Cataract Prep

Top-Notch Surgical Care: It Takes a Team

Laurie K. Brown, COMT, COE, OSA, OCS, CPSS, Eugene, OR

Suwanna Smith (left), technologist, Dr. Richard Hoffman and Laurie Brown, administrator with the practice of Drs. Fine, Hoffman, Packer & Sims, Eugene, Ore.

Here's how the ophthalmic technician participates in state-of-the-art cataract surgery.

Because the entire ophthalmic practice team participates in preparing patients for state-of-the-art cataract surgery, comprehensive and efficient communication between the clinic practice and ambulatory surgery center (ASC) is necessary to achieve the best outcomes and patient experiences. In this article, I'll describe the ophthalmic technician's role as part of the team that prepares patients for cataract surgery.

Pre-appointment prep

The surgeon's support team goes into action from the moment the patient calls to request the cataract evaluation appointment. In our practice, we direct patients to our secure patient portal web site for registration, medical history gathering, and ophthalmic information in advance of the appointment. We happily mail forms in advance if requested, and offer forms on our web site, which can be printed for the patient to bring with them to their appointment. Quality of life evaluation is efficiently performed with a standardized form available on our web site. Cataract symptoms and usual course of care information is also available online for patients to access to begin their education. In addition, our site describes the outpatient surgical experience available in the Oregon Eye Surgery Center.

Cataract evaluation

At the cataract evaluation appointment, our skilled certified technicians take thorough histories utilizing an electronic health record (EHR). These histories include visual symptoms, lifestyle hindrances and frustrations typically related to cataract. A comprehensive eye examination then ensues, including manifest refraction, BAT (brightness acuity test) glare testing as indicated, corneal topography and wavefront analysis and dilation, as well as additional patient education taking place in advance of the physician exam. We provide a significant amount of in-office patient education to patients using DVDs that discuss cataract and intraocular lens implant (IOL) options consent. These DVDs are shown on personal DVD players with headphones. If a spouse or a family member is present with the patient, dual headphones are offered.

The comprehensive exam

Once dilation is complete, the surgeon performs a comprehensive exam dictating to his or her scribing technician, who enters the data into the EHR in real time during the exam. The surgeon then discusses the examination results and offers cataract surgery as indicated. A full PARQ (procedure, alternatives, risks and questions solicited) discussion between the surgeon and patient is held and documented by the scribe. Available advanced technologies through our research opportunities will be offered when appropriate. Included in the discussion are the elective options of IOL type and astigmatism correction. Utilizing our EHR to enhance our efficiency, our scribes document each patient decision so that it is available for our surgery coordinator to reference as the procedure is scheduled with the patient.

The tech team, L to R back row: Amber Ambrozaitis, COT, OCS; Jon Cassidy, COMT, OCS; Brandy Hunt, COA, OCS; Suwanna Smith, COMT, OCS; Donnie Hammers, OA; Peggy Coffman, COT, OCS; L to R front row: Wendy Fandino, OA; Sue Stuhr, COT, OCS; Rachel Solberg, COA; Tina Callina, COMT, CCRC, OCS; Not pictured: Tony Reynolds, COT, OCS; Laurie Brown, COMT, OSA, OCS, COE.

Included in our EHR Quick Text for scheduling surgery are the patient specifics of desired post-op goal, IOL type, back up IOL type and elective procedures chosen. Other key information stored in the EHR includes confirmation of dilated exam performed, full PARQ discussion held, requirements met for payer guidelines, surgeon's assessment of the patient's ability to undergo monitored anesthesia care and topical anesthesia, as well as pre- and post-op medication choices, estimated length of procedure, and any anticipated, non-routine surgical supplies that may be needed, including those when the surgeon anticipates performing a complex cataract extraction. These scheduling particulars are then visible to the surgery coordinator and ASC staff as needed. This typical cataract evaluation appointment is completed in approximately 60 minutes.

Scheduling surgery

Following the surgeon's visit, the cataract patient is escorted to meet our surgery scheduler who efficiently assists the patient in choosing a date for surgery. The related appointments are then entered in the system for both the office and ASC to reference. The surgical decisions made by the patient with their surgeon are consented to by the patient, with the coordinator answering any additional logistical questions as needed and collecting any supplementary health data required by the ASC. All fees are disclosed and consented to, payment arrangements made, and pre- and post-op care instructions given verbally and in written form for the patient to reference later.

It is at this time we send to our insurance and referral department any needed requests for pre-authorization. The surgical coordinator electronically sends patient-particular case notes from the surgeon's Quick Text along to the ASC to ensure all needed supplies will be available for the patient on their surgery day.

The surgery coordinator then pages a technician to perform the pre-op measurements. Should a patient be wearing contact lenses, a protocol is followed for the discontinuation of contact lens wear prior to a separate appointment for pre-op measurements. If a referral is required for additional testing, a second pre-op measurement appointment is scheduled. The coordinator typically takes less than 15 minutes to accomplish their counseling work with the pre-op patient.

Biometry and other testing

Our clinic float technician then performs biometry and any other pre-op measurements required. Technicians follow surgeon protocols for obtaining pre-op measurements, ensuring data is consistent with the manifest refraction and ocular history, and perform any clarifying measurements required, such as immersion biometry if optical biometry is insufficient. The patient's visit is then concluded for the day and they are instructed to return on the surgery day and to let us know if any questions or concerns arise in the meantime.

Behind-the-scenes prep work

Within a few days following the patient visit, technicians perform the data entry for IOL calculations according to the surgeon's protocol. A biometry interpretation document is created with pertinent data entered from measurements taken and calculations performed, as well as patient-specific notes from the surgery scheduling Quick Text. Next, the technicians route the information to the surgeon's EHR desktop for IOL ordering. We keep current with our patient calculations, often ordering the IOL more than a week in advance, to enable the ASC to work to ensure the surgeon and patient needs are met for each surgical case.

At least two days before surgery and often sooner, the surgery coordinator completes the preliminary history and physical and surgical orders in our EHR system and routes these to the surgeon for finalization, signature, and forward routing to the ASC well in advance of the surgery day. One of the many wonders of EHR, which we greatly appreciate, is the ability to call forward data fields as needed into specific forms for the ASC, such as the physical examination results into the H&P document. Data entry errors are far fewer utilizing EHR technology, and the ability for anyone involved in a patient's care to access any related data at any time is a distinct advantage.

Once scheduled at the ASC, a patient's data is immediately available to the nursing staff to enable them to use whatever workflows are advantageous to them regarding their responsibilities with our mutual patient.

The surgical assistant's role

It is our clinic team's goal to get needed information to the ASC in a timely and accurate fashion to support our surgeons and patients well. Each of our surgeons have their own assigned technician as surgical assistant, although every assistant works with each doctor from time to time to ensure familiarity and the ability to cover for absences or vacations at any time. The surgeon's assistant will check the surgery schedule arrangement two days in advance of the surgery day to ensure the cases are in the order preferred by the surgeon. This also ensures that all ancillary needs are met for the day. The assistant will communicate with the ASC scheduler and OR manager as needed to ensure the smoothest surgery session possible. Our surgical assistants offer a great continuity of care between the clinic practice and surgery center team. Our patients appreciate seeing familiar faces from their office visits at the time of surgery; we consider this to be not only comforting, but as well a distinct advantage in providing the best care possible. In addition, the assistant has proven to be invaluable in interpreting ophthalmic-specific measurement data and terminology for operating room nurses.

Key details

There are many details that are important to communicate to the ASC in advance of surgery. Examples include potential needs for endocapsular tension rings in post vitrectomy or pseudoexfoliation patients, pupil dilators such as iris hooks or Malyugan rings needed in poorly dilating or miotic pupils, and anterior capsule dye for extremely dense cataracts. Our ASC has created a large print “letter” to hang on the wall in the OR during the surgical case. When printed, the letter pulls the patient-specific case details from the EHR and highlights them for the entire OR team. This allows a final confirmation of important details before starting the surgery. It is also used as part of the OR standard time-out protocol in which everyone in the surgical suite stops to focus together as a team for one minute prior to the first incision to verbally confirm the patient identity, operative eye, procedures to be performed, and any other pertinent case-dependent details.

Ophthalmic technicians play a vital role in the outcome of cataract surgery by actively participating in patient care throughout the pre-, intra-, and post-op periods. Their accuracy and attention to detail in providing patient care and education, gathering data, obtaining measurements, and first-assisting at surgery is paramount to the high-quality, cost-effective, and professional care we desire to provide to each and every patient. OP

Ms. Brown is practice administrator for Drs. Fine, Hoffman, Packer & Sims, a world-renowned cataract and refractive surgery practice. She has held JCAHPO certification and worked in ophthalmology in various capacities for over 27 years.