Cataract study evaluates anesthesia use, costs

(Editor’s note: This is the first of a two-part series on the second study of Cataract Extractions with Lens Insertion conducted by the Accreditation Association for Ambulatory Health Care’s Institute for Quality Improvement. This month, we look at pre-procedure time, procedure time, and discharge time. Next month, we look at costs.)

More details about types of anesthesia, narcotic costs, and anesthetic administration are a few of the enhancements added to the second Cataract Extraction With Lens Insertion Study from the Accreditation Association for Ambulatory Health Care’s (AAAHC’s) Institute for Quality Improve-ment (IQI) in Wilmette, IL. (See "Sources and resource," at the end of this article, for ordering information.)

Eighteen same-day surgery programs participated in the study, a decrease from the 22 organizations that participated in the 1999 study, says Naomi Kuznets, PhD, managing director of the institute. As with most IQI benchmark studies, it was not necessary that the participant be a member of AAAHC.

Participants find advantages

Not all of the 18 participants in the current study, which cost $400 for participation, were involved in the 1999 study, which was free to participants. However, there were a number of repeat participants, including Kris Kilgore, RN, BSN, administrative director of the Surgical Care Center of Michigan in Grand Rapids. In addition to seeing where her facility ranked in terms of procedure times, costs, and types of anesthetics used, it was helpful to read the notes that accompany the charts for each category evaluated, says Kilgore.

"I like seeing an explanation of how the best performer achieved their ranking," she says. "This information is similar to the type of tips you share with each other at conferences, but $400 is a lot less than I would spend going to a conference," she adds.

There were no dramatic changes in the median times for the pre-procedure, procedure, and discharge categories, says Kuznets. Any changes that occurred were small and might have been due to a different group of participants, she adds.

Kilgore did not see significant differences in her facility’s performance from one year to the next, but she still finds the results beneficial. When evaluating your performance in a benchmarking study, it is important to not assume that you are doing something wrong if you are not the best performer in a category, Kilgore points out.

23.5 minutes is average discharge

In the discharge time category, which is defined as the interval between leaving the operating room to discharge from the recovery unit, Kilgore’s facility posted a 30-minute average. The median discharge time was 23.5 minutes, and the average times for facilities ranged from less than 10 minutes to almost 60 minutes.

"We took a look at what the best performer did to achieve a 10-minute discharge, but we decided that our procedures are best for our patients and our facility," says Kilgore. Her concern was that less time would result in less understanding of postoperative instructions, she says. "In this case, it was OK not to be at the top of the category," she adds.

The best performer in the discharge time category does call the patient within the first few hours to review instructions and answer questions, according to the study report. "This extra call still requires staff time, so I don’t know that it is more efficient than holding the patient an extra 15-20 minutes to make sure instructions are understood," says Kilgore.

Early arrivals affect pre-procedure time

The median time for pre-procedure, which is defined as the time the patients checks in until the time the patient is in the operating room, was 78 minutes overall, with individual times ranging from fewer than 60 minutes to almost 120 minutes. The Opticare Eye Health Center in Waterbury, CT, posted an average pre-procedure time of 80 minutes, which surprised director of nursing Grace Niedmann, RN, a little.

"We have patients show up 60 minutes prior to surgery so we can make sure their eyes are fully dilated," explains Niedmann. While this accounts for 60 of the 80 minutes, Niedmann is taking a look at the extra 20 minutes to see if that was an anomaly of the cases included in this study or a opportunity for improvement.

Using benchmarking information to start discussions of internal processes is important, says Kilgore. "We share benchmark studies at staff meetings as a way to open up conversations of changes we might make to improve our service," she explains. "Not all of the ideas suggested by a study will work for us, but they might trigger other ideas that will."

Procedure time for organizations in the study ranged from less than 10 minutes to almost 35 minutes, with the overall median at 16.9 minutes. "We averaged almost 20 minutes for procedure time," says Niedmann. "We have 12 surgeons, two of whom are slower than others, so there is not a lot we can do to change our performance in this category."

Type of anesthesia also affected procedure time, points out Kuznets. While the median procedure time was 16.9 minutes, the procedure time for facilities using topical anesthetic only was 16 minutes, and the procedure time for those using an anesthetic block was 17.4 minutes, she adds. Forty-five percent of the study participants used topical anesthetics, 24% used peribulbar block, 15% used retrobulbar blocks, and 16% used other techniques, she adds.

Study pinpointed costs

With cost containment high on everyone’s priority list, the sections that evaluate lens costs and narcotic or sedative costs were of great interest to many participants, says Kuznets. While the difference in lens costs can be attributed to the types of intraocular lenses and the difference in narcotic costs can be attributed to medications used, it also was apparent that standardization and using one primary vendor are key reasons some facilities maintain low costs, she adds.

The good feedback from participants and facilities that have purchased reports of previous performance measurement studies is encouraging as the Institute plans studies on tumescent liposuction, surgical/procedural patient satisfaction, cataract extraction with lens implant, knee arthroscopy with meniscectomy, and medical event reporting, says Kuznets.

Kilgore is glad that there is a low-cost option for same-day surgery programs to participate in IQI’s benchmarking studies. "With benchmarking a requirement for many accreditation programs and a limited number of same-day surgery focused studies available, it’s nice to have an affordable option to help us evaluate our performance," she says. 

Sources and resource

For more information about the Accreditation Association of Ambulatory Health Care’s Institute for Quality Improvement’s 2000 Cataract Extraction Study, contact:

Naomi Kuznets, PhD, Managing Director, Institute for Quality Improvement, 3201 Old Glenview Road, Suite 300, Wilmette, IL 60091-2992. Telephone: (847) 853-6060. Fax: (847) 853-9028. E-mail: naomi@aaahc.org.

Kris Kilgore, RN, BSN, Administrative Director, Surgical Care Center of Michigan, 750 E. Beltline N.E., Grand Rapids, MI 49525. Telephone: (616) 940-3600.

Grace Niedmann, RN, Opticare Eye Health Center, 87 Grand View Ave., Waterbury, CT 06708. Telephone: (203) 465-1401.

A copy of the 2000 Cataract Extraction Study is $40. To order, contact: Accreditation Association for Ambulatory Health Care, Institute for Quality Improvement, 3201 Old Glenview Road, Suite 300, Wilmette, IL 60091. Telephone: (847) 853-6079. Fax: (847) 853-9028. Web: www.aaahc.org.