Getting ASCs Ready for Retina
Incorporating retina into an ASC can create benefits for all those involved.
BY RACHEL RENSHAW, EXECUTIVE EDITOR

The advantages to performing surgery in an ambulatory surgery center (ASC) setting include shorter surgical times, more streamlined procedures, staff members who are more knowledgeable about specific procedures, and the overall quality of care that surgeons are able to offer their patients. While these advantages need not differ for retinal surgery, ASC owners and administrators alike have reservations about incorporating retina into the ASC setting for 3 main reasons: inherently longer procedure times, the more complicated nature of posterior segment surgery, and cost. However, adding retina to an ASC can benefit a practice by making it more comprehensive and increasing the patient base. In this article, I will explain why this is so.

OUTFITTING AN ASC FOR RETINA CASES

Leo T. Neu, III, MD, a partner in Mattax-Neu-Prater Eye Center and Surgery Center, which has locations in Missouri, has been performing retina surgery in his surgery center for 5 years.

"When we bought our ASC, it was already an ophthalmological ASC for cataract surgery, so it had a microscope and everything that one needs for cataract surgery," says Dr. Neu. "To accommodate retinal procedures, I converted my existing laser for use in the operating room and purchased some retinal equipment."

Dr. Neu was already using the Millennium (Bausch & Lomb, Rochester, NY) for cataract surgery so he added the vitrectomy component for his posterior segment work.

"It's a matter of trying to monitor your equipment costs and not letting them get out of control," Dr. Neu says.

SHORTENING SURGICAL TIMES

Robert B. Feldman, MD, partner and retinal surgeon at the Florida Eye Clinic and Florida Eye Clinic ASC in Altamonte Springs, FL, made the switch from the hospital setting to his ASC for retina cases approximately 10 years ago. His average time for a routine vitrectomy is 30 to 40 minutes, and he feels that his case time is about half of what it would be in a hospital setting.

"The time savings is huge," says Dr. Feldman. "First of all, you will never be bumped by an appendectomy or wait several hours for your nonophthalmic colleague to finish his case. Second, my patients are given peribulbar blocks in the preoperative/recovery area by 1 of my full-time CRNAs while the surgical room is being turned over."

"I use short- and long-acting peribulbar blocks, depending on the case," he says. "I typically use midazolam hydrochloride (Versed, Roche) and fentanyl (Duragesic, Janssen) and have the patients take ondansetrom (Zophran, GlaxoSmithKline) afterward to cut down postoperative nausea."

According to Dr. Feldman, one of the main advantages to performing retinal procedures in an ASC as compared to a hospital is that the staff in an ophthalmology ASC is devoted to that specialty. He believes that he benefits from the dedication of his employees, who range from "scrubs" who know his surgical routine well and turn over the rooms quickly, to CRNAs who do not over- or undersedate his patients during procedures such as internal limiting membrane peeling.

Dr. Neu agrees. "Our ASC is dedicated to eyes only, so the staff can adjust to, and troubleshoot the equipment much easier because we use the same machinery all the time. In the hospital, we still end up with circulating nurses and technicians in the room who do other nonocular procedures, so they are not as in tune with troubleshooting retinal equipment and it takes them longer to figure the problem out."

"In our particular situation, we never use a general anesthetic," continues Dr. Neu. "We have a nurse anesthetist who does our periorbital blocks who has 20 years of experience. He's also very familiar with how much anesthesia to give systemically through the IV to relax the patient."

Dr. Neu emphasizes the importance of consistency in the operating room. He adds that anesthesiologists who routinely work in other specialties, such as orthopedics or general surgery, do not have a complete understanding of what the eye surgeon needs.

Dr. Feldman says that he is in the process of obtaining 25-g instrumentation to further cut down surgical time.

"I believe that 25-g technology will save time on opening and closing of cases and make postoperative recovery more comfortable for patients," he says.

Erin Duffey, RN, is director of operating room services at the Ambulatory Surgery Center of Greater New York in the Bronx. Duffey has worked in ophthalmology since its infancy in the ASC setting. The most common procedure performed at her facility is pars plana vitrectomy (PPV) endolaser for patients with diabetic retinopathy.

While Duffey's ASC does not use technology, such as the 25-g vitrector, they still have reduced their surgical time and costs by combining a highly skilled technical and professional staff with high-speed vitrectomy and competent surgeons.

PATIENT FLOW

Beth Hurley, RN, BSN, CRNO, COE, who is the director of clinical development at Sovereign Healthcare in Newport Beach, CA, has had more than 18 years' experience working with retina cases in an ASC setting.

"Posterior cases can utilize existing present staff and equipment," Hurley says. "In an ASC, the retinal surgeon has access to a knowledgeable staff that knows ophthalmology, so that there is greater efficiency in patient flow and case turnover. Posterior cases also add variety, as every case is different."

In addition, says Hurley, the quality of case rendered to patients is greater in an ASC, as is demonstrated by patient outcomes and satisfaction surveys.

Four surgeons utilize the ASC where Dr. Neu operates.

"We found that [prior to performing retinal procedures] there was downtime on certain days where the surgery rooms weren't being utilized." Dr. Neu's ASC pays 5 days' salary to employees, so if the center is going unused for some of that time, it is not cost effective.

"I had time in my surgical center to incorporate retinal surgery without taxing the system. On my designated day in our ASC, I perform my anterior cases first and then do retinal surgery thereafter," he says. "Other days of the week when the operating room is not being used, I can schedule retinal cases on my time and not be controlled by a hospital schedule."

Dr Neu says that this strategy helps him by not having to take retina cases to the hospital.

"Saving time and improving the dynamics of retinal surgical procedures makes it much easier when you own your ASC," says Dr. Neu.

BENEFITS TO PERFORMING RETINA IN AN ASC

After 8 years of performing retinal surgery in an ASC, Dr. Feldman says that efficiency, not profitability, drives the success of including retina. However, there are bottom-line benefits to adding retina to an ASC. According to Dr. Feldman, retinal cases can be scheduled in between cataract cases, and when there is a lull in both, doctors can see patients for postoperative check-ups.

Dr. Neu views the main benefits of performing retinal cases in the ASC as those affecting time management, and thus, quality of life.

"By performing retinal surgery in the ASC, I can decrease my overall time in the operating room compared to the hospital by half. In the hospital, it may take me 2 hours to do everything, not just the procedure, but also the overall orchestration of the procedure," says Dr. Neu. "In our ASC, we can cut that time in half. So, I'm saving about a half a day a week by doing these procedures in the ASC. I can use that half-day to see other patients, which drives the overall bottom line to a higher level, or I can take time off to live a fuller life, rather than just work all the time."

Patients also benefit in that they are able to have their retinal procedures performed in the same building as their office examinations. The continuity of having all eyecare visits and procedures in 1 location increases the convenience level for patients and also increases the level of comfort and confidence.

However, he does not discount the financial benefits to the surgeon who owns or partners in an ASC.

"The professional fee for the retinal surgeon is going to be the same whether it's done in the hospital or the ASC, but the facility fee payment is going to be a bonus," says Dr. Neu.

However, says Dr. Neu, it is critical that those handling reimbursement keep an eye on the overall cost of the procedures that are being performed.

"You have to really watch your costs to make sure you're not losing money on the facility fee, because the Medicare system only pays a set amount," Dr. Neu says. "If you buy a lot of fancy equipment, require a lot of extra instrumentation or require more personnel in the room with high salaries, you could barely break even or actually lose money on the facility side."

Regarding financial matters, Hurley cautions, "Coding posterior segment surgery is imperative."

Multiple procedures are common in some cases, so this must also be taken into account. Either having a seasoned coding person on staff or hiring an experienced consultant is a good idea when getting started.

TRANSITIONING AN ASC FOR RETINA

When incorporating retina into an ASC, several factors should be considered. Often, it is helpful to talk with colleagues who have already added retina to learn from their experiences.

Following are combined tips from those interviewed for this article for administrators and physicians who are getting ready to incorporate retina into the ASC setting:

Carefully select cases. Retinal procedures that are performed in an ASC should be routine and noncomplex. If you choose a procedure that is complex, money will most likely be lost because of the extended procedural time and staff wages. Remember that Medicare and insurance companies will only pay a certain amount in some cases.

Monitor costs. Closely monitor equipment purchases (e.g., microscopes, lasers). Do not buy an instrument that will be used once every 2 years. That procedure should be performed in a hospital setting.

Make sure that retinal surgeons have ASC mindset. Retinal surgeons should understand the issues that affect overall efficiency, such as time and costs.

Have good help. Nurses, surgical technicians, and anesthesiologists should be familiar with performing ophthalmic cases in an ASC and be aware of the important issues that are specific to ophthalmology.

Ultimately, while efficiency and costs are important factors, the quality of patient care is the most important consideration. Patients will appreciate shortened procedure times, dedicated staff, and the convenience that an ASC offers. If incorporated carefully and correctly, adding retina can be a rewarding experience for ASC owners and staff. These rewards can be passed on, in the form of better, more streamlined care, to every patient who walks through the doors.

The Outpatient Ophthalmic Surgery Society (OOSS) contributed sources and information for this article. OOSS is a source for ASC leadership and advocacy. For more information about OOSS, contact Claudia A. McDougal, Executive Director, at 866-892-1001, or go to www.ooss.org.