SMOOTH OPERATOR How do you keep your cataract cases humming along?

From femtosecond lasers and sutureless clear corneal incisions to multifocal IOLs and dropless surgery, cataract surgery continues to make great clinical advances. Yet the most commonly performed surgery in the world is difficult to manage. Here are 5 tips that might help.

1. Constant contact
4-3-2-1 sounds like a countdown because, well, it is. It's also a system you can use to prepare your patients for cataract surgery. The countdown begins 4 weeks from surgery with a call from a staff member to go over the patient's surgical plan — including the type of lens the doctor has chosen — and to answer any questions. Three weeks before surgery, staff reminds the patient to tend to his history and physical examination. With 2 weeks to go, the center's financial coordinator telephones to review the patient's application and verify his insurance. The call the week before surgery covers arrival time, use of pre-operative eye drops, and a reminder to not eat or drink after midnight before the procedure.

Before the Eye Surgery Center of Georgia in Atlanta implemented 4-3-2-1 5 years ago, it wasn't unusual that 4 of the 20 cataract surgeries scheduled each day were cancelled because a patient wasn't NPO, didn't use his drops or had unresolved financial issues. Not anymore, says CEO Scott Bullock.

2. Let patients know when to arrive
Mr. Bullock never imagined that his years as a golf pro would one day help him run an ophthalmic surgical center. But as it turns out, setting up tee times isn't all that different from scheduling cataract surgeries.

"You have tee times every 10 minutes, you remember what it's like," says Mr. Bullock. "That front nine takes two-and-a-half hours, so you know that it's going to affect tee times on that No. 1 tee. You've got to keep everything moving in the right direction."

Whether it's a tee-time or surgery schedule, Mr. Bullock knows that people get antsy if they have to wait. To keep traffic flowing, the Eye Surgery Center staff created the "unit system" to determine when a patient should arrive. Here's how it works. Each unit is 20 minutes long, roughly the time from when a patient is rolled into and out of the operating room. That equates to 3 units of operating time per hour or a maximum of 24 units for an 8-hour surgical day. But doctors operate at different speeds and there are a variety of procedures at the center on any given day. Once the surgery units are booked, the scheduler works backward from the end of the day. So if the last case takes 3 units (1 hour) and the day ends at 3:30 p.m., that case will begin at 2:30 p.m. That means the patient must arrive at 1:30 p.m. Before the unit system was introduced, the surgical day ended at 3 p.m. only 50% of the time. Today it ends at 3 p.m. between 85 and 90% of the time.

"It really works well because you can see if you have room to add another case or if you are overbooked," says Mr. Bullock. "It helps us to manage overtime and underutilized surgery time."

Memorial Hospital Outpatient Surgery Center in Marysville, Ohio, used to bring one cataract patient in every hour. Not anymore. Today the first 5 patients arrive in 15-minute intervals. "Bringing these patients in up front let us spend time with each patient," says Dannielle Schroder, Memorial's clinical coordinator of surgical services. "It kind of gives us a head start to the day."

GRAB AND GO Each sterile tub is numbered to correspond with a specific cataract case and contains everything needed for that surgery.

3. Dropless surgery
All your patients who've had cataract surgery know that there are multiple drops needed for weeks to months after surgery to avoid such post-operative complications as inflammation and infection. For many of them, it's an expensive and hard-to-remember hassle to apply antibiotic and steroid eye drops 3 or 4 times a day for weeks. The Laser and Surgical Eye Center in Medford, Ore., is among the growing number of facilities that have eliminated the need for patients to administer drops before and after surgery. In so-called dropless surgery, the surgeon injects a single compounded antibiotic-steroid formulation transzonularly into the anterior vitreous after the IOL is in place.

"Our patients can avoid the hassles and high costs associated with post-operative drop therapy," says Jessica Jones, RN, the center's surgical director. The benefits are many, she says, including simpler post-op care and less cost to the patient and insurer. Studies have also shown that injecting antibiotics into the eye prevents eye infections better than drops.

4. Pull supplies for each case
The Kirk Eye Center in Loveland, Colo., pulls all supplies needed for each case and stores them in a see-through tub, each of which is numbered to correspond with a specific cataract case. "Everything is in that tub and we just pull the tub out and everything is ready to be set up for the case," says Kerry McKillop, the practice and surgery center administrator.

5. Quick Chop technique
For the past 15 years, Harry Lebowitz, MD, has been a proponent of the Quick Chop surgical technique for cataracts. The procedure, says the surgeon from Delaware Ophthalmology Consultants, lets him perform the exact same nucleus disassembly for almost all cataracts. Unlike other techniques that require creating grooves, Quick Chop impales the cataract with the phaco tip while the horizontal chopper bisects the cataract. One hemisphere is then impaled and bisected into quarters. Based on a cataract's density, the quarters can be bisected again or emulsified and aspirated. Quick Chop surgery takes 10 to 15 minutes, says Dr. Lebowitz. "It allows a larger majority of cataracts to require the same number of steps for removal as opposed to many of the other techniques," he says. OSM