Vital Stats
Nurse Manager: Robin Palmer, RN
Surgical and Safety Coordinator: Jill Hutchison, CST
Types of surgeries: Ophthalmology
Staff: 9 - 2 RNs, 1 LPN, 1 CST, 1 ORT, 3 CRNAs, 1 center director
ORs: 1
Operating surgeons: 1
Monthly case volume: 80
Years in operation: 2.5
Ownership: Two physicians

At the ophthalmology-only Perimeter Surgery Center in Cookeville, Tenn., a 90-minute drive from Nashville, surgery day is Tuesday. That's it - just one day a week. Staffers are part-time or per diem; the part-timers work a few days a week on scheduling, coding and billing, ordering and stocking.

"I think our high volume (20-plus cases per surgical day) and the low overhead of part-timers has been key," says physician-owner Stewart Galloway, MD. "What has been most pleasing is that we are able to make a very handsome profit while not cutting corners on supplies."

Dr. Galloway has considered adding utilizing physicians and another surgical day or two per month, but for now it's a one-day-a-week operation. But the staff makes it count as it redefines the term same-day surgery.

In, out, on your way
Because of its rural location, Perimeter offers truly same-day surgery. Out-of-town patients with appointments at adjacent Cookeville Eye Specialists (CES) can be evaluated and added to the surgery schedule the day of their appointment.

"We'll know in advance if they're coming to have a cataract evaluation." says nurse manager Robin Palmer, RN. "The same-day patients will know it's possible they'll be operated on that day. They will be screened and evaluated by Dr. Galloway and the staff at CES. CES will get everything together, and the patients will come to us for surgery that day. It can save them from another hour or two-hour drive."

Perimeter averages two or three same-day patients per Tuesday, says Ms. Palmer; making this happen requires coordination with CES.

When Safety and Surgical Coordinator Jill Hutchison, CST, sets up the surgical schedule, CES tells her how many same-day cataract consultations are coming in and when. She then builds the schedule, slating diabetics for the first procedures of the day (so they can eat sooner and maintain blood-sugar levels), and leaves time blocks open one hour to two hours after patients are scheduled at CES.

"That timing lets us get all the paperwork done, but keeps patients from having to wait very long," says Ms. Palmer. "Dr. Galloway will walk over to CES between cases and evaluate the patient. Depending on the extensiveness of the cataract, the patient is operated on, recovered and on his way in about an hour-and-a-half."

Same-day patients have the option of following up nearer to their homes with their primary care optometrists.

"This program has spread by word of mouth," says Ms. Palmer. "Physicians in surrounding cities and counties will call to see how they can refer to us. Most patients need to have surgery on both eyes and will come back the next week to have the other eye operated on."

Keeping it moving
In addition to strategic, flexible scheduling, fast turnover is of the utmost importance in working the patients into the surgical day. Doing one intense day of surgery each week means the staff at Perimeter has devised a turnover plan that keeps turnover time to two minutes, at most, says Ms. Palmer. Here's how they do it:

• Three beds in the pre/ post-op area. "We prep three patients and have them ready by 8 a.m.," says Ms. Palmer. "We keep these beds moving."
• Scrub techs splitting the work. "One's in the OR, the other helps in pre-/post-op," says Ms. Palmer. "One scrub works half the cases in the OR, then they switch."
• The whole OR team on top of things..."The minute Dr. Galloway pushes the phaco machine back, the scrub tech is tearing down her table," says Ms. Palmer. "Anesthesia rolls the patient out, and the circulating nurse has the paperwork ready for Dr. Galloway to sign and write comments."
• ...and the surgeon, too. While anesthesia prepares the next patient, Dr. Galloway will pack the instrument set to sterilize between cases. "We have two trays; one is sterilized as the procedure is going on," says Mrs. Palmer. "We have a third, just in case one tray is down, but it's not in the rotation."

When Dr. Galloway is back in the room, the next patient is waiting, the instruments are up, and the process starts again.

"Our turnover time is tremendous," says Ms. Palmer. "Repet-ition has gotten it to that point. We just keep our focus."

- Stephanie Wasek