Challenge. Turnaround time at Gottlieb's nine inpatient ORs used to be so slow that it was harming productivity and thus the income of ophthalmologists on staff. When Dr. Proctor arrived at Gottlieb in 1994, turnaround between procedures took 45 minutes. "I could go into the doctors' lounge, watch a little TV and even visit a few of my patients in the hospital," he recalls, "but I realized my volume was really suffering." He could only do about four cases in a half-day. After a few changes focusing on efficiency were introduced in the early 2000s, turnaround time fell to about 20 minutes, allowing him to perform two or three more cases in the same time period, but it was still not good enough.
Preparation. Dr. Proctor and the main OR nurse began planning new efficiencies for eye surgery about four years ago. They consulted with the outpatient surgery coordinator, OR nurses and other OR personnel, and Dr. Proctor drew heavily from efficiencies he had seen in nearby ASCs where he also worked.
Introducing changes. The team came up with the following 11 changes.
1. Reduce pre-op paperwork. Previously, the OR team had to gather about 15 pages of standard surgery information on each patient, much of which had nothing to do with eye surgery. For example, an eye surgery patient doesn't need a blood transfusion. Paperwork for cataract surgery was reduced to about 10 pages.
2. Use specialized personnel. The same nurse and orderly now attend to all eye surgery patients in the pre-op holding area. These personnel know exactly what eye patients need, such as administering eye drops in preparation for surgery. The orderly attaches all lines for the heart monitor and oxygen and then positions the patient so staff can immediately begin prepping the eye when the patient is rolled into the OR.
3. Add two more patient carts. Since eye surgeries are shorter than other surgeries, more carts for patients are needed. These carts had to be specially equipped for eye surgery. Using more carts means patients don't have to be moved from the cart to a surgical bed to free up the cart for the next patient. This reduces time and effort.
4. Create a customized eye tray. Every surgical tool is in the same exact place in the tray so the surgeon does not even have to ask for an instrument. "I just hold out my hand," Dr. Proctor says. Only essential instruments for a standard cataract case are in the trays, reducing clutter and confusion. Peel-packed instruments needed in special circumstances are easily accessible in a nearby eye cart.
5. Place all equipment in the "eye room." All eye instruments, equipment, intraocular lenses and extra ocular medications are in the designated eye surgery OR so the surgical team can stay in one place, focusing on the patient, rather than wander the surgical floor looking for equipment.
6. Strategically position large equipment. The microscope and phacoemulsification machine are placed so they do not have to be moved between cases even when changing from right eye to left. This saves two to three minutes moving around equipment between operations, adding up to more than 30 minutes saved in the half-day.
7. Batch left eyes, right eyes together. A surgeon working on just one eye, either right or left, does not have to switch positions, readjust the chair or move the foot pedals. Having only one particular eye to operate on also enhances surgical site safety. While batching eyes is not always possible, it can be done often enough to impact time.
8. Use a pillow to immobilize patient. Instead of immobilizing the patient's head with tape, which is time-consuming, the OR now uses an L-shaped pillow prevents the patient's head from moving away from the surgeon.
9. Use the bed rails. Bed rails used to be lowered and the patient was strapped to the bed with Velcro straps. Now the rails are kept up without strapping. As long as the surgeon is only operating at the head of the bed, the rails will not interfere and are more dependable than straps if a patient starts to roll.
10. Make it easy for everyone to identify the patient. A sheet of paper on the wall identifies the patient's name, lens type and power, and which eye is to be operated on. This is not only a safety feature but also helps the staff quickly identify the needed lens.
11. Keep the patient's family close by. Because the patient leaves the holding area for only about 15 minutes for surgery, the family can stay in that area. Instead of looking for family members in the waiting area to talk to them afterwards, the surgeon can join them back in the holding bay with the patient. Afterwards, the surgeon can immediately go to the next case, typically next door, and has a cleaner environment than the waiting area.
Implementation. Efficiencies came slowly as the team experimented to find the best way to implement them. For example, it took several different iterations of chart pages before the best combination was found. "It was a work in progress," Dr. Proctor recalls. "It wasn't like a switch was turned on."
Results. Dr. Proctor now can perform up to 17 surgeries in one room in half a day, a stunning increase over the six or seven cases he could do before the changes. Overall, cataract surgery volume at Gottlieb has risen from 479 in 2006-2007 to 565 in 2007-2008 and to 659 in 2008-2009. "Not only are we more efficient but I think it's a safer environment for both the patients and the staff," Dr. Proctor says. Surgeons in a few other specialties at Gottlieb are now adapting the program to make their own ORs more efficient.
Contact Dr. Proctor at proctor1211@comcast.net. Learn more about Gottlieb Memorial Hospital.