The management pattern carried out in a cataract surgery day ward.
Lin Jing,Fang Xiaoqun,Wu Suhong
Eye science
PURPOSE:To evaluate the management practice and process of a cataract surgery day ward. METHODS:From January to December in 2012, a portion of the cataract patients were evaluated for the pattern of day ward management. Methods were as follows: 1) Establish the cataract day ward. 2) Enroll the patients who met the following criteria: voluntary, local residents or outsiders who stayed in a hotel near the hospital, accompanied by family, and who had simple senile cataract without any systemic major diseases. 3) Establish the hospitalization process. 4) Analyze the nursing process. After cataract day surgery, the patients were followed for 2 hours and completed a questionnaire about their needs and sentiments. RESULTS:A total of 3971 cases were observed in this study; 49 cases were switched to a normal pattern of hospitalization because of operative complications, 1 case had a strong desire to switch to a normal pattern of hospitalization because of ocular discomfort, 8 cases went back to the hospital for treatment because of ocular pain, and 52 cases called on the phone to seek help. Overall, 3820 cases(96.2%) returned on time the next day to visit the doctor. No patients showed severe postoperative complications and 98% expressed great satisfaction with the day ward process. Only 200 cases expressed great concern about not knowing how to deal with postoperative pain, the changes in condition outside the hospital, the therapeutic effects, and the problem of expense reimburse-ment. CONCLUSION:Day ward cataract surgery is an efficient and safe mode, and has the potential to relieve the demand for inpatient beds and to ensure timely treatment of the patients. In addition, it helps the patients enjoy health care at public expense, reserving reimbursement for those who need to be hospitalized. Nurses should pay more attention to systemic evaluation of the patients, health education, and psychological guidance, and keep in close communication with doctors, which is the key to ensure the safety of day ward practice.
Outpatient cataract surgery: incident and procedural risk analysis do not support current clinical ophthalmology guidelines.
Koolwijk Jasper,Fick Mark,Selles Caroline,Turgut Gökhan,Noordergraaf Jeske I M,Tukkers Floor S,Noordergraaf Gerrit J
Ophthalmology
OBJECTIVE:To evaluate whether an ophthalmologist-led, non-anesthesia-supported, limited monitoring pathway for phacoemulsification/intraocular lens cataract surgery, can be performed safely with only a medical emergency team providing support. DESIGN:Retrospective, observational, cohort study. PARTICIPANTS:All patients who underwent elective phacoemulsification/intraocular lens surgery under topical anesthesia in the ophthalmology outpatient unit between January 1, 2011, and December 31, 2012. METHODS:Cataract surgery was performed by phacoemulsification under topical anesthesia. The intake process mainly embraced ophthalmic evaluation, obtaining a medical history, and proposing the procedure. A staff ophthalmologist performed the procedure assisted by 2 registered nurses in an independent outpatient clinic operating room within the hospital. The clinical pathway was without dedicated presence of or access to anesthesia service. Perioperative monitoring was limited to blood pressure and plethysmography preoperatively and intraoperatively. Patients were offered supportive care and instructed to avoid fasting and continue all their chronic medication. MAIN OUTCOME MEASURES:The primary outcome measure was the incidence of adverse events requiring medical emergency team (MET) interventions throughout the pathway. Secondary outcome measures were surgical ocular complication rates, use of oral sedatives, and reported reasons to perform the surgery in the classical operation room complex. RESULTS:Within the cataract pathway, 6961 cases (4347 patients) were eligible for analysis. Three MET interventions related to the phacoemulsification/intraocular lens pathway occurred in the 2-year study period, resulting in an intervention rate of 0.04%. None of the interventions was intraoperative. All 3 patients were diagnosed as vasovagal collapse and recuperated uneventfully. No hospital admittance was required. Eight other incidents occurred within the general ophthalmology outpatient unit population during the study period. CONCLUSIONS:Cataract surgery can be safely performed in an outpatient clinic, in the absence of the anesthesia service and with limited workup and monitoring. Basic first aid and basic life support skills seem to be sufficient in case of an adverse event. An MET provides a generous failsafe for this low-risk procedure.
10.1016/j.ophtha.2014.08.030
Failure Modes and Effects Analysis of bilateral same-day cataract surgery.
Shorstein Neal H,Lucido Carol,Carolan James,Liu Liyan,Slean Geraldine,Herrinton Lisa J
Journal of cataract and refractive surgery
PURPOSE:To systematically analyze potential process failures related to bilateral same-day cataract surgery toward the goal of improving patient safety. SETTING:Twenty-one Kaiser Permanente surgery centers, Northern California, USA. DESIGN:Retrospective cohort study. METHODS:Quality experts performed a Failure Modes and Effects Analysis (FMEA) that included an evaluation of sterile processing, pharmaceuticals, perioperative clinic and surgical center visits, and biometry. Potential failures in human factors and communication (modes) were identified. Rates of endophthalmitis, toxic anterior segment syndrome (TASS), and unintended intraocular lens (IOL) implantation were assessed in eyes having bilateral same-day surgery from 2010 through 2014. RESULTS:The study comprised 4754 eyes. The analysis identified 15 significant potential failure modes. These included lapses in instrument processing and compounding errors of intracameral antibiotics that could lead to endophthalmitis or TASS, and ambiguous documentation of IOL selection by surgeons, which could lead to unintended IOL implantation. Of the study sample, 1 eye developed endophthalmitis, 1 eye had unintended IOL implantation (rates, 2 per 10 000; 95% confidence interval [CI], 0.1-12.0 per 10 000), and no eyes developed TASS (upper 95% CI, 8 per 10 000). Recommendations included improving oversight of cleaning and sterilization practices, separating lots of compounded drugs for each eye, and enhancing IOL verification procedures. CONCLUSIONS:Potential failure modes and recommended actions in bilateral same-day cataract surgery were determined using an FMEA. These findings might help improve the reliability and safety of bilateral same-day cataract surgery based on current evidence and standards.
10.1016/j.jcrs.2016.12.025
Office-Based Cataract Surgery: Population Health Outcomes Study of More than 21 000 Cases in the United States.
Ianchulev Tsontcho,Litoff David,Ellinger Donna,Stiverson Kent,Packer Mark
Ophthalmology
PURPOSE:To identify safety and effectiveness outcomes of office-based cataract surgery. Each year, approximately 3.7 million cataract surgeries in the United States are performed in Ambulatory Surgery Center (ASC) and Hospital Outpatient Department (HOPD) locations. Medicare in July 2015 published a solicitation for expert opinion on reimbursing office-based cataract surgery. DESIGN:Large-scale, retrospective, consecutive case series of cataract surgeries performed in Minor Procedure Rooms (MPRs) of a large US integrated healthcare center. PARTICIPANTS:More than 13 500 patients undergoing elective office-based cataract surgery. METHODS:Phacoemulsification cataract surgery performed in MPRs of Kaiser Permanente Colorado from 2011 to 2014. MAIN OUTCOME MEASURES:Postoperative visual acuity and intraoperative and postoperative adverse events (AEs). RESULTS:Office-based cataract surgery was completed in 21 501 eyes (13 507 patients, age 72.6±9.6 years). Phacoemulsification was performed in 99.9% of cases, and manual extracapsular extraction was performed in 0.1% of cases. Systemic comorbidities included hypertension (53.5%), diabetes (22.3%), and chronic obstructive pulmonary disease (9.4%). Postoperative mean best-corrected visual acuity measured 0.14±0.26 logarithm of the minimum angle of resolution units. Intraoperative ocular AEs included 119 (0.55%) cases of capsular tear and 73 (0.34%) cases of vitreous loss. Postoperative AEs included iritis (n = 330, 1.53%), corneal edema (n = 110, 0.53%), and retinal tear or detachment (n = 30, 0.14%). No endophthalmitis was reported. Second surgeries were performed in 0.70% of treated eyes within 6 months. There were no life- or vision-threatening intraoperative or perioperative AEs. CONCLUSIONS:This is the largest US study to investigate the safety and effectiveness of office-based cataract surgery performed in MPRs. Office-based efficacy outcomes were consistently excellent, with a safety profile expected of minimally invasive cataract procedures performed in ASCs and HOPDs.
10.1016/j.ophtha.2015.12.020
Usefulness of surgical complexity classification index in cataract surgery process.
Salazar Méndez R,Cuesta García M,Llaneza Velasco M E,Rodríguez Villa S,Cubillas Martín M,Alonso Álvarez C M
Archivos de la Sociedad Espanola de Oftalmologia
OBJECTIVE:To evaluate the usefulness of surgical complexity classification index (SCCI) to predict the degree of surgical difficulty in cataract surgery. MATERIAL AND METHODS:This retrospective study includes data collected between January 2013 and December 2014 from patients who underwent cataract extraction by phacoemulsification at our hospital. A sample size of 159 patients was obtained by simple random sampling (P=.5, 10% accuracy, 95% confidence). The main variables were: recording and value of SCCI in electronic medical record (EMR), presence of exfoliation syndrome (XFS), criteria for inclusion in surgical waiting list (SWL), and functional results. SCCI was classified into 7 categories (range: 1-4) according to predictors of technical difficulty, which was indirectly estimated in terms of surgical time (ST). All statistical analyses were performed using SPSS v15.0 statistical software. RESULTS:Prevalence of XFS was 18.2% (95%CI: 11.9-24.5). In terms of quality indicators in the cataract surgery process, 96.8% of patients met at least one of the criteria to be included in SWL, and 98.1% gained ≥2 Snellen lines. The SCCI was recorded in EMR of 98.1% patients, and it was grouped for study into 2 categories: High and low surgical complexity. Statistically significant differences in the distribution of ST were found depending on the assigned SCCI (P<.005) and the presence of XFS (P<.005). CONCLUSIONS:The SCCI enables to estimate the degree of surgical complexity in terms of ST in cataract surgery, which is especially useful in those areas with high prevalence of XFS, because of the higher theoretical risk of surgical complications.
10.1016/j.oftal.2016.01.010
Day care versus in-patient surgery for age-related cataract.
Lawrence David,Fedorowicz Zbys,van Zuuren Esther J
The Cochrane database of systematic reviews
BACKGROUND:Age-related cataract accounts for more than 40% of cases of blindness in the world with the majority of people who are blind from cataract living in lower income countries. With the increased number of people with cataract, it is important to review the evidence on the effectiveness of day care cataract surgery. OBJECTIVES:To provide authoritative, reliable evidence regarding the safety, feasibility, effectiveness and cost-effectiveness of day case cataract extraction by comparing clinical outcomes, cost-effectiveness, patient satisfaction or a combination of these in cataract operations performed in day care versus in-patient units. SEARCH METHODS:We searched CENTRAL (which contains the Cochrane Eyes and Vision Group Trials Register) (2015, Issue 7), Ovid MEDLINE, Ovid MEDLINE In-Process and Other Non-Indexed Citations, Ovid MEDLINE Daily, Ovid OLDMEDLINE (January 1946 to August 2015), EMBASE (January 1980 to August 2015), Latin American and Caribbean Health Sciences Literature Database (LILACS) (January 1982 to August 2015), the ISRCTN registry (www.isrctn.com/editAdvancedSearch), ClinicalTrials.gov (www.clinicaltrials.gov) and the World Health Organization (WHO) International Clinical Trials Registry Platform (ICTRP) (www.who.int/ictrp/search/en). We did not use any date or language restrictions in the electronic searches for trials. We last searched the electronic databases on 17 August 2015. SELECTION CRITERIA:We included randomised controlled trials comparing day care and in-patient surgery for age-related cataract. The primary outcome was the achievement of a satisfactory visual acuity six weeks after the operation. DATA COLLECTION AND ANALYSIS:Two review authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We collected adverse effects information from the trials. MAIN RESULTS:We included two trials. One study was conducted in the USA in 1981 (250 people randomised and completed trial) and one study conducted in Spain in 2001 (1034 randomised, 935 completed trial). Both trials used extracapsular cataract extraction techniques that are not commonly used in higher income countries now. Most of the data in this review came from the larger trial, which we judged to be at low risk of bias.The mean change in visual acuity (in Snellen lines) of the operated eye four months postoperatively was similar in people given day care surgery (mean 4.1 lines standard deviation (SD) 2.3, 464 participants) compared to people treated as in-patients (mean 4.1 lines, SD 2.2, 471 participants) (P value = 0.74). No data were available from either study on intra-operative complications.Wound leakage, intraocular pressure (IOP) and corneal oedema were reported in the first day postoperatively and at four months after surgery. There was an increased risk of high IOP in the day care group in the first day after surgery (risk ratio (RR) 3.33, 95% confidence intervals (CI) 1.21 to 9.16, 935 participants) but not at four months (RR 0.61, 95% CI 0.14 to 2.55, 935 participants). The findings for the other outcomes were inconclusive with wide CIs. There were two cases of endophthalmitis observed at four months in the day care group and none in the in-patient group. The smaller study stated that there were no infections or severe hyphaemas.In a subset of participants evaluated for quality of life (VF14 questionnaire) similar change in quality of life before and four months after surgery was observed (mean change in VF14 score: day care group 25.2, SD 21.2, 150 participants; in-patient group: 23.5, SD 25.7, 155 participants; P value = 0.30). Subjective assessment of patient satisfaction in the smaller study suggested that participants preferred to recuperate at home, were more comfortable in their familiar surroundings and enjoyed the family support that they received at home. Costs were 20% more for the in-patient group and this was attributed to higher costs for overnight stay. AUTHORS' CONCLUSIONS:This review provides evidence that there is cost saving with day care cataract surgery compared to in-patient cataract surgery. Although effects on visual acuity and quality of life appeared similar, the evidence with respect to postoperative complications was inconclusive because the effect estimates were imprecise. Given the wide-spread adoption of day care cataract surgery, future research in cataract clinical pathways should focus on evidence provided by high quality clinical databases (registers), which would enable clinicians and healthcare planners to agree clinical and social indications for in-patient care and so make better use of resources.
10.1002/14651858.CD004242.pub5
Ambulatory surgery scheduling. Assuring a smooth patient flow.
Voss S J
AORN journal
Managing the surgical schedule and facilitating patient flow through the ambulatory surgery unit is an administrative challenge. Each area is dependent on the other, making good communication among staff members essential. This communication begins in the physician's office when the surgical procedure is scheduled and continues with the patient and family through the entire perioperative experience.
Ambulatory surgery centers: possible solution to improve cataract healthcare in medical deserts.
Journal of cataract and refractive surgery
PURPOSE:To investigate the epidemiological impact of an ambulatory cataract surgery center providing a fast-track procedure without anesthetic evaluation on the access to cataract healthcare. SETTING:French nationwide study. DESIGN:Retrospective cross-sectional study. METHODS:The study included individuals undergoing cataract surgery from the French national administrative database of medical information. Data analyses focused on patients living in the Cher and neighboring areas. Epidemiological indicators of patient flow and healthcare efficiency were calculated. A medicoeconomic analysis was performed. RESULTS:Between 2012 and 2018, activity increased by +50.2% (3665 to 5506) interventions in the Cher area compared with a national increase of +22.7% (720 351/884 254), while maintaining a constant ophthalmologist workforce. The leakage ratio decreased by 5.9 points (26.3% to 20.4%), whereas the attractiveness and self-sufficiency ratios increased by 2.3 (8.6% to 10.9%) and 8.6 (80.6% to 89.2%) points, respectively. The age- and sex-standardized rate of healthcare utilization for cataract surgery increased by 4.3 points (11.6 to 15.9 cataract surgeries per 1000 inhabitants), making the Cher the second best French area in 2018 for the rate of cataract surgery despite ranking 96th of 109 French areas for ophthalmologist density. The cost of the cataract removal procedure was 523.99€ (666.22€ in the conventional operating room). CONCLUSIONS:An ambulatory cataract surgery center with a fast-track procedure could represent a solution in medical deserts to improve cataract healthcare without supplementary funding. Nonetheless, consulting activity should be optimized to detect eye disorders and schedule interventions.
10.1097/j.jcrs.0000000000000452