For retinal surgeons, streamlined systems for vitreoretinal surgery may foster a sense in retinal surgeons that the surgical process has been predetermined. However, there are elements of surgical set-up and teamwork that, when optimized, improve efficiency and cost effectiveness in the operating room. Input from nurses and technologists can be invaluable in this way. Here, surgeons and retinal surgery team members weigh in with advice from their experiences.
A WELL-PREPARED TEAM
Dawn Williams, RN, who works with Peter K. Kaiser, MD, at the Cole Eye Institute of the Cleveland Clinic, has trained numerous new scrub techs and nurses on the efficient preparation and knowledge required to ensure a successful retinal case.
“Given a strong background in technique, most scrub techs can be easily trained to scrub basic retina cases, even for those not dedicated to ophthalmology,” says Ms. Williams. She adds that preparation and an understanding of what can go wrong during a vitrectomy system set-up, and more importantly at key points during the surgery, is critical to success. “This is no different from any other surgery, but the numerous specialized instruments used in retina can be daunting. Knowing what may be needed in a case and having the instruments you need in the room differentiates a scrub tech who understands the surgery versus someone who is following a checklist.”
Ms. Williams teaches scrub techs and operating room (OR) nurses that simply looking at an OR schedule for organizing the case setup can be misleading. Schedulers often book all cases as vitrectomies, not noting a scleral buckle, lens exchange, or even trauma. The setup and supplies required for a complicated diabetic tractional retinal detachment is very different from an epiretinal membrane peel. A surgeon often has a gauge preference for vitrectomies. The scrub needs to know all these things and be ready to tailor the tray to not only the surgery, but to the surgeon.
Jessica Jenkins, a certified surgical technologist at Ophthalmic Consultants of Boston, works with surgeon Jeffrey S. Heier, MD. She says that while set-up is fairly standard now for 23- and 25-gauge vitrectomies, well-trained staff is key. “I believe that the most helpful aspect of our center is having dedicated and engaged scrub nurses and circulators who have a true understanding of retinal surgery,” says Ms. Jenkins. “Knowing what equipment and supplies you would need for each type of surgery saves money and time.” She adds that being able to troubleshoot equipment and anticipate what the surgeon will need is invaluable.
“Especially in subretinal cases, surgeons can focus on what they are doing without having to think about whether you will have what they need,” she says.
SHORTENING PATIENT TURNOVER
A knowledgeable team is also critical to the efficient turnover of patients, says Willie Smith, who has been a retinal material surgical coordinator at Good Samaritan Hospital in Los Angeles, California, for more than 30 years. He works with the 10 retinal surgeons there, including David Boyer, MD. At Good Samaritan Hospital, there are 4 retinal material surgical coordinators. One nurse is the primary retinal service line coordinator, dedicated primarily to retinal surgery and responsible for medications, follow-up with patients, and scheduling. Other nurses have been trained to assist if needed.
“We have improved the time from when the nurse rolls the patient over to recovery, clears out the computer, and loads up the next patient information into the computer. Patients are transported to surgery and recover on the same bed. Our turnover time is about 12 minutes — no more than 14 minutes.”
Mr. Smith agrees that a team that is well versed in all equipment and processes is going to work most efficiently. Good Samaritan Hospital has 2 identical rooms for retinal surgery, but team members always work in the same room. And members of the team read the schedule 2 to 3 weeks ahead of time, anticipating needs for each surgery. Questions are encouraged, so if a planned procedure is changed, the right equipment is ready.
“Teamwork and preparation are what make our ORs extremely efficient,” says Carrie Silva, BSN, RN, CRNO, director of nursing at Spectra Eye Institute, where retinal surgeon Pravin U. Dugel, MD, performs surgeries. Silva agrees that knowledge of the surgeon’s preferences and being able to anticipate what the doctor wants from each individual instrument to the upcoming cases for the day makes surgery go smoothly. “Every second counts,” she says, “and if each team member knows exactly what role they have, less time is wasted. This also improves confidence in our physicians and our patients. Circulators wheel patients to the post-anesthesia care unit and know to bring the next patient into the room right away. The scrub tech hands off instruments to decontamination while another scrub tech is setting up for the next case with the help of patient care techs to turn the room over.”
“The misperception that people have is that efficiency is speed, and that is absolutely not true,” says Dr. Dugel, of Retina Consultants of Arizona in Phoenix. He stresses that speed is a component of efficiency, but not the most important component. Good outcomes and safety are paramount to efficiency.
To create efficiency, says Dr. Dugel, the OR team must consider a series of financial and technological factors. “From a financial point of view, we incentivize our staff to be as efficient as possible. We keep a very close eye on the turnover. We realize how much it costs for us to stay open minute by minute, so there is an incentive for the staff to be as efficient as possible.” And, in order to incentive efficiency, surgeons must create a culture where efficiency is valued.
“Efficiency does not mean being fast, it means being really good,” says Dr. Dugel. “Being thorough is just as important in efficiency as anything else. We define for the staff what we want to do, which is to provide the very best care we can in a way that’s as safe and effective as possible.”
Technological support is another important component of efficiency, he says. “For instance, I haven’t used a microscope in 3 years. I use the Alcon Ngenuity system, and everyone sees what’s going on. It’s easy because it’s such a huge picture for everyone to see what stage of surgery we’re in, what I need, what instruments I need, if I need silicone oil or not, when patients should be blocked - everyone can see it and knows it.” His surgical team achieves a turnover time of less than 5 minutes year after year.
“The important thing to realize here is that my time in surgery is never rushed,” says Dr. Dugel. “My surgery time and what I do in surgery does not change. What changes is that in surgery I don’t have to talk much. My staff knows what I need based on their experience and working closely with me, and that helps enormously. Also, what happens around me is very different - people bring me things I need before I ask for them. Efficiency is not magic; it is about defining what efficinecy is, cultivating a culture that embraces efficiency, and then supporting that culture with financial incentives and technological advances.”
COMMUNICATION IS THE FOUNDATION OF OPERATING ROOM PREP
For the 12 retinal surgeons at the Cole Eye Institute, pick lists are created that are specific to each surgeon’s preferences. These lists can include their preferred microscope settings, glove size, gauge preference, and any specific instruments desired for a particular surgery. The pick lists can be delivered to the team the day before surgery. “However, even though a case may be prepared according to the list, every case is different,” says Ms. Williams. “A primary retinal detachment repair is very different from a proliferative vitreoretinopathy detachment, but both may be listed under retinal detachment. Therefore, I like to look at the chart to see why the patient is having surgery, and also have a quick conversation with a resident, fellow, or attending during set-up to address anything specific that is needed for the upcoming case. Open communication ensures the OR is prepared for the case.”
Dr. Boyer, senior partner at Retina Vitreous Associates Medical Group in Los Angeles, California, points out that the surgeon plays a big part in this communication loop. “Our scrub technicians are some of the best and most experienced in the country,” he says. “However, it is the surgeon’s responsibility to convey to the nurses, technicians, and anesthesiologists the particulars of each case so instruments are pulled and available, if needed. The surgeon may know that the patient’s pupil is small and may need iris hooks, or that cautery or a marker or chandler may be needed.”
Communicating clearly with anesthesiologists about the types of anesthesia needed also helps to streamline surgeries, says Mr. Smith. And techs working closely with the anesthesiologist during the surgery helps prevent patient movement. “Under the microscope, any little movement is like an earthquake. I give the anesthesiologist a heads up if I notice a patient moving. Then, they might give a little more propofol or pain medication,” he says.
MAXIMIZING EFFICIENCY AND STERILITY
Mr. Smith says that, for an efficient surgery, the team must stay one step ahead of the surgeon. For example, when nearing the end of a case with laser, Mr. Smith is prepared with gas for the air-fluid exchange. After that, he says, “We’re not going to go back in the eye, so there are certain things that I start getting rid of that I know are no longer going to be of use for this procedure. I’m breaking down at this point. That’s how we get to a 12-minute turnover.”
Sterility, as for all surgical procedures, is critical to the outcomes and overall cost of retinal surgery. “Sterility is number one in our operating room,” says Mr. Smith. As part of the turnover procedure, he soaks the lens with a sterilized 12-minute cold soak solution (OPA; Cidex). Before the day’s procedures, Smith opens all of the retinal surgery packs for the day, ensuring that none are broken.
For patient prep, he has found that a bar to keep the drape from touching the patient’s nose helps with patient comfort under local anesthesia. “Some people get claustrophobic under the drape and they don’t want something touching their face. So, we make a bridge from the right cheek to the left cheek.” He uses Steri-Strips (Nexcare) to seal off any other openings, then uses a 1060 drape with a rolled towel around the head, where the patient’s arm rests. After that, he brings in the sterile tubings, the lines, the light pipes, the cutters, and any other equipment needed for the surgery.
“You can clean eyelashes but you can’t sterilize them,” Mr. Smith says. “And that’s all part of putting those Steri-Strips on. We retract the eyelashes as far as we can. When we make our stabs with the trocars and other instruments, we try to avoid touching the eyelids or any eyelashes around the field. A bad prep can give you a bad outcome, no matter how well the surgery goes.”
Ms. Silva says that having a system in place for each scrub is key for efficient surgery. “We supply every case with basic retina instruments, but with each surgeon comes specifics, and we try to accommodate that within the trays we use.” For example, she says, the team at Spectra Eye Institute knows that Dr. Dugel uses a 27-gauge vitrectomy pack, which can offer better opportunity for entry. “We have a 27-gauge 10,000 vitrector that we hope to offer in all the different gauges to allow closer contact to the retina. We set up the cords and machine the same way every time so it becomes a routine and makes the case more efficient. The microscope and tables stay the same for every case so everyone knows in what proximity to arrange the patient.” Ms. Silva adds, “Using a Mayo stand allows us to put cords across it from the machine. There is little to no room to contaminate between the microscope and cords, so this ensures a quicker start time. We have instruments included in our instrument trays or in the room for every case in case incision closure is needed.”
Mr. Smith cautions that to reduce waste and unnecessary cost, the surgical team should never open any equipment until the surgeon has confirmed that it’s needed. “Surgeons can change their mind in the middle of a procedure, if for example they thought there was a tear but it’s really just a few floaters. Don’t open anything up until you’re sure, or it could be wasted.”
SHARED BUY-IN FOR TECHNOLOGY
Involving the surgical team in decision-making for new equipment purchases can also benefit the hospital. “You don’t want to buy something when you’ve already got three different types of forceps on the shelf that perform the same function,” says Mr. Smith.
He also says that new technology, although it requires more up-front capital expense, has reduced the need for multiple surgical devices, which required more time to set up and use. Good Samaritan Hospital uses the Alcon Constellation vision system, which includes a fragmatome, laser, silicone oil, and cutter. The controls are all on one foot pedal that the surgeon can access, and the surgical technician can change phases of the surgery on a touch screen. “It saves time that you’re not asking the nurse to come over repeatedly, and it saves the hospital money in time and resources,” he says.
TAKEAWAYS FOR THE RETINAL SURGEON
The surgical team is critical to efficient, sterile, and effective retinal surgery. Dedicated staff know the routines and can anticipate the needs of the surgeon and the operating room. Maintaining good communication with the team keeps them informed and well prepared for surgery, including changes that happen during procedures. This reduces potential waste of time and resources, as well as ensures good patient outcomes. RP