Improvements in OR Performance and Efficiency Performance and ...

1
Improvements in OR
Performance and Efficiency
American Academy of Ophthalmology 2010
Course #289
Chicago
Faculty
Richard J. Ruckman, MD – Lufkin,TX
Preoperative Protocols
R. Bruce Wallace, III, MD – Alexandria, LA
Operative Protocols
Larry E. Patterson, MD – Crossville, TN
Postoperative Protocols
R. Bruce Wallace, III, MD, FACS
Alexandria, Louisiana
Changing Demographics:
Growing Population for Cataract and
RLE Surgery
80
70 55 to 74 years
Clinical Professor of Ophthalmology,
Louisiana State University
Assistant Clinical Professor of
Ophthalmology, Tulane University
Consultant for AMO, Allergan, B+L, LenSAR
Population (millions)
60
50
40
30
20
10
0
1995 2000 2010 2030
Preoperative Protocols
No financial interest in products discussed.
Richard J. Ruckman, M.D.
Lufkin, , TX
Cataract Surgery
in the Ambulatory Setting
• The Past, Present and Future
• 3.1 million cataract surgeries in 2008
• 75% performed in ASC’s
• Presbyopia correcting lens 6.2%,
down from 7%
• Refractive lens exchange 2.3% of
lens extractions
• Expected to grow 6-15% by 2015
Market Scope, Sept. 25, 2009

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What are the Challenges
to Your ASC
• Healthcare Reform
• ASC’s will not go away: “quality, low
cost providers”
• Payments
• Overall 0.6% increase to ASC’s
• Cataract 66982/66984, 3%
• Retina and glaucoma up
TOA Newsletter, Oct. 2009
Fed. Register, July 20, 2009
Surgistrategies, Sept. 09, Vol. 8,
#9
• Increased ASC costs – infection
#10
Oct. 09, Vol. 8,
What are the Challenges
to Your ASC
• Static reimbursements
• High cost of technology in both equipment and
supplies
• Increasing overhead costs
• Necessity of certification and its associated costs
• Need for highly trained staff
Improved efficiency is not a matter of choice;
it is a matter of survival.
What are the Challenges to the Success
of Your ASC
• Static reimbursements
• High cost of technology in both equipment
and supplies
• Increasing overhead costs
• Recent increased CMS scrutiny
• Necessity of certification and its associated
costs
• Need for highly trained staff
Improved efficiency is not a matter of choice,
it is a matter of survival.
The Importance of Efficiency
Where does the Money Go
• ASC expense*
• Salaries 43%
• Overhead 33%
• Supplies 23%
The majority of expense is time dependent.
You cannot control reimbursement, but you
can influence your costs through
efficiency of time.
* Multi specialty ASC
Federated Ambulatory Surgery Association, 1996
The Importance of
Financial Benchmarking
Successful ambulatory surgery
centers are diligent in gathering,
measuring, and managing data. .
Management Ratio Examples
Payroll/Gross Income 15-20%
Net income 20-40%
Man hours per case 9-12 hrs per
case
Bruce S. Maller, The ABC’s of
ASC’s ASOA 2004
The Importance of Benchmarking
Compare Yourself to National Norms
• Accreditation Association For Ambulatory Health Care
(AAAHC)
• Performance Measurement Initiative (PMI)
• Institute for Quality Improvement
Cataract extraction with lens insertion 2008
77 organizations
64 to 12,000 Procedures
Total 143,491 Sample size
71% Free standing single specialty
22% Multi-specialty
.07% Office based surgery practices
AAAHC – 2009

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Practice Comparison - PMI
• 65% Single specialty
• 24% Multispecialty
• 11% Other
Annual volume 70-8,000
Practice Comparison - PMI
Pre-Procedure Procedure Time
Time patient checks into facility to time in O.R.
Median 76 minutes
Range 37-138 minutes
Best case
• Paperwork completed when scheduling patient
• Patient is sent home with a packet, vision function
questionnaire, pre-surgery instructions
• Compounded dilating drops are begun in “dressing
room”
• Routine cases early in day
AAAHC -
2008
AAAHC - 2009
Practice Comparison - PMI Procedure
Times
• Time from start of procedure to end
• Median 15 minutes
• Range 7-33 minutes
• “Best case”
• 3 autoclaves and 2 O.R.’s
• Streamlined paperwork
• Specific O.R. staff
• Second O.R. ready by time surgeon arrives
• Minimal instruments
• “Practicing” with patients while they are draping
• Scrubs/circulators “never” leave room
Practice Comparison - PMI Discharge
Time
• Out of operating room to discharge
• Median 23 minutes
• Range 3-41 minutes
• “Best case”
• Minimal sedation
• Routine post-op op orders
• Teaching patients in pre-operative phase
to expedite discharge
• Patient stays on stretcher with monitor
• Give post-op op kits at pre-op visit
AAAHC -
2008
AAAHC - 2008
Practice Comparison - PMI
Facility Time
• Time patient checks in to discharge
• Median 121 minutes
• Range 62-189 minutes
• “Top performance may be attributed
to the reasons for each component
with streamlining the procedure
process.”
Does Size Matter:
“How Does Your
Cataract Service Compare”
Facility Size
Check in
to Check out
Surgery
Time
2000-4000 sq. ft. 104.31 min. 17.8 min.
4500-6500 sq. ft. 104.76 min. 14.62 min.
7000+ sq. ft. 94.75 min. 14.35 min.
AAAHC - 2008
Outpatient Surgery Magazine, October
2007

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Pre-Operative Protocols
Pre-Operative Protocols
• Efficiency begins at initial exam and
scheduling of procedure
• Exam (patient education begins at this
time)
• Financial/Insurance
• Pre-op
• Entire “blank” chart available
• Check boxes on all forms
• Kits, Rx’s, and preprinted, color-coded coded
pre-op
and post-op op instruction sheets
are given
• Pre-op
• Plan the day – summary sheet
•List eye, IOL, special
procedures
•Use patients ID sticker
•Post in all areas of O.R.
•Charge nurse keeps master
copy
Pre-Operative Protocols
Pre-Operative Protocols
• Patient flow
• ID attached to patient clothing
• 1 st set of dilating drops instilled
~ we use compounded dilating
drops
• To pre-op via patient bathroom
• Patient does not change clothes
• Patient flow
• Patient placed on stretcher
• Monitor is attached with limb
leads
• Saline lock for medications on
all patients
• Baseline vital signs taken by
RN
Pre-Operative Protocols
• Patient flow
• Patient identification sheet
on stretcher with name,
operative eye, allergies
• Physician marks site
• Patient transferred into O.R.
on same stretcher with
monitors already in place
Anesthesia Choices
• IV Sedation
• 1-2 mg Versed in pre-op
• Occasionally Fentanyl in O.R.
• Topical
• Tetracaine (TetraVisc)*
• Intracameral
• Lidocaine 1% MPF
* OCuSOFT

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Cataract Anesthesia Survey
Primary Anesthetic Technique
80
60
40
20
0
2000 2002 2004 2006 2008
RB
Periocular
Topical
Blunt cannula subtenons
• Between 1995 and 2000 topical anesthesia went from
11% to 50%
• Of those using topical anesthesia for cataract
surgery 76% use it with intracameral lidocaine
Number
of Cases
900
800
700
600
500
400
300
200
100
0
IV + Topical
IV + Peribulbar
IV
IV + Retrobulbar
Topical + Oral
Peribulbar
AAAHC 2009
Practice Styles and Preferences of U.S. ASCRS Members – 2008 Survey
David Leaming, M.D., ASCRS – 2009 Posters on Demand
Anesthesia Options
• Topical
• Eye drops (TetraVisc*) or
lidocaine gel
• Gives good conjunctival
anesthesia
• No lid akinesia
• Eye movement present
• Deep eye pain present
* Ocusoft
Regional Anesthesia
• How to decide when more is needed
• Problems with A-scan
• Alzheimer’s/Mental retardation
• Hard of hearing/Language barrier
• Lack of cooperation during first eye
• Younger age
• Significant prescription drug history
• Physical problems – “bad back”
• Routine second eyes – may need
Moving the Patient
to the O.R.
• Communication is the key
• RN to RN handoff
• Direct observation by staff
• Signals – lights go on in O.R.
• Video monitoring