapsular nucleus disassembly: novel technique and results of first-in-human randomised controlled study. Br J Ophthalmol. 2019;103:176-180.
2. Internal user survey, n=279, Iantech Data Analytics 20190708 PPT, data on file.

Farrell (Toby) Tyson, MD, FACS, practices with Tyson Eye, which has nine locations in southwest Florida. Disclosures: Dr. Tyson is a consultant for Alcon.