November 2018


Presentation spotlight
Ergonomics of cataract surgery

by Stefanie Petrou Binder, MD, EyeWorld Contributing Writer

According to Dr. Rosen (not pictured here), three major components that improve efficiency include: surgery preparation and planning, the layout of the surgical facility, and performing efficient, effective, complication-free surgery.
Source: Getty Images

“It’s not just about the surgeon; we are only part of a team. Simple things matter a lot, and we need to support each other while we are operating to improve safety, efficiency, and outcomes.”
—Paul Rosen, MD

Keep surgery flowing smoothly and avoid errors by checking, and checking again

Ophthalmic surgeons agree that highly efficient surgical teams consistently produce better outcomes. Organized team work is crucial for a smooth work flow and effective surgeries.
Paul Rosen, MD, Oxford Eye Hospital, Oxford, U.K., discussed the ergonomics of cataract surgery at the 22nd ESCRS Winter Meeting, explaining that well-planned and executed cataract surgery not only gets the right results and provides a satisfying experience for the surgical team, but also improves the patient experience. “Ergonomic cataract surgery provides a calm and efficient atmosphere that relaxes the patient and inspires confidence,” Dr. Rosen said. “When the surgeon is relaxed, the surgical outcomes are likely to be better. Even if there are complications, the patient feels good about the way the surgery was organized and about the competence of the surgical team.”
Patient outcomes and satisfaction are a top priority, however, well-organized surgeries are also more cost effective and maximize productivity. Three major components that improve efficiency include: surgery preparation and planning, the layout of the surgical facility, and performing efficient, effective, complication-free surgery. The perfect operating session should be effortless for everyone, with a surgical team that communicates seamlessly to ensure a smooth flow, fast but not rushed, stress-free, with safe, reliable, and reproducible care, much like a safe and efficient production line.

Oxford care pathway

The Oxford cataract care pathway itemizes each step of the cataract surgical procedure. The very first step into this pathway ensues from a proper referral from the family doctor or optometrist. Once referred for cataract surgery, the patient begins the preoperative assessment clinic (PAC) where a thorough clinical assessment determines whether the patient needs and wants cataract surgery, and if payment guidelines can be met. Patients in the PAC are given a comprehensive patient education about their surgery. Dr. Rosen thinks that cataract patients should be informed before they get to the hospital and continue receiving information while they are in the hospital, so that they can make an informed decision about whether they want to go ahead with the procedure.
PAC establishes ocular comorbidities and the need for additional resources and equipment for the surgery (e.g., iris hooks). The anesthesia is planned at this time as is the biometry/desired refractive outcome and the choice for special lenses, such as torics or multifocals. The PAC step includes informed consent, educates patients about the procedure either verbally from the nurse, by video, through written information, or the web, and makes sure that the patient’s expectations and the surgeon’s expectations of the patient are clear.
Once PAC is complete, Dr. Rosen turns his attention to scheduling. “You need to have a realistic operating list. For a surgeon in training, it is reasonable to have six surgeries on the operating list, otherwise more like eight to 10 cases,” he explained. “It is important to perform one type of surgery only in order to stay consistent and minimize the variation in surgery and anesthesia.”
Dr. Rosen and his team check the patient records at 1 week before surgery and make sure that the appropriate lens implant is going to be available. They verify type of procedure to be performed and ensure all extras make the list, such as iris retractors and iris hooks. On the day of surgery, at the start of the session, he holds a preop briefing that includes the World Health Organization (WHO) checklist as well as role assignments in the OR for the time of surgery.
The day of surgery is all about checks. The surgeon goes to the preop area, confirms the eye that is to be operated, goes through the WHO check list, confirms patient identity and consent, marks the correct eye, confirms the local anesthetic (topical, sub-Tenon’s, sedation), and checks the biometry/ lens to avoid wrong lens insertion. The same exact procedure is repeated in the anesthetic room. “We also write on the white board to further ensure no mistakes are made: the lens power, the name of the patient, and which eye is to be operated,” he said. “Then the patient has the surgery and goes to the postop recovery area where the postop drops are explained and a review appointment is made, if necessary.”

Wrong IOL

“We are increasingly aware of inserting the wrong IOL. It causes distress for the patient and for the surgeon and the nursing staff (the secondary victims), involving a large investigation and potentially litigation,” Dr. Rosen said. “In the U.K. this is called a ‘never event.’ It is, in theory, avoidable. There seems to be an increased incidence and it may be something that went undetected in the past, with patients continuing to use glasses. It has become a large issue in the context of other wrongly implanted implants, like of the hip and knee. The incidence varies. Moorfields Eye Hospital reported six cases in one quarter year and Oxford had three within the course of 1 year. Overall, this may be due to an increasing awareness, and it is being countered by increasing checks.”
Choosing the wrong IOL can result from a number of different causes. Etiologies may include: biometry measurement errors, lack of training in the use of specific IOLs, wrong patient/wrong biometry printout, human error in looking at printout, mental math (surgeon factor), misuse of electronic patient records (wrong patient, transcription error, multiple records open), and selecting and picking up the wrong lens, which could happen when more lenses are being prepared for upcoming surgeries.
Prevention of wrong IOL insertion (distinct from refractive surprise) involves: repeated checks and a WHO check (biometry check, patient verification in the anesthesia room, check the correct formula, check toric and special lens calculations, verify choice with colleague, and sign off). In the operating room, preventive measures include writing relevant information on the white board and training and empowering the nurses in reviewing biometry to help spot errors.
“There are many ways that different facilities have tried to improve safety and efficiency. At Moorfields, they coined the expression ‘Patients From England Like Tea’ as a method of checking the operation details. P: Patient detail, F: correct Formula, E: which Eye, L: Lens type, and T: Target refraction,” Dr. Rosen said. “There is also ‘The Productive Operating Theatre,’ which is based on efficient operating lists that lead to surgeries that are more productive, more cost effective, safer, and make happier patients and staff. Finally, key performance indicators (KPIs) help to improve efficiency based on the motto ‘If it’s measured, it will improve.’ These include: operation start and finish times, time into and out of the OR, turnaround time (time patient is out of the OR to the time of the next anesthesia), time utilization (minutes in session divided by minutes used), number of cases completed safely and efficiently, complications, patient satisfaction, and surgeon satisfaction.” It is very important that the drive for efficiency does not compromise safety and outcome.
Barriers to efficient surgery include: poor pre-assessment (high cancellation rate), ineffective planning, bad ergonomics of the OR suite, poor teamwork, and slow, inefficient, and unproductive operating lists.
Dr. Rosen thinks that a professional, multi-skilled, and flexible team that knows its job and the responsibilities of those around them are the makings of a successful, safe, ergonomic surgical experience. The environment and equipment, patient positioning, and the surgeon’s operating position all have to be correct. The surgeon and staff need to be aware of how sensitive patients will be to the wrong word, sound, or vibe in the OR. “It’s not just about the surgeon; we are only part of a team. Simple things matter a lot, and we need to support each other while we are operating to improve safety, efficiency, and outcomes,” he said.

Editors’ note: Dr. Rosen has no financial interests related to his comments.

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