Times are changing in ophthalmic surgery. New techniques for cataract surgery have significantly decreased operating time, allowing for larger case volumes. In the last two years, increasing case volumes, and a desire to balance quality care with efficiency, motivated us to reconsider our ophthalmic anesthesia process.

The end result is a more streamlined process that allows us to comfortably turn over cataract cases every 15 minutes, while accommodating even our fastest ophthalmic surgeons. At the same time, we are confident that patients and ophthalmologists are satisfied with pain control and related issues. In fact, our new process optimizes ophthalmic anesthesia and still empowers us to tailor anesthesia to individual surgeons' needs.

Our process is easy to implement and centers around four key changes. You may find them useful for streamlining cataract procedures in your facility.

1. Modify blocks
Since our ASC opened more than six years ago, it has been a single-specialty facility offering a full range of eye surgery. Of course, cataract is the most frequent procedure, but for some time our anesthesia was geared more toward longer cases, such as retina. All patients received a peribulbar or modified retrobulbar block of 4% xylocaine, 0.75% marcaine and wydase.

As the pace of cataract surgery picked up, we realized that we no longer needed such a long-acting block, especially because it delayed recovery of eyelid function for cataract patients.

At the same time, we did a survey of our surgeons that indicated that they were committed to using a block, rather than moving toward topical anesthesia (with intracameral lidocaine), which is recommended by some efficiency-minded surgeons. We've observed that this technique numbs the surface of the eye, but some patients dislike the accommodation to the microscope light and the feeling of pressure during surgery, even with intravenous sedation.

Like many ASCs, we experienced something of a "generation gap" among our surgeons who were trained in differing eras. Some surgeons like to talk with patients during surgery, while others do not; some move through a case in as little as four minutes, while others take twice that time, or more. We needed a process that would bridge this gap, as well as improve our efficiency.

We proposed a trial, starting with 25 patients. We were fortunate to have the support of the surgeons, who understood our interest in efficiency and cost-savings.

The first few patients were given a block of 2% xylocaine and wydase. We liked the idea of using less than 4% xylocaine to minimize the risk of adverse outcomes related to sequestration of the agent or muscle injection. However, 2% xylocaine proved unsatisfactory for some surgeons, because it did not provide the amount of lid akinesia they desired.

At this point, we developed the idea of mixing 2% xylocaine with 4% xylocaine to produce 3% xylocaine, combined with wydase. This satisfied the surgeons' akinesia needs and gave us a standard anesthetic that was safer and more economical. At the time, this change reduced our local anesthetic drug costs by 30 percent per case. Most of our surgeons have stayed with this peribulbar block ever since, but we are committed to providing the anesthetic technique that works best for each surgeon, and we do tailor this block when needed. Some older surgeons still want marcaine, and their patients receive it. One young surgeon prefers topical anesthesia with intracameral lidocaine, and his patients receive this technique.

2. Get the patient involved
As with most efficiency issues, we found it beneficial to review our entire ophthalmic anesthesia process to identify other timesaving opportunities. We looked at our pre-operative prep, especially the dilating drops, which required several "go-rounds" from the prep nurses.

We considered the use of plegettes infused with dilating drops, which some clinics have found useful. However, our nurses were concerned about maintaining the plegettes in elderly patients' eyes, so we developed an effective alternative.

Prior to the day of surgery, the surgeon's office gives each patient a sample size of the dilating drops and instructs the patient about instilling them. The patient instills the drops at home before arriving for surgery, and thus is already dilating. Once patients have arrived, our prep nurses only have to instill one additional round of dilating drops.

3. Work with CRNAs
A major key to our efficient anesthesia process and our patient flow is our CRNAs. Since we opened our doors, we've contracted with a CRNA group, which includes one per-diem and three full-time CRNAs. Our CRNAs sedate our patients and perform all our blocks, so the patient is anesthetized and fully prepped when the ophthalmologist enters the OR. Our physicians take on the responsibility of collaborating with our CRNAs, and they greatly appreciate the fact that they can enter the OR and immediately begin the procedure. Teaming with CRNAs allows our highest-volume surgeons to work out of two ORs.

We usually work with four ORs and three CRNAs. While this may be a higher ratio of anesthetists than some facilities use, we feel it ensures safety and quality care for our patients.

Here's a typical workflow.
1. The anesthesia provider interviews the patient in the pre-op area. He then dilates the patient, sedates him or her with a low dose of propofol, and administers a peribulbar or modified retrobulbar block.

2. The anesthetist then wheels the patient into the OR and remains with the patient until the patient is fully conscious. He then assesses the eye block and patient comfort level. If indicated, the block may be supplemented or IV anxiolytics or narcotics may be given to provide conscious sedation. The surgery then commences.

3. While the surgeon is finishing up, the anesthetist leaves the OR to prepare the next patient. One of our circulating nurses (all of whom are ACLS-certified) monitors patient breathing and other vital signs while the procedure is completed and then moves the patient to recovery.

4. While the first case winds up, the CRNA is already assessing, sedating, and administering the block to the second patient.

5. The second patient is moved into the second OR, prepped, and often draped before the surgeon arrives from the first OR.

6. The first OR is then prepped for the next case, which proceeds as described above.

Our process and staff allow us to complete cataracts in only 15 minutes (this includes a five-minute room turnover as well as prep time).

4. Streamline documentation
Paperwork is an inevitable and crucial aspect of every case. To facilitate efficiency but still ensure completeness, we streamlined the pre-op assessment visit with a new form that places all the pertinent information the anesthetist needs to initiate sedation and anesthesia on a single, easy-to-read sheet. We also cut down on the time needed for documentation with a new anesthesia form that allows the CRNA to simply check off or circle pertinent information, rather than write it out long-hand (see page 22). These forms might save just a minute or two per patient, but when you're processing 25 cataracts in a day, that can add up to 45 minutes or more.

By working together, we're able to achieve a high level of efficiency, greater cost-savings, as well as high patient and surgeon satisfaction. To us, that is the best possible definition of streamlining our ophthalmic anesthesia.

Click here to view the Pre-Operative and Post-Operative Anesthesiology Notes document provided by Dulaney Eye Institute, Towson, Md.

Ms. Hyatt is Administrator and Mr. MacLeod is Director of Anesthesia Services for Dulaney Eye Institute, Towson, Md.