At The Eye Care Center in upstate New York, we see office-based surgery (OBS) as the next step in the evolution of outstanding surgical care for patients in our practice. With OBS, our goal is to provide complete continuity of care from initial consultation through surgery and into postoperative care. The Eye Care Center is a multispecialty practice, and within our OBS we are currently performing cataract, corneal, microinvasive glaucoma surgery (MIGS), and oculoplastic procedures.
This article discusses our shift to OBS, safety and quality standards, patient and surgeon considerations, the patient experience, advantages for the practice, and the impact on staff.
The shift to OBS
The impact of the pandemic provided the initial impetus for many practices, including The Eye Care Center, to shift to OBS. In some instances, we found that it became problematic to obtain space, time, and consistent staffing in hospital- or ambulatory surgery center (ASC)-based ORs due to staff turnover and shortages, including shortages of anesthesiology providers. OBS helped us avoid these issues and continue to provide the highest quality sight-restoring care. iOR Partners provided us with the training, logistical, and billing support for us to make our transition to OBS with confidence.
Safety and quality standards
In any surgical setting, quality of care and patient safety are paramount for optimizing outcomes. OBS suites, hospitals, and ASCs all adhere to the same safety standards. Accreditation is provided for all three entities through the Joint Commission, Accreditation Association for Ambulatory Health Care, or the American Association of Accreditation of Ambulatory Surgery Facilities. Already, more than 40,000 cases have been performed safely within OBS, and that number is expected to grow exponentially.1
The difference between an OBS suite and an ASC is that OBS functions under the physician’s license while the ASC functions under a separate license — the equipment and surgical staging requirements are the same.
Patient and surgeon considerations
OBS may not be appropriate for every type of case, for every surgeon, or for every patient. Complex cases that are challenging, longer, or more uncomfortable may be easier for the patient if IV sedation is used, which may also provide some degree of amnesia. Surgeons must be able to adapt their skills to perform selected procedures in the office in a fashion that is relaxing and reassuring to the patient.
Patients who have serious health concerns such as organ failure, or conditions requiring cardiac monitoring, may be better served where an anesthesiologist can be solely focused on these issues. However, many patients with mild to moderate medical problems can be considered for OBS. Since fasting and the withholding of normal medications is not required in cases using oral sedation, blood sugar will be less disrupted and run more in line with normal levels. It is important that providers exercise good judgment and perform within their comfort zone.
Our OBS patient experience
At our practice, we have found patients often prefer the OBS experience when they are candidates. By bringing everything under one roof, they are familiar with the building, the physician, and the staff, which can be comforting. In our office, a single team provides this cohesive approach to patient care. We provide a peaceful and relaxing environment for them to dilate prior to the surgery. There is a gentleness and familiarity that can comfort the patient. In addition, patients do not need to change into hospital gowns; rather, they remain in their own clothing of comfort.
In our OBS suite, we choose to only offer oral sedation, the impact of which is mild. Even then, about one-third of our patients proceed through cataract surgery comfortably without any sedation. For smaller sized patients or older patients that request sedation, we typically start with just 5 mg of diazepam. Rarely, a patient will request more. One of the advantages of oral sedation is that patients are no longer required to fast, making it easier to attend to their normal activities before arrival. This also makes it easier to schedule patients over the course of the day as patients can conduct their normal routines until their arrival time without the lethargy and mental fogginess that may come with fasting. By using oral sedation, patients avoid the anxiety and discomfort of IV placement, abnormal respirations, or disinhibited movements that can make their surgery more complex, and untoward problems of postoperative nausea and vomiting. And after the procedure, recovery is fast with oral sedation. These are some reasons why ophthalmic and other office based-surgical specialties are moving towards oral sedation.2,3
More efficient workflows and less time for recovery reduces patients’ overall time in the surgical setting from 2-3 hours in a hospital or ASC to 1 hour in OBS.
Efficiency and familiarity for the practice
OBS offers other advantages for our physicians, the surgical team, and the office staff. For example, because we are coordinating a smaller number of providers related to the practice, we can schedule patients to improve overall office efficiency.
In addition, switching between procedures and office setting can be realistically and easily accomplished, allowing physicians to be accessible, not just to the OR but to other patient or staff needs. For example, the physical proximity makes it possible for some doctors to see patients for clinical visits while the operating room is being turned over. Also, in our OBS, there is no risk of being bumped or losing surgical time to more acute surgical cases or health system needs. This type of control and access has significantly reduced stress on our scheduling staff.
OBS also offers the advantages of being able to choose familiar equipment and supplies and develop a surgical team that can master the work-flow processes.
The team takes ownership
Our team takes ownership of and has great pride in delivering the best experience possible. We welcome their feedback regarding our surgical processes, and staff are empowered to manage workflows and make critical decisions. For example, our staff rearranged the room to improve efficiency in steps for themselves and the patients. They have given us feedback in how to provide continuous process improvement in areas such as sterilization and documentation.
Being integrated in the patient experience from evaluation through surgery, and into postoperative care, helps staff better understand the value of their contribution and how they relate to the patient’s experience. OBS has also offered staff opportunities for personal and professional growth. The technical staff’s background in ophthalmological knowledge and awareness and connection to the patient leads to a high level of precision and caring. The surgical team has learned how to plan, prepare, and conduct outstanding surgical care. The surgery schedulers coordinate this care within our larger practice and clinical work. Across the office, we all share in the pride and enthusiasm of creating an outstanding experience for our patients.
Overall, the change to OBS has been one of the most impactful of my career. It really highlights how much advancements in our field have evolved to be able to offer patients a more pleasant experience, one that is safe and continues to meet our high-quality standards. OP
References
1. Durrie DS, Cummings AB. Ophthalmic office-based surgery; safety outcomes from 47,714 real-world procedures. Paper presented at AAO 2023; San Francisco, CA.
2. Siegel NH, Fiorello MG, Ness S, et al. Patient satisfaction with oral vs intravenous sedation for vitrectomy surgery: A randomized, non-inferiority trial. J Vitreoretin Dis 2021, Aug 3;6(3):201-209.
3. Hedenbro JL, Ekelund M, Aberg T, et al. Oral sedation for diagnostic upper endoscopy. Endoscopy 1991 Jan;23(1):8-10.
