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San Francisco-Attention to safety, speed, staffing, standardization, simplicity, and suppleness is the key to efficiency and effectiveness in the operating room (OR), explained Bradford J. Shingleton, MD, at glaucoma subspecialty day during the American Society of Cataract and Refractive Surgery annual meeting.
"Speed is an important component, but it should be targeted for quality's sake," said Dr. Shingleton, assistant clinical professor of ophthalmology, Harvard Medical School, Boston. "Anyone can be fast, but safety is foremost. Then, be sure to empower your staff, standardize your process, keep things simple, and have a supple system that can adapt to change as you aim to keep moving forward and improve your process."
In providing pearls that can benefit the glaucoma surgeon, Dr. Shingleton began by quoting American industrialist Lee Iacocca who said, "The main thing is to keep the main thing the main thing."
A team effort
With that in mind, a team approach is critical, and Dr. Shingleton encourages and empowers his team, delegates responsibilities appropriately, and makes sure they are cross-trained so that there is always coverage in the event of staff absences. Each case is done with one scrub, one circulator, and one nurse anesthetist, and the team is kept consistent, but another staff member is able to step in as needed.
"This can take a lot of effort, but it is worth working hard for," he said.
Standardization-integrating simplicity, consistency, and reproducibility-is another important principle. Dr. Shingleton noted he is a minimalist in his steps and instruments and has templates for placement and positioning of all equipment ranging from surgical instruments to the set up of the operating microscope, operating table height and inclination, irrigation bottle position, and position of the phaco foot pedal.
"These measures sound like very simple things but they make me a much better surgeon because they allow me to avoid wasting steps and to focus entirely on the operation," he said.
Careful preparation preoperatively also makes things run smoothly in the OR. Once a patient is identified as a surgical candidate, all of the pertinent testing and evaluation information is obtained in the outpatient setting before the surgeon's evaluation. Then, the surgeon and patient communication and consent discussion can be completed in a single encounter facilitated with the use of a surgical planning checklist.
Surgical scheduling is handled by a coordinator and is based on a unit system with case complexity increasing through the day. For example, routine phaco cases are considered one unit, a standard filtering procedure is three units, and a shunt procedure or deep sclerectomy is four units. The goal is to complete six to seven units per hour and a total of 50 units for the day.
"Time is the most precious commodity we have, and increasing efficiency in the OR has a valuable payoff for increasing productivity," Dr. Shingleton, who is also clinical instructor of ophthalmology, Tufts University School of Medicine, Boston. "For the surgeon who operates twice a week, gaining 10 units a day translates into 15 extra days a year."
Making sure he never arrives late on surgical days, Dr. Shingleton first reviews the flow sheet for the day so that he is aware of special needs. For each case, the ancillary team will already have taken care of all the preoperative preparation, and from preoperative to postoperative, the patient is kept on the same stretcher chair or bed.
"Transfers take time and the patient should never have to leave the bed," Dr. Shingleton said.
Dr. Shingleton moves between two surgical suites, but he noted surgeons can be efficient working in a single room. If two rooms are used, they should be identical with respect to layout and stock.