Ambulatory—often called outpatient —surgery has been one of the most dramatic changes in an ophthalmic practice. In contrast to the previous patterns of hospitalization and restricted activity, most types of ophthalmic surgery, including cataract, glaucoma, and intraocular surgery, are now performed on an ambulatory, outpatient basis. For example, whereas 85% of cataract surgery used to be performed on an inpatient basis, now more than 98% of cataract surgery is performed on an outpatient basis in one of three specially designed ophthalmic surgery areas: hospital-based facilities, free-standing surgical centers, and office surgical suites. The patient goes home soon after the surgery.
Several factors have influenced this dramatic change. The shift from intracapsular surgery to extracapsular ophthalmic surgery and now small-incision phaco and femtosecond laser has contributed to the safety of cataract surgery performed on an ambulatory basis. Wounds have become smaller and the capsule has remained in place to prevent vitreous herniation. Suture material has improved, with increased tensile strength and elasticity; there is also a greater knowledge about better wound closure. Valve-like wound architecture is now possible.
However, a hospital admission may be required in cases of cardiovascular risks, older adults, the uncontrollable patient, and the infant and young child in whom general anesthesia may be required.
Ambulatory surgery centers
The development of ambulatory surgical centers (ASCs; surgicenters) throughout North America has contributed significantly to the changes in ophthalmic surgery. The overall emphasis of surgery is now placed on keeping hospital inpatient beds reserved for ill patients who require acute or prolonged care and attention. By avoiding hospitalization, significant financial savings can be realized by the public, the insuring agent, and governments.
Economics, however, was not the primary motivating factor for the directional change toward ambulatory surgery. Progressive ophthalmologists have long questioned the medical necessity of keeping patients immobilized for 24 hours after surgery, with gradual ambulation over several days. Dr. Norval Christie was a pioneer in this area, having operated on thousands of cataract patients annually in Pakistan on an outpatient basis. Other leading surgeons in the world followed with ambulatory surgery and immediate ambulation for their patients. Phacoemulsification surgery, with its small wound opening, gave impetus to this approach to surgery. Thus ambulatory surgery was ushered in and the Outpatient Ophthalmic Surgery Society (OOSS) was created to form a union of those who have free-standing eye centers.
One major value of an office-based or a free-standing surgical facility is that there is continuity of patient care. The same people are involved from the initial workup to the final discharge. This continuity with familiar faces, combined with trained personnel who care, eases the patient’s anxiety.
The American Society of Cataract and Refractive Surgery (ASCRS) and OOSS have established standards for surgical ophthalmic centers that address the areas of construction, asepsis, and record keeping. These standards provide for the safety of patients, as well as the legal responsibility of the surgicenter for monitoring and maintaining continual self-assessment programs for quality control. Periodic site reviews are carried out. Equipment standards also are required.
To be eligible to receive Medicare payments, ASCs must be inspected by state Medicare agencies and certified that they meet federal standards. These standards require the ASC to:
Comply with state licensure requirements.
Name a governing board that assumes full legal responsibility for the ASC’s policies.
Have an effective procedure for the immediate transfer to a hospital for emergencies, as well as a written transfer agreement with the hospital; all of the ASC’s physicians must have privileges at the hospital.
Have policies relating to surgical procedures and ASC privileges for qualified physicians, including examination of the patient by the physician before and after anesthesia.
Have policies on the discharge of patients, including who should be discharged in the company of a responsible adult.
Have procedures for ongoing, comprehensive self-assessment of the quality and necessity of care.
Have a safe and sanitary environment.
Be accountable to the ASC governing board; policies must be established for granting clinical privileges, periodic reappraisal, and supervision of the nonphysician staff.
Have direct and staff nursing services to ensure that the nursing needs of all patients are met.
Maintain complete, comprehensive, and accurate medical records to ensure adequate care.
Provide drugs and biologic agents in a safe and effective manner, according to accepted professional practice and under the direction of a responsible designated individual.
Have arrangements for obtaining routine and emergency laboratory and radiologic services from approved facilities.
The advantages of a surgical outpatient facility have been pointed out by Dr. Sanford Severin of Albany, California. These advantages include the following:
Patient acceptance. A more pleasant and comforting environment is provided, with ready access to familiar faces.
Cost effectiveness. There is a major saving for the patient and the government or insurance company. The government can save more than $1 billion per year if the 1 million cataract extractions in the United States are charged a small facility fee.
Complete control of the operating room. Personnel can be chosen who work well together and are effective, not only in knowing the surgeon’s routines and the purchasing and replacement of equipment and supplies but also in maintaining good public relations with the patients and answering questions in a meaningful way, allaying patients’ fears. Thus a surgical team is evolved that relates to both the surgeon’s and the patient’s wishes.
Scheduling. Scheduling is at the convenience of the surgeon. There is no waiting for surgical time or being “bumped” for emergencies of other surgeons. One can schedule late in the day and on weekends.
True effectiveness. There is a better efficiency of time for the surgeon and the patient. There is less travel time for the surgeon, less waiting time for surgery for the patient, and a reduction in the wait between cases for maximum use of the operating room and the staff’s time.
There are commercially available sterile and disposable drapes, gowns, and medical supplies.
The disadvantages of a free-standing ophthalmic surgical center or an office surgical center include the following:
The surgeon and staff must assume more responsibility in maintaining adequate stock, equipment, and sterility.
Medicolegal responsibilities increase; if a patient should become seriously ill during surgery, the ASC staff is responsible for the care of the patient and the transfer to a general hospital.
The need for ongoing interaction with agencies for payment reimbursement and peer review for certification standards.
Expenses can be greater than the reimbursement rate unless a large number of procedures are being performed; the center may not be cost-effective for small numbers.
The ambulatory center as a major financial commitment is threatened in the case of sickness of the primary surgeon or key staff members or a reduction in surgical volume.
There may be a lack of patient compliance with the postoperative regimen after the patient is discharged from the surgical center.
Tips on medical/legal protection
About one in 10 physicians will be sued at some time during their average medical career. Approximately 75% of these claims result from surgical procedures. Ophthalmologists, fortunately, have the lowest rate of malpractice and litigation in the medical profession. Only about 2.5% of practicing ophthalmologists claim to have been sued. The most common suits are negligent performance of cataract surgery, negligent treatment of ophthalmic conditions, failure to diagnose ophthalmic conditions, postoperative vision loss, and complications as a result of negligent surgery or follow-up ( Box 34.1 ).
Ensure that you identify the correct patient and the correct side for any surgical procedure. Mark the procedure site preop and double-check before proceeding.
Establish good rapport with the patient. The patient who likes the physician and the environment where surgery is performed is less likely to sue. Some lawsuits are started because of the patient’s vindictiveness, even if the physician is fault-free. A doctor whom the patient views as compassionate and understanding has already acquired some protection against legal actions.
Discharge the patient into the care of a competent adult, one who will take care of the patient at home. The name of this individual should be recorded on the chart.
Provide written, easy-to-understand directions for the follow-up care and return visits. These should be read and explained to the patient or relative and all questions answered.
Include in the list problems or symptoms that may arise at home and what to do if they occur.
Provide in the instructions some directions for obtaining an appropriate physician for medical problems. Telephone numbers of the physician, ophthalmologist, and a nearby hospital emergency room should be given.
Arrange for a nurse or assistant to telephone that evening or the next day to check on the patient’s condition if the situation warrants it, and record this on the chart.
Make operative notes immediately after surgery, not weeks or months later.
Instruct patients to leave valuables at home or arrange some system for safekeeping of the patient’s valuables during surgery. Often lockers are provided.
Make sure that life-sustaining equipment is available and in good working order.
Be sure there is an adequate consent form that is well outlined to the patient. Good personal communication with the patient as to risks, benefits, and alternatives is highly valuable. An informed consent for major surgery is mandatory. These consent forms can range from a simple page or two to an elaborate 12-page document with video viewing and the patient’s response questionnaire. Each physician determines his or her own comfort level. Appendix 3 contains the principles of informed consent.
Maintain good records in the office and the hospital. The quality and legibility of your records affect the quality of your practice. It is important to attach to the records a log of telephone advice. Cursory, sloppy, or nonexistent notes call the physician’s credibility and standards of practice into question. The practitioner should initial all laboratory and x-ray reports before they are filed.
Preparation for admission
In preparation for admission to an ambulatory surgery center, each patient should have a careful medical evaluation by the ophthalmologist, family physician, or internist. A checklist should be made of such events as routine laboratory tests and electrocardiograms ( Box 34.2 ). A complete eye workup should be performed. Intraocular lens measurements should be determined. If the power of the intraocular lens is beyond the range of stock maintained, then a correct dioptric power intraocular lens should be obtained from the manufacturer. An additional visit may be required for the patient to consult with the anesthesiologist, who can review the laboratory results and the workup of the family physician ( Box 34.3 ).