If you're thinking about building an ophthalmic surgery center, forget what the self-help books say. Sweat the small stuff. I've been involved in the planning and building of several facilities and can assure you that no detail is too minor. For example, when we were building a recent facility, it wasn't until the walls were up, the electric was run and we were about a month from opening that I brought a couple of techs over and asked them to walk through a case. I said: How do you set up the room? How do you get your instruments? What do you do after the case? Where do you take the instruments?

Only then did we realize that the facility's design would have forced the techs to put instruments down, open the OR doors, pick the instruments back up, go through and close the doors behind them. A detail like that may sound minor, but wasted seconds add up, especially in a volume-driven specialty like cataract surgery. Fortunately, we still had enough time to install electronic opening devices with kick plates at foot level. The lesson: Every decision is important. You can't do too many walk-throughs and process reviews when assessing the following design essentials.

? Room size and layout. You don't need a lot of space for an all-purpose ophthalmic operating room. Most guidelines suggest at least 325 square feet (15 x 15). You do, however, need to be strategic in terms of where the medical gases are piped in and where the overhead lights are situated. As long as you have those 3 components — adequate space, gas and good lighting — you can make any OR work.

If you're doing retina cases, you also need a nitrogen line for the vitrectomy machine, in addition to the general anesthetic gases. The positioning of the gases is important, because it can really help with both the layout and the overall flow of the room. Ideally, equipment should be a very short distance from where you're going to be plugging it into the wall.

The layout should also make sense in relation to how you're going to bring the bed into the room and where you're going to position it, where staff will typically be, where the equipment is in relation to the bed, where the outlets are and where you want to put wall-mounted monitors. Be sure to scrutinize the layout with the room fully loaded to make sure you have everything positioned properly.

? Equipment decisions. Design planning also needs to encompass the special equipment and supplies each ophthalmic specialty requires. The cost to outfit a typical OR for cataract surgery is between $350,000 and $400,000, depending on the equipment you buy.

After looking at surgical microscope options, we decided to go with mobile, floor-based models, as opposed to ceiling-mounted scopes. The advantage is they give us greater flexibility to reconfigure rooms, if needed, or to change things around if and when we invest in new technology. We bought a phaco machine with high flow rates and high vacuum levels, which help our surgeons operate faster. We're also evaluating toric- and IOL-imaging software and might consider adding it in the future.

Another small detail to consider: If you plan to incorporate optiwave refractive analysis (ORA), which uses intraoperative wavefront aberrometry to measure the refractive power of the eye after the cataract is removed (so you can be sure you've chosen the most appropriate IOL), you'll want to make sure you're storing alternative lenses as near as possible to your ORs. The technology is so precise that you might implant a different lens than the one you originally planned to use in about 1 of every 3 cases.

Retina requires a vitrectomy machine, a cryosurgical system, a laser, an indirect microscope and a large number of disposable instruments. Since ocular plastics and glaucoma are instrumentation driven, you'll need a lot of stocking space.

Our retina specialists have recently embraced heads-up 3D technology. They have a 50-inch monitor at the foot of the bed and wear a pair of 3D glasses, so they're never actually looking through the microscope. Instead, they're looking straight ahead and seeing the patient's eye in 3 dimensions throughout the procedure. We're also in the evaluation phase with optical coherence tomography (OCT), which uses light waves to take cross-section pictures of the retina.

? Laser cataract surgery. Femtosecond lasers make a perfect capsulorhexis; they make perfect incision points and they do a great job of pre-chopping cataracts. So why wouldn't you outfit your new ophthalmic facility with a femto laser? Because there are several other factors you must consider.

From a construction standpoint, the first is the space needed to house the laser machine. At minimum, you need a 10-by-10 foot area, and some lasers have very precise temperature and humidity requirements. You'll also need the correct electrical and information technology (IT) requirements. Most platforms aren't Wi-Fi enabled, so IT connectivity is needed to let the unit communicate data and allow for offsite troubleshooting.

So why not just put the laser in your OR? That might be fine if you have only a single OR, but if you have 3 cataract surgeons doing procedures in 3 ORs, it can become a logistical nightmare. I've seen practices that were on the first floor, but had their femto on the third floor because that was the only space that worked. Again, location, flow and efficiency are the important factors.

Femto lasers are costly pieces of equipment, both in terms of up-front investment, per-click fees and annual service contracts. As an administrator, you need to do an analysis and make sure the deal being presented to you works financially for your facility. Finally, you need surgeon buy-in. They need to understand the technology and how it's going to affect their surgical day. Some surgeons aren't convinced that femto lasers improve clinical outcomes when compared with manual techniques, so be sure enough of your physicians will use the technology often enough to justify adding it.

If you can check off those 3 boxes — space, economic sense and surgeon buy-in — a femto is likely to be a good deal for your facility.

? Patient flow. We're able to get away with fairly small pre- and post-op bays, and use that valuable square footage in other areas of the facility, in part because we don't ask patients to change their clothes for surgery. But be aware that different states have different regulations with respect to whether or not patients can wear street clothes into the OR. Depending on yours, you might have to allow for more space in pre- and post-op areas.

Not having to change cataract patients into surgical gowns for surgery improves perioperative efficiencies. We've also boosted efficiency by investing in patient monitors that ride on the foot of the bed. The monitors are then mounted onto the table, so we connect them in pre-op and they ride with the patient all the way through the surgical experience. That means we don't have to waste time hassling with disconnecting and reconnecting them multiple times as patients travel from pre-op, to the OR, to post-op.

? Convenient workspaces. Outside the OR, think about where the anesthesia office, supply storage area and medication room will be in relation to the flow and efficiency of your facility. Also, where is your leadership going to sit? All our clinical managers are expected to pitch in and help, so it's important to have them centrally located and easily accessible.

Expert advice

Here at the Cincinnati Eye Institute, we've been expanding. In addition to our main facility, where we do almost 14,000 ophthalmic surgical procedures a year, we partnered in 2017 with Mercy Health Systems on the west side of Cincinnati.

We opened a new facility in Middletown, Ohio, last year. We took over what had been a failing multi-specialty ASC, signed a long-term lease, hired staff, bought equipment and turned it into an ophthalmic-only ASC with 3 ORs. At Middletown, we have the staff and equipment to handle just about everything: cornea transplants, cataracts, retina, glaucoma and ocular plastics all in the same facility. Because cataracts are ophthalmology's bread and butter, we're set up to handle them in all 3 operating rooms.

The best advice I can give anyone planning to develop a new ophthalmic surgery center is to find a partner, somebody who has done it before, who knows the questions to ask, and who can help guide you through the process. It's a daunting task, so it makes sense to talk to architects and consultants who have intimate knowledge of surgery center flow.

Sweat the small stuff and you'll have less big stuff to sweat later. OSM