Strategies for Enhancing Productivity in your ASC

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Strategies for Enhancing Productivity in your ASC

• Paul N. Arnold, MD, FACSSpringfield, Missouri
• I have no financial interest in any products
  discussed

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In 1990, Built Clinic and ASC
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2003 New Clinic
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And New ASC
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Walk through process from front to back
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Prior to Surgery Day

• Experienced Team
• Have all paperwork finished
• H P, Pre-op orders
• Discharge instructions
• Surgical note fill in blanks, addenda
• The day of surgery, just sign charts
• Any deviation from the norm can be noted

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The Master List

• 3x5 pocket card - surgeon
• Master patient list with all info
• Name, check-in time, procedure, anesthesia, IOL
  style power
• List is placed everywhere
• on scope phaco RN desks (circulator
  pre-op)

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ASC Reception Room

• Check-in process
• Patient signs ASC consent
• Mark operative eye with a red dot over brow
• Begin dilation in the reception room
• Nicer for patients to sit and talk with family
• Dilation becomes indelible mark for site of
  surg
• ALWAYS make a pit stop before pre-op
• Wheelchair garage in hallway

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Wheelchair Garage
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Pre-op Preparation

• Foot sheet with ALL patient info
• ALL monitors at foot of bed, go with pt.
• Knee pillow
• Warm blankets

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Lopsided Pillow

• Lopsided pillow for temporal approach
• Dick Mackool, from Impex

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Foot sheet
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Monitor Knee Pad
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Anesthesia

• gt 90 topical IC with IV sedation
• Propofol titration as needed in 1cc doses.
  Usually total of 2cc (20mg) IV
  1cc in pre-op, 1cc in OR
• Save midazolam for the young anxious
• Longer acting - somnolence
• Deep topical, holding lids open, with counsel
• TetraVisc (Paul Koch, MD)
• Topical 5 povidone iodine in AT in pre-op

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Anesthesia

• Peribulbar 10for squeezers, movers shakers,
  and complicated cases
• Usually a 4cc IV push of propofol
• 2 lidocaine without epi, with HUD (usu. 6-7cc)
• Single site, single injection 1 inch 25 ga. sharp
• See Arnold, PN. Prospective Study JCRS, Vol.
  18, pg 157-161, March 1992
• Remove tape or patch 4 hours after discharge

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In the OR

• Diagonal bed placement
• Maximizes room around the head
• Time out occurs while patient is prepped
• Circulator, scrub, and surgeon all
  verbally confirm eye IOL
• We are preparing Mrs. Jones right eye for a
  22.0D AcrySof IQ
• Space savers ceiling mount scope,
  in-wall cupboards with glass faces

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Diagonal Corner Monitor
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Large Screen OR Corner Monitor
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Space Saving Ideas

• Table Top Sterilizers eg, Tuttnauer
  units X 2-3 2540 EKACycle time 10 min. _at_ 275

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Space Saving Devices

• In wall cabinets, labeled drawers
• Compact Phaco machines
• Small back table, no Mayo

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In the OR

• Prepare all syringes before first case
• Split Ocucoat and Viscoat for duovisc
• Intracameral preservative free 1 lidocaine
• Keep all in sterile metal covered tray
• We never use a hot phaco handpiece
• After sterilization, handpieces are placed in
  sterile metal covered tray for later cases

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Sterile Covered Tray
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Family Viewing Room

• Bring the family into the OR
• Patient and family are reassured
• Positive PR no fear
• Can achieve viewing connection by
• Direct viewing from adjacent room
• View by a monitor in a distant room
• Patient / family liaison
• Audio contact

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Viewing Room
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Viewing Room
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OR Cameras

• Room camera
• Microscope camera
• TV Monitors in OR, Viewing room, pre-op
• CPU to control video input / output
• Digital Video
• Editing Recording

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OR Scope
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OR Cameras
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2 cameras, 2 views
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Computer Control of ImagesMedXChange
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CPU controls video input/output
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2 Surgical Pearls

• 1.) Make paracentesis fixate eye with 0.8mm
  blunt sided diamond
• This fixates the eye for 2.8mm keratome
• R. Bruce Wallace, MD
• 2.) Cystotome on VE syringe
• 1 in and out vs. 2 or even 3

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In the OR

• If you have 1 scrub and one RN
• Can cut turnover time in half with one more
  technician the machine tech
• Alternate scrubs on cases 4-5 cases/hour
  in 1 OR
• Many benefits to 2 surgical techs
• Less boring for them
• Learn the phaco machine better
• Backup for sick days

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Post-op Patient/Family Counsel Room

• Room is adjacent to pre/post-op door
• Saves nurse time in post-op
• Family joins patient for counseling
• Good time for snack and coffee
• Private room for surgeon discussion

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Post-op Counseling Room
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Some Good ASC News

• CMS issued new payment system regs
• Begins 1/1/2008 phased in over 4 years
• ASCs paid 65 of HOPD rate linked
• 66984 up each year in HOPD frozen in ASC
• In 2010, annual COL Adjustments
• Procedures list eliminated
• If paid in HOPD, covered in ASC

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Closed Arnold Vision in June

• You never learn from success.
• Success you take as the natural order
  of things. David Ivor Young
• Kept off 2 major managed care/hospital panels
• Patients who could see us paid 2.5X as much

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Having built 2 and sold 1 ASC,What Id do
differently

• Prepare for worst possible scenario
• Make sure of case volume before building
• Beware of managed care exclusion
• If you build it, they will come NOT !!!
• Larger ORs are better circulation space
• Build 2 ORs even if one is a shell
• Ceiling scopes are great, but not for resale
• Consider piping for O2 may need gas

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Best Advice

• Constantly re-evaluate your procedures
• What can we be doing better?
• Better for patients, staff, and surgeons
• Faster is not synonymous with Better
• What can we learn from our colleagues?
• Attend OOSS meetings !!!
• Enlist the advice of staff in each area
• Constant Quality Improvement

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A Few Good Ones