Do the job properly: See cataract surgery clearly
August 1, 2001 6 minutes read
Do the job properly: See cataract surgery clearly
Cataract surgery is the most common surgery done in an ambulatory setting. If you want to be a top performer, then you should hone your teamwork skills, says Naomi Kuznets, PhD, director of the Accreditation Association for Ambulatory Health Care’s (AAAHC) Institute for Quality Improvement (IQI) in Wilmette, IL.
The institute looked at 329 cases submitted by 18 organizations in its second study on cataract extraction with lens insertion. Nothing much changed between the 1999 and 2000 study, she says. But it is even more clearly evident that the best organizations are the ones that take the teamwork message to heart.
"The best performers don’t sit back on their laurels," she notes. "They are interested in continually doing better and in working together to improve." Prima donnas need not apply to these organizations, she notes. "In the best of the best, the anesthesiologists clean up their own mess. Why wait for a tech if that will slow down the turnover of the room? They pick up slack from each other and aren’t married to specific job descriptions," Kuznets adds.
Among the findings of the study:
• Pre-procedure time ranged from a low of less than an hour to two hours. The median time was 78 minutes. Tips from the better performing facilities include having only one patient at a time in each area; providing multiple patients with their blocks at the same time; and making sure the patient is ready when the surgeon walks in so he or she is not delayed at all.
• Procedure time ranged from about seven minutes to 35 minutes, with a median time of 16 minutes. The best performer has learned over time that it takes five sets of instruments to support proper cleaning and sterilization and to maintain the team’s pace.
• Discharge time ranges from less than 10 minutes to about an hour. The median time is 23.5 minutes. The best performer states that its patients recover from Brevital before going to the OR and is ready for instructions immediately in the post-op area. Nursing staff at that organization also call patients within a few hours of surgery to check patient status, verify understanding of instructions, and answer questions. Good patient education seems a common thread among those with the lowest discharge times.
| Cataract Surgery: Anesthetic Block Combinations | ||
| Anesthetic | Percentage of Respondents Using |
|
| Retrobulbar alone | 20% | |
| Peribulbar, monitored anesthesia care (MAC)* | 19% | |
| Retrobulbar, IV, MAC | 18% | |
| Peribulbar, IV | 14% | |
| Peribulbar, IV, MAC | 9% | |
| Peribulbar alone | 8% | |
| Retrobulbar, IV | 7% | |
| Retrobulbar, Peribulbar, other | 3% | |
| Retrobulbar, MAC | 2% | |
| * Monitored anesthesia care differs from local and regional anesthesia by the use of sedatives and other agents that are given as inhalants or by IV; the dosages are so low that the patients are responsive and breathe unassisted. | ||
| (Editor’s note: Those using block anesthetics completed their procedures in an average of 17.4 minutes compared to 16 minutes for those using topical anesthetics. About 45% of respondents use the latter.) | ||
| Source: Institute for Quality Improvement, Wilmette, IL. | ||
Knowing how long it takes to move a patient through the system is important to success, says Kuznets. "We are going to be looking at this in many more studies now. If you have a really long pre-procedure time, but find it isn’t long enough, you have a problem."
She says another differentiation between the best organizations and their counterparts is that the better performers are able to negotiate better deals for drug and supply costs. "Even if you aren’t big and you know enough — and your physicians are willing to do an exclusive deal with a company to get better prices — you can negotiate good deals."
Many representatives will say they can’t get customers prices as low some of the better performers report. "But if you know your market and you ask the right questions, you could be surprised," she says.
Average cost for intraocular lenses ranged from just less than $40 to more than $150. The best performer uses Alcon Intraocular Lens, has a midrange annual volume of procedures, but is able to negotiate this good price. It does 80% of its business exclusively with one company. The next best performer, which had the lowest annual volume, uses the Chiron Intraocular Lenz and only pays an average of $40 each. If a facility is owned by a hospital, it may be easier to get better supply costs, regardless of the size of the organization or its volume.
Sedative and narcotic costs combined ranged from less than a dollar per case for an organization that only used sedatives, to about $6.50 for a facility that uses both. The best performer uses Midazolam (1.5 mg to 3.5 mg) and Fentanyl (50 mcg) for each case.
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There is a great deal of interest among members in this study, Kuznets says. "People are interested in seeing how implementing changes one year impacts their performance the next. When we do satisfaction evaluations of our studies, we get comments that participants do use this information."
Just how well the changes organizations made last year will impact their performance this year should be evident next spring, when the 2001 Cataract Extraction with Lens Insertion study becomes available. The institute is collecting the data now and should start the number crunching this fall.
Along with that third cataract edition, the IQI is working on two other studies of interest, says Kuznets. In an upcoming diagnostic colonoscopy study, procedure time will be compared to how many polyps and other abnormalities were found. "Some organizations that look like they have a long procedure time were actually doing well compared to others which had less complicated cases."
More than 800 patients in 33 organizations will be featured in that study. "One interesting finding is that a small but significant group say they wouldn’t go back for another colonoscopy even if it was recommended," says Kuznets. "A large number of those had severe discomfort: a four or five on a scale of five. And of those, most of them had no preoperative medication. That has a potentially disastrous public health consequence. It means we may not catch cancers early."
A second upcoming study is not a traditional study, but looks at the 1,300 organizations accredited by the AAAHC. Forty-five percent of them responded to questions about medical errors that result in injury or illness as well as near-miss situations. "The Institute of Medicine looked at hospitals. We want to look at ambulatory settings."
Some 30% of the accredited organizations are looking at medical errors and near misses. Some are involved in mandatory programs, while others have started voluntary efforts, Kuznets says. "We asked them if they were not involved now, what would motivate them to become involved. Only a very small number say nothing would entice them to investigate this subject."
Although the data are still being analyzed, the larger the organization, the more likely it is to be interested in understanding its medical error and near-miss rates, she says.
The exception is ambulatory surgery centers, which although they might not be associated with a network, have large clinical staff that are affiliated with professional organizations that offer them help with this subject. "We have to find ways to help the smaller organizations," she says. "Maybe national professional organizations have to take a bigger role. For the small group, there are issues of confidentiality, of time and money."
This report will be sent on to state legislatures, state medical boards, and branches of the federal government that are interested in the topic.
[For more information, contact:
• Naomi Kuznets, PhD, Director, Accreditation Association for Ambulatory Health Care, Institute for Quality Improvement, 3201 Old Glenview Road, No. 300, Wilmette, IL 60091. Telephone:(847) 853-6079. Web site: www.aaahc.org.]
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