Increased allied healthcare professional participation can increase efficiency of ISBCS
Immediate simultaneous bilateral cataract surgery (ISBCS) combined with an optimum participation of allied healthcare professionals can greatly increase the number of procedures performed in a theatre session and reduce costs for both patients and medical facilities, reports Professor David O’Brart MBBS, MD, FRCS, FRCOphth, Guy’s and St Thomas’ NHS Foundation Trust, King’s College London.
“With the current COVID-19 pandemic and increasing cataract burden we need higher volume surgical models and ISBCS is potentially more efficient with Time and motion study modelling.”
Time and motion study (TMS), widely used in industry, was first introduced by Winslow Frederick Taylor in the early 20th Century as a means of standardising the amount of time a task should take and optimising work methods in order to increase productivity. In previous research, Prof O’Brart and his associates performed a TMS of cataract theatre lists at five UK institutions, recording individual tasks and their duration for every member of staff during 140 cataract procedures performed over the course of 18 theatre sessions (Roberts et al, BJO2018;102:1259-1267).
The study showed that there was an inverse correlation between the duration of surgery and the number of allied healthcare professionals (AHPs) participating and the number of tasks they performed (p<0.001). That is, surgical time was reduced by 0.95 minutes for every additional AHP, 0.38 minutes for every additional task an AHP performed and 0.19 minutes for each additional minute spent by AHPs performing tasks. In addition, there was a similar inverse correlation between the amount of time patients spent in theatre and the time AHPs took to perform key tasks (p<0.001). That is, patients’ time in theatre was reduced by 0.75 minutes for each task performed by AHPs and by 0.19 minutes for each minute AHPs spent performing tasks. “Basically, what this study showed is that by having enough allied healthcare professionals in the theatre supporting the surgeon you could increase the numbers of surgeries by about 70% in a four-hour period, even with high-volume surgical models. I always like to use the aircraft analogy where you wouldn’t expect your pilot on a flight from London to New York to suddenly stop in Greenland to serve the dinners and then take off again. And that’s what we tend to do with cataract procedures in the public health sector, where we have surgeons doing multiple tasks in the operating room which can be performed by other staff members instead of performing surgery,” Prof O’Brart said. TMS MODELLING
In a subsequent study, Prof O’Brart re-analysed their findings from their TMS study to construct a hypothetical model where all except one patient underwent ISBCS to calculate the gains in efficiency that could be achieved through optimal participation of AHPs.
They found that with TMS modelling they could expect a mean 16% reduction (range 9.8-17.8%) in the time taken for two cataract operations. That, in turn would translate into a mean 54% increase (range 38-67%) in the number of cases currently performed per list and a mean 18% increase (range 9-28%) even if the number of unilateral cases per list had been fully maximised. An average number of four ISBCS cases per list (range 3-6) were required to achieve sufficient time savings to allow an extra unilateral surgery to be conducted.
Prof O’Brart noted that randomised prospective studies have shown that there is no difference between the outcomes with ISBCS and delayed sequential bilateral cataract surgery (DSBCS) in terms of postoperative acuity or refractive predictability. Research also shows that patients have lower quality of life scores when they have to wait for second-eye surgery compared to when they undergo ISBCS. Furthermore, ISBCS has cost advantages compared to DSBCS for both patients and medical facilities in terms of decreased travel time and decreased hospital visits as well as reduced visual recovery time.
He added that although there might be some concerns about the possibility of bilateral sight-threatening complications, there have to date been only five reports of endophthalmitis following ISBCS among the millions of such surgeries performed, and in all of those cases there was breakdown in the usual high aseptic standards.
“Therefore, on the basis of the current public scientific literature, I think most cataract services are happy to perform ISBCS. It also has the possibility to improve surgical efficiency, especially in the public health sector by reducing patient turnover,” he said.
GAINING PATIENTS’ CONFIDENCE
There is still some ground to be gained in terms of improving patients’ understanding and acceptance of ISBCS, he noted. When he and his associates contacted 265 patients awaiting surgery and asked them if they would be willing to undergo ISBCS, 45% said they were happy to do so, but 50% expressed concern about the risk of bilateral simultaneous ocular complications and 23% said they were not familiar with concept of ISBCS.
“Patients are open to ISBCS but they require more information and education about the option, which will hopefully bring more patients on board,” Prof O’Brart added.