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Secrets to Our Cataract Case Efficiency
The right equipment and a dedicated staff will send patients safely and quickly through your facility.
Vickey Hawkins
Publish Date: January 18, 2008   |  Tags:   Ophthalmology

Here are eight timesaving tips that will shave minutes off your cataract cases without sacrificing quality patient care. These are the keys to how we comfortably perform five cases per hour in each of our procedure rooms.

1. Consider a coordinator.
If you perform 200 cases or more per year, you should consider hiring a dedicated surgical coordinator. Low-volume facilities can perhaps get away with having a tech serve in this role. When performed correctly, the surgical coordinator's daily responsibilities are vital to keeping surgeons, staff and patients up to speed. I'm the coordinator for our clinic and surgery center, acting as an extra set of eyes, ears and hands for our surgeon, Larry Patterson, MD. Working in both settings lets me manage the communication between the surgery center and surgeon. That's not a small factor in keeping the surgical schedule running smoothly. It's my responsibility to make sure Dr. Patterson is in the OR and ready to go before the day's first case begins.

2. Preplan for success.
Part of my pre-op planning involves the review of each patient's chart with Dr. Patterson before the day of surgery. We go over everything, from quirks in a patient's eye anatomy that might demand extra care during surgery to the size and optical power of the IOL to be implanted. A game plan is set with the aim of eliminating surprises, and therefore delays, in the OR.

On the day of surgery, my familiar face provides continuity for the patients who had their pre-op tests performed in our clinic. Sure, that's comforting for patients, but my relationship with them also serves a practical purpose. I'm able to notify the clinical team of concerns — patient allergies, potential anxieties and positioning concerns, to name a few — that may lead to complications and surgical stoppages.

In the procedure room, I'm able to back up the surgical tech, assist in room turnovers, manage operative notes and help with the autoclaving of instruments — whatever it takes to keep our cases humming along.

3. Jumpstart cases.
Eye wicks soaked in a cocktail of anti-inflammatory, antibiotic and dilation medications are some of our biggest time savers. Each drop cocktail consists of equal parts gatifloxacin (Zymar), ketorolac (Acular LS), viscous neosynephrine 10% and Mydriacyl 1%. The wicks are placed under the patient's upper or lower eyelid and remain in place until the pupil dilates, which takes about 10 minutes. Instead of having to prepare, administer and monitor several drops, pre-op nurses, are free to help transport patients or assist in room turnovers after placing the wick.

Want to speed the eye-prepping process? Consider creating a single prep tray that can be used throughout the surgical schedule. Here's how. Place two boxes of sterile 4x4s in an autoclaved Genesis tray with a lid. Soak one set in betadine prep solution; the other box should remain dry. Staff simply prep the patient's eye with a betadine-soaked 4x4 and dry the eye with one of the plain pads. Keep a setup on a rolling cart in each of your procedure rooms for easy access. This method is efficient and cost-effective because nurses avoid opening individualized preps for each patient.

Another tip: ask your nurses to prep one-handed. Have them open a pack of surgical gloves one side at a time. For one patient, they can apply the prep wearing the left-handed glove from the pack. To prep the next patient, they can wear the pack's right-handed glove. By using this alternating pattern, you'll need just one pair of gloves to prep two patients.

4. Dive right in.
We're fortunate to work with a surgeon who leads by doing. Dr. Patterson motivates our staff to go above and beyond their job descriptions when rooms need to be turned over. He'll help transport patients to PACU, open supplies or adjust equipment between cases.

Your clinical team must be self-motivated, adapt well to change and willing to help others when needed. Efficient practices thrive on attention to detail, so you'll want to fill your facility with employees who sweat the little things. With tongue planted not-so-firmly in cheek, I'd say the best nurses and techs are super-organized neat freaks who drive their spouses crazy at home. Those Type-A personalities do well in eye centers.

5. The stretcher is the operating table.
Outfitting your facility with stretcher beds means patients will remain on one surface from pre-op to PACU. Then nurses don't have to transfer patients from stretcher to OR table and back again, saving valuable minutes during a day of surgery.

We've taken this timesaving concept one step further by adding a footplate to each of our four stretcher beds. The footplate is a raised shelf that holds vital signs monitors. Patients are hooked to the monitors only once — in the pre-op holding area — and remain attached to the equipment throughout the procedure and recovery period, eliminating the need to unhook patients from the monitors between pre-op, the OR and PACU. The time saved by using the combination stretcher bed and footplate lets us perform about one additional case per hour.

The design of our surgical scope also assists in efficient room turnovers. We program the scope's zoom focus and light concentration settings once, at the start of the day, and reset them to the surgeon's preference between cases with the push of a button. Over the course of the day, this saves time.

6. Setup is instrumental.
One of our scrub techs comes in early to pull and organize the medications and viscoelastic we'll need for the entire day. She places needed supplies and specialized instruments in a sterile Genesis tray, including post-op injections, intracameral lidocaine and the assembled viscoelastic. She places that tray on the top shelf of a cart that we keep in the back of each procedure room. We keep unopened viscoelastics, extra tubing, phaco cassettes, BSS and vitrectomy supplies on the cart's bottom shelf. The techs simply head back to the cart during cases instead of wasting valuable time by assembling instruments or drawing medications.

Fill your instrument trays with only the tools that you use for each case. We built three streamlined trays, each containing a phaco handpiece, I/A handpiece, nucleus rotator, chopper, speculum and drape scissors. We sterilize all three trays at the start of the surgical day. As each one is used, it's passed through the sterilization process. We rotate the sets between two tabletop sterilizers; each sterilizer can turn instruments over in about 22 minutes.

To save time on the back end of the reprocessing cycle, our scrub techs irrigate and clean used instruments in sterile water during the case. That way, the instruments are ready for reprocessing as soon as they reach the sterilizer room. Beware: accidentally getting sterile water inside an eye can damage the corneal endothelium, among other things. We keep our sterile water in a plastic container away from the instruments. After we irrigate the used instruments with the sterile water, we separate them from the other instruments so that they never reenter the eye. It's critical to use great care when working with sterile water around your OR table.

One note on tabletop sterilizers: The reprocessing times of most models are comparable. Just don't skimp on size. In my opinion, the sterilizer's chamber should be no less than 10 inches across in order to accommodate the tray sizes that maintain efficient instrument reprocessing.

With three instrument sets in constant motion through two tabletop sterilizers, we rarely — if ever — have to wait for instruments before starting a case. Remember, every second counts in cataract surgery. Instrument sets don't have to be completely ready before the next case's patient enters the OR. Our scrub tech is known to finish preparing the instruments as the patient is wheeled into the room, draped and prepped, and as the phaco machine is primed.

7. Organize your day.
After every fifth case, our CRNA and circulator take a short break to assess pre-op patients in groups of five. Those five patients then become part of the next wave to hit the procedure rooms. Grouping patients in this way streamlines the pre-op assessment process and keeps the schedule running smoothly.

Our CRNA pushes patients to PACU at the conclusion of each case, swings by the pre-op area to administer oral sedation (5mg to 10mg of Versed) to a waiting patient and takes an already sedated patient to the OR. While he's wheeling the sedated patient, the Versed starts to take effect on the patient who's next in line.

Schedule complicated cases last. Procedures that you know will be difficult for your surgeon to perform belong at the end of the surgical schedule. Technically challenging cases can throw off the day's entire schedule if they run long in the morning. A surgeon will also be better able to focus on the task at hand at the end of the day when pressure from his internal stopwatch is less of a factor. Scheduling challenging cases late in the afternoon also has a public relations benefit; if complications do arise, other patients won't be around to see them occur.

Don't wait for a case to conclude before beginning room turnovers. Start by clearing the OR's back table after IOL insertion. Begin moving the patient out of the room as soon as the procedure is completed. That's where the stretcher bed's footplate again comes in handy. The monitoring equipment is moved right along with the patient, instead of staff taking the time to disconnect the patient from the monitors.

8. Make your paper work.
Microsoft Word features a "merge" function that lets you add customized information to your boilerplate documents. We've used the feature to customize our surgical documents. Information such as the patient's name, age, allergies, diagnosis, procedure (with billing codes), date and time of surgery are added to data fields and subsequently updated throughout 15 pages of the patient's H&P, pre- and post-op instructions, consent forms, prescriptions for post-op eye drops, explanation of benefits and op report. Using Word's merge feature increases the accuracy of surgical documentation and reduces the time staff spend on creating handwritten records on the day of surgery.

The surgical coordinator completes the pre-printed op note simply by checking boxes that correspond to clinical decisions made during the procedure. Because our cataract cases are so refined, we rarely add to the op report's template. If needed, the coordinator notes minor deviations from the expected at the bottom of the document. We retype the template to explain any major complications.

Your way to the highway?
If you're already incorporating these concepts into your daily routine, you're on the right (fast) track. If you're not, you should be. But remember that speed alone doesn't equate to efficiency in cataract surgery. Efficiency calls for striking a balance between providing safe, personal care for your patients and cramming too many cases into too little time. Remember, no matter how fast your staff and surgeons work, quality must always take precedence over quantity. Never assume your way is best. Be open to new ideas. Ask staff, surgeons and anesthesia providers for suggestions on how your facility can improve its performance and constantly brainstorm about ways to increase patient flow.

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