At the Wellington Eye Clinic, we consider it a necessity to run the operating room (OR) as efficiently as possible. There are several scenarios that could disrupt the efficiency of an OR and its staff, thereby hindering the surgeon’s ability to perform his or her job: The patient is not ready for surgery; there are delays between patients; scans and tests are not available for the surgeon’s review; the correct instruments are not available or are not working; and, possibly the worst-case scenario, the staff is not properly trained for the procedures being performed, whether for assisting the surgeon or operating the technology.
It is a team effort to guarantee that everything runs smoothly in the OR. All employees, from the administrative, nursing, and technical staffs to the surgeon(s) and optometry staff, play a role in its success (Figure 1). This article provides an overview of how to make a surgeon’s job easier in relation to working as part of a team in a busy cataract and refractive clinic. The following are routine procedures that increase our efficiency in the OR, which, in turn, keeps the surgeon content and the patient safe.
PRIOR TO SURGERY
It is important to ensure that the OR is well stocked, that all instrumentation is available for the procedures on the OR list, and that all machines are calibrated to full working order. An excellent standard of cleanliness must also be maintained.
In planning the OR list, the timing of appointments should be scheduled to match the types of appointments patients are offered when booking. It is important to allocate enough time for any given treatment and to book patients efficiently so as to avoid gaps in the OR list; it is equally important not to overbook patients. Ideally, patients should be advised as to how long they will be at the clinic for their procedure. This allows patients to plan their length of stay and coordinate their travel arrangements.
A longer than expected visit to the clinic can cause added stress to patients and their companions and can influence how relaxed they are for surgery. The surgeon may then be required to deal with an overly nervous patient heading into the OR when this could be avoided if the patient was better informed prior to the surgery day.
From an administrative standpoint, patient notes and files should be pulled at least 1 week before the day of surgery. It is important to ensure that all files are present and that each corresponds to the patient’s name, date of birth, and file number booked on the OR list. If additional patients have been added within the past week, then those notes should be pulled. At this stage, the staff should confirm that the patient is booked for the correct procedure on the list. It cannot be emphasized enough that the more checking that is done with the OR list, the less likely a mistake is to occur on the day of the procedure.
Once all of the patient’s notes are available to the doctor, he or she can determine the treatment plan for the procedure. Depending on the protocols and technology available to each clinic, it may be possible for a member of the support team, such as a nurse, technician, or optometrist, to enter the patient information into a planning laptop. We are fortunate to have a facility that can be used prior to the day of surgery, and all patient information is networked to the laser in the OR. This gives the staff the flexibility to input these data anytime prior to the procedure day and enables them to again check on the planned treatment intended for each patient.
DAY OF SURGERY
There should be an adequate number of trained staff members scheduled to cover the OR list, allowing plenty of time to set up the room and check the calibration of all machines being used that day. Before surgery, the patient is interviewed, he or she signs a consent form (which the doctor has previously discussed at length during the initial evaluation), and a list of postoperative medications is explained. It is important to give a patient the chance to ask any additional questions and to confirm what his or her procedure entails. Properly trained staff members can also quickly determine whether a patient needs additional medication to relax before surgery. It is easier for the surgeon to care for a wellinformed, relaxed patient who knows what to expect at every step of the procedure.
The staff allocated to the pre- and postoperative areas play a vital role in the efficiency of the OR. These individuals ensure that the next patient is ready for surgery once the previous patient is finished. A relaxed manner from a friendly nurse can put a nervous patient at ease. Just before surgery, the nurse puts a gown on the patient, instills an antibiotic drop into the eye(s), and cleans around the eye(s) with povidone iodine to reduce the risk of postoperative infection. The nurse also puts a hat and shoe covers on the patient while talking and keeping the patient relaxed. Patients are also invited to bring a family member or friend into the OR. The surgeon should always speak with the patient immediately before the procedure to discuss what he or she will experience during surgery and to confirm his or her target refraction following treatment.
While the nurse looks after the patient preoperatively outside the OR, a scrub nurse and optometrist check the calibration of the WaveLight EX500 and FS200 lasers (both by Alcon Laboratories, Inc.). This ensures that there are no surprises once the procedure begins. The optometrist also double checks the patient’s intended correction on the laptop to ensure that the optimum result is achieved. All these verifications reassure the surgeon that best practices are being put into place.
When the patient is in the OR, he or she is given anesthetic drops and a stress ball to squeeze rather than his or her eyes. The optometrist and nurse communicate with the patient while the femtosecond laser makes the LASIK flap and the EX500 laser performs the ablation. The optometrist may offer a hand to hold if the patient is nervous. The patient is told what to expect, including when the lights will go dark, when pressure will be felt, when fluids are introduced onto the surface of the eye, and when changes in temperature when colder fluids are used will occur, as in LASEK.
When the procedure is finished, the patient is asked to sit up and look around the room to notice what he or she can see postoperatively compared with when they entered the OR. A good indicator of success for many patients is being able to read the time on a wall clock. All members of the staff feel a great sense of pride when a patient states that the procedure was easier than anticipated. A huge contributing factor to patient satisfaction is the constant communication between the staff and the patient.
Once the patient leaves the OR, the nurses in the postoperative area make sure that he or she is comfortable and offer light refreshments. The patient stays in the clinic for an additional 30 minutes to relax. The nurse checks the eye at the slit lamp before discharging the patient, to confirm that there are no postoperative complications such as flap movement or unexpected debris in the interface. It is always better to detect these complications in the first 30 minutes after surgery than the next day. On the rare occasion that a complication does occur, the surgeon can wash the interface immediately, reducing the likelihood of having to bring the patient back to the OR the following day. At the time of discharge, we strive to have a happy patient who has had his or her procedure go perfectly, in part thanks to a great team effort.
The nurses working in the postoperative area play a pivotal role in ensuring that the OR list runs smoothly by preparing patients for surgery and discharging them in a comfortable, relaxed manner. Good communication among the pre-, peri-, and postoperative staff is vital. If there is any change in the order of surgeries, it is imperative that all staff members are aware, especially the surgeon, to prevent mistakes and ensure a safe and professional experience for the patient.
In the OR, the surgeon should have confidence in the staff. Ultimately, he or she is the one performing the procedure, but in order to be at ease, having the support of a well-trained staff is essential. The surgeon’s choice of music can also help set his or her mood.
On days when there are visiting doctors in the OR, the staff helps orient them and run through the behindthe- scenes work. This helps the surgeon, as the visitors will have the basic information they need before the patients arrive.
CONCLUSION
At the Wellington Eye Clinic, we pride ourselves on our team approach, whereby everyone helps each other. This teamwork results in a safe and comfortable experience for patients and allows the surgeons to work in an enjoyable and relaxed environment.
Lisa McLoughlin, RN, RM, SNM3, is the Clinic Nurse Manager at the Wellington Eye Clinic in Dublin, Ireland. She may be reached at e-mail: l.mcloughlin@wellingtoneyeclinic. com.
Isobel Brennan, BSc (Nursing), is a General Nurse at the Wellington Eye Clinic in Dublin, Ireland. She may be reached at e-mail: isobel.brennan@wellingtoneyeclinic.com
Teresa Fitzgerald, BSc (Nursing), is a General Nurse at the Wellington Eye Clinic in Dublin, Ireland. She may be reached at e-mail: teresa.fitzgerald@welligntoneyeclinic.com.
