Fourteen cataract cases in an hour. That's about 4 minutes, 30 seconds per case. That's a lot of rolling beds and swiveling heads. That's two adjoining ORs in constant bustle, either in use or being set up and torn down. That's awfully fast. And that's awfully efficient.

"It's not so much about speed as it is about organization," says Gina Stancel, CST, administrator at the Eye Centers of Florida in Fort Myers, a Mecca of cataract surgery efficiency. "Some people may view it as assembly line surgery, but patients are much more appreciative of efficiency and organization than chaos and confusion."

On Mondays, Tuesdays and Thursdays, when David C. Brown, MD, is operating at the Eye Centers of Florida, it is not uncommon for a visiting surgeon to be trailing him, trying to unlock the secrets of his phaco flip technique, a repetitive, easily reproducible operation that can be performed in a wide range of clinical situations. In less than 3 minutes, Dr. Brown can get a cataract out and an implant in. "They're captivated with Dr. Brown," says Ms. Stancel. "Surgeons will watch a couple of cases, then look at their watches and shake their heads."

But as you'll see in this article, cataract efficiency is as much about what happens before and after the surgery as it is about surgical technique. There's much more to getting the patient in and out than getting the cataract out and the implant in. OR staff members must have very clearly defined roles and perform them with precision, orchestrating every patients' every move, from the time that they arrive to the time that they leave your facility - which, in the case of the Eye Centers of Florida, is with a rose and a smile.

No wasted time
Here is an overview of the tried-and-true system played out by 12 staff members, one receptionist and one surgeon three times a week at Eye Centers of Florida:

• Upon arrival, the patient is identified. The proper eye is verified and dilated, and the patient is taken to the holding/pre-op area.
• A nurse and a nurse anesthetist review the patient's history. A nurse anesthetist starts an IV, gives the patient a small amount (1-2 cc) of Versed, administers a peri-bulbar block and places a pressure-reducing ball on the eye.
• While the patient is wheeled to the OR and positioned and prepped, the circulator and scrub tech are setting up the room and instruments.
• Dr. Brown enters the room and begins the procedure.
• After the cataract surgery is complete, Dr. Brown walks directly to the adjoining OR, where another patient has been prepped and draped and is awaiting his arrival.
• The completed surgical patient is wheeled from the OR into the recovery room. Another patient is immediately taken into the recently vacated OR and positioned and prepped.
• The patient in the recovery room has vitals taken and is seated in a recovery chair for refreshments, then escorted to the reception area.

"Nobody likes to think of surgery as being like an assembly line," says Dr. Brown. "So maybe a better way to think of it is as a well-choreographed performance."

The Rule of Three's 3 instruments on the tray 3-mm or smaller incisions 3-minute operative time 3 p.m. finished with surgery - Robert Kershner, MD

Improving patient flow
From the preoperative area, to the OR, to recovery, there are many small and not-so-small ways to improve patient flow, each time-saver shaving off seconds that add up to minutes.

Some facilities have found ways to take tasks traditionally performed by the surgical staff and shift them out to the clinic staff. At the Eye Center of Central Georgia in Macon, the clinic staff use a sponge to apply the dilating drops and antibiotics while they take the patient history. "That might seem like a little thing," says Malcolm Sidney Moore, MD, "but it has made a significant difference in our practice. First of all, the dilating drops work better when they're applied with a sponge. The sponge is also a reliable way for one of the clinic staff, rather than a surgical nurse, to apply these preoperative medications. That frees up the nursing staff to prepare the OR for the patient."

They practice "keep your clothes on" cataract surgery at Silver Spring Ophthalmology in Silver Spring, Md. "Not only are patients more comfortable and relaxed," says administrator Mary Jo Cain, "but we can discharge patients sooner because they don't have to disrobe and we don't have to transport them."

Rather than transferring the patient back and forth from a surgical table to a gurney, why not leave the patient on the very gurney he is placed on during preoperative preparation? "Wheel them in and out of the operating room on the same gurney," says Robert Kershner, MD, director of cataract and refractive surgery at the Eye Laser Center in Tucson, Ariz. "We save time, and it's also less bother for the patient." Says Dr. Moore: "Patients are put on a gurney preoperatively, and they will stay on the gurney through surgery and in the recovery area."

The OR team should check all the IOLs for every case before you start surgery for the day. Store all the supplies you might need in surgery right in the OR so that you don't waste time going to a central supply room. In addition to the tray with standard instruments you use in every case, set up another sterile tray every day with less frequently used instruments and keep it covered unless you need something. "Keep instruments like corneoscleral scissors that are used very rarely but are essential for complicated cases in sterile packs, store them in the OR and open them only when needed," says Dr. Kershner.

Another tip from Dr. Kershner: You can eliminate the need to mop the floor and scrub surfaces between cases if you adhere to clean procedures during each case. "The room is disinfected when we show up in the morning, and we're careful to keep it clean all day," says Dr. Kershner.

At Eye Centers of Florida, all Dr. Brown does is perform surgery after surgery, nothing else. While he's operating in OR No. 1, a patient is wheeled into OR No. 2, given a Betadine prep, draped, and positioned at the proper height and angle under the microscope. No detail is too small: Dr. Brown prefers to have the patient's chin pointed slightly upward. "The staff takes care of all this so that when I sit down I can start the procedure right away without readjusting the position of the patient, the microscope, the speculum and so on," says Dr. Brown. "At the end of the case, I check to make sure the incision is closed and the eye has sufficient pressure, and then I go right into the next room and begin another case.

"On days that I operate, I don't take phone calls and I don't leave the OR," adds Dr. Brown. "I want to stay focused 100% on solving the patient's problem. When I talk with the surgical team during a case, it will usually be about the procedure rather than what movies I saw or what I did over the weekend."

A telltale sign of inefficiency - and a harbinger of a backed-up schedule - is a crowded recovery room. "If the recovery area fills up," says Dr. Kershner, "you can't move patients out of the OR, and new cases can't go in." For routine cases, don't use injected anesthetics, stitches, patches or patient sedation, says Dr. Kershner. This way, the patient won't have to stay in the recovery area for a long time after surgery.

"The big challenge to efficiency is patient turnover," says Dr. Moore. "You need to have a good system to move patients from the preoperative area into the OR and then into recovery. You need to know how quickly each surgeon operates and how quickly your staff can turn over the room." Keep track of time, says Ronald L. Lowery, MD, of the Arkansas Surgery Center in Batesville. "And not just the time of the surgery, but also the room turnover time," he says. "We compare this week's times to what we did last week and last month, and the staff sets goals to improve."

The bottom line of a cataract surgery practice shouldn't be improved primarily by cutting costs, but by improving patient flow through the OR, says Kip Fesenmaier, vice president for operations of cataract surgery outsourcing provider Midwest Surgical Services. "Efficiency is not about speed as much as it is about following good practices like aseptic technique and having reliable, routine staff procedures that help the practice achieve predictable outcomes," he says.

From incision to close
All of this preparation leads to the surgery itself, where efficiency is very much a matter of time being money. Get to the OR early to do a ?pre-flight' check of the position of the operating microscope, the selection of instruments on the tray and the programming of the phaco machine, suggests Dr. Kershner.

Outcomes are key. Every administrator, surgeon and nurse we interviewed for this article says the same thing: no center can be efficient without achieving good outcomes.

"Patients appreciate having a brief, painless experience under the microscope and then seeing clearly 24 hours later," says Dr. Brown. "And rule No. 2 for efficiency is avoiding complications. The expectation today is that cataract surgery will be 100% effective without any problems. In addition to the real harm done to the patient, complications add significantly to the cost of care. Fortunately, the outcome of cataract surgery is made or broken in the operating room."

The mark of a good cataract surgeon? Using as few instruments as possible, says Dr. Brown. "It's not a good use of the staff's time to have them clean and sterilize instruments that you don't really need. ?Lean and mean' is the best approach."

Dr. Kershner echoes those beliefs. "The OR team can be more efficient if the surgeon doesn't demand a lot of ?extras' on the instrument tray," he says. "Almost every case can be done with just a diamond- or steel-blade keratome, capsulorrhexis forceps and the IOL injector. Those instruments and the phaco tips are the only reusable items that need to be turned over with each case."

Many facilities balk at the two-OR approach for cataract surgery because of the initial outlay of dollars and the difficulty of predicting a return on the investment. But many say that there's no better way to avoid turnover-related delays than a second OR.

"Operating room turnover time is a ?soft' cost because it is measured in minutes rather than dollars," says Midwest Surgical Services general manager Jim Tiffany. "But there is a real cost in efficiency when the patient and surgeon are ready but have to wait for the room. It's frustrating, and it doesn't have to happen. Some facilities contract with us just to get a second operating room, equipment and staff so they can avoid turnover-related delays."

For a two-OR setup, experts say you need at least three instrument trays. That allows you to have one in use, one in the second OR for the next case and one in the autoclave getting ready for the first OR turnover."

It's all about time
Facilities that routinely perform eight, 10, 12 or more cases per hour have a simple recommendation for you: take aggressive measures to cut costs, become more efficient and build volume. To these administrators, surgeons and OR staff, this means finding out whether less or more is needed at each step of each case to achieve excellent outcomes and improve patient satisfaction. Invest in what is necessary, pare down the nonessential and growth will follow.

Mr. Hoffman ([email protected]) is a medical journalist specializing in ophthalmology.