Kate Goldblum, CFNP Albuquerque, New Mexico

Disclosures   I have no financial or other conflicts of

interest relevant to this presentation.

  I do not discuss an off-label use of any commercial product in this presentation.

Evaluation for Cataract Surgery   Visual acuity – near and distance   Glare disability   Axial length   Keratometry   Anterior chamber depth   White-to-white distance   Corneal pachymetry   Lens thickness   Other parameters (pupillometry, visual axis

eccentricity, retinal thickness)

Preparing the Patient  Routine for us, sometimes terrifying for our

patients!  What can we do to make the process less

stressful?

Visual Acuity  Does the patient even need cataract

surgery?  Glare disability determination   Issues impacting IOL power

  Patient expectations and goals   Preoperative refractive correction   Refractive surgery status   Ability to pay for premium lenses

Measurements for IOL Power Determination   IOL Master  Lenstar

IOL Master  Partial coherence interferometry (PCI)  Captures 4 measurements

  Axial length   Keratometry   Anterior chamber depth   White-to-white distance

Lenstar   Optical low coherence reflectometry (OLCR)   Captures nine measurements

  Axial length   Keratometry   Anterior chamber depth   White-to-white distance   Pachymetry   Lens thickness   Pupillometry   Eccentricity of the visual axis   Retinal thickness

Postoperative Vision  Assess patient expectations and goals!  Willing to accept spectacle wear after

surgery?  Or no glasses for near, distance, or both?

Preoperative Refractive Error  May affect postoperative goals  Hyperopic before surgery – more likely to

accept need for near correction  Myopic before surgery – more likely to

dislike need for near correction  “Perfect” before surgery – post-refractive

surgery more likely to seek same “perfection”

Correction Options   Intraocular lenses

  Standard monofocal   “Premium” lenses

 Multifocal  Accommodating (Crystalens)  Toric  Aspheric

  Monovision  Monofocal  Multifocal (blended monovision)

Decreasing Patient Stress  Spend enough time with the patient to

assess patient’s individual needs  Demonstrate and project knowledge,

competence, professionalism, and empathy

 Determine what the patient needs/wants to know about the process and surgery

Procedural Information  You’ll check in at . . . .   In the holding area . . . .   In the operating room . . . .  After your surgery, you’ll go . . . .  Before we discharge you to go home . . . .

Sensory Information  Visual – what will the patient see?  Tactile – what will the patient feel?  Auditory – what will the patient hear?  Gustatory – what will the patient taste?  Olfactory – what will the patient smell?

Preoperative Medical Clearance Assuring Patient Safety

ASORN 2012

Carol A Matthews FNP

*  I have no financial or other conflicts of interest relevant to this presentation.

*  I do not discuss an off-‐label use of any commercial product in this presentation.

Disclosures

*  Cataract *  Cornea *  Glaucoma *  Muscle *  Pediatric *  Plastics *  Retina

Types of Surgery

*  Surgeon *  Skill level of the surgeon *  Attending clean & fast *  Student slower *  Adaptability of surgeon *  Type of anesthesia required *  Length of surgery

Patient Safety Considerations

*  Allergies *  Difficult intubation *  Hard to awaken post-‐procedure *  Nausea and vomiting *  Family history of anesthesia problems

Anesthesia: Prior Issues

*  For risk stratification

*  Is the patient acceptable candidate for ASC

*  Consider all medical problems and look for RED FLAGS

History and Physical

*  AIRWAY *  Thick neck *  Obstructive sleep apnea (OSA) *  Large tongue *  Small mouth *  Poor mobility *  History of radiation to neck *  Goiter

Anesthesia Red Flags

Airway Assessment

Opens mouth normally Adults > 3 cm Children varies by age

Ability to visualize at least part of the uvula and tonsillar pillars with mouth wide open and tongue out

ASA Airway Classification

*  Grade murmur *  Obtain recent echocardiogram *  Is patient symptomatic *  Has patient received continuous care *  Medication compliance

Aortic Stenosis

*  Chronic kidney disease (CKD) stage *  End stage renal disease (ESRD) *  On dialysis *  On transplant list *  Obtain labs (chemistry and CBC *  If on dialysis or abnormal potassium, repeat on day of

surgery

Renal Disease

*  What are fasting sugars at home *  HgA1c within past three months *  Episodes of hypoglycemia *  Comorbidities *  Regular check ups with PCP

Diabetes

*  How short of breath is the patient – can she *  Walk across the room? *  Talk without gasping? *  On O2 *  O2 saturation below 92 *  Unable to lie flat *  Paroxysmal nocturnal dyspnea (PND) *  Tripod breathing

Severe COPD

*  Needs recent echocardiogram *  Pulmonary function tests (PFTs) *  Recent follow up with treating MDs

Pulmonary Hypertension

*  New onset *  Rate controlled *  Asymptomatic *  Treated *  Anti-‐coagulated *  Can surgery be done while patient on anticoagulants *  Do they need Lovenox bridge *  If stable, can they be held

Atrial Fibrillation

*  When were they placed? *  Type of stent *  Minimal usual wait is 6 weeks for elective cases *  Drug-‐eluding stent (DES) wait is 12 months for

elective cases *  If surgery is necessary, requires in-‐hospital facility

with invasive cardiology services available

Cardiac Stents

*  Level *  Ability to cooperate *  Tactile sensitive *  Previous anesthesia history *  Other factors

Autism

*  Type *  Level *  Ability to cooperate *  Determine anesthesia needs

Developmental Disabilities

*  Review information & determine next step *  Is patient a good candidate for surgery in an ASC? *  Yes – proceed & no further workup *  No – need more information & action

*  Order & interpret required labs *  Abnormal labs *  Send to PCP *  Review by anesthesia prior to surgery *  Patient informed

*  Does patient need a “tune up” by PCP? *  HTN not controlled *  Increased SOB *  If yes – refer back to PCP

What Next?

*  New onset fibrillation *  Compensated – facilitate appointment with PCP *  Non-‐rate controlled *  Patient needs to see PCP ASAP *  Mutual decision – urgent care versus emergency

Immediate Medical Issue

*  Request to maximize patient for surgery *  Call or send note to treating MD to see patient;

include explanation of need *  Treating provider responds *  Patient stable & may proceed *  Patient requires further workup

Referral to PCP or Specialist

*  Borderline candidate for ASC *  Questionable airway *  Child with disabilities *  Extremely anxious parent *  Anesthesia always happy to see

Anesthesia Consult

*  Collaborate with anesthesia to determine if ASC surgery is in best interest of patient *  If workup indicates patient is not ASC candidate

inform surgeon & determine location *  Outpatient in hospital *  Rady Children’s Hospital *  Inpatient

Is ASC in Patient’s Best Interest?

*  Give all patients prescriptions as needed *  Review instructions *  Answer questions *  Pediatric patients *  Instructions with play therapy *  Tour of surgical facility *  Meet OR staff & anesthesia personnel if available

*  Discharge patient to see at surgery

CONCLUSION

Kate Goldblum, CFNP Albuquerque, New Mexico

Disclosures   I have no financial or other conflicts of

interest relevant to this presentation.

  I do not discuss an off-label use of any commercial product in this presentation.

Schedule Information  Procedure  Surgeon  Start time  Which eye  Length of procedure  Availability of equipment & supplies

Schedule Considerations  Patient’s needs  Difficult cases last  Similar cases done in succession  Similar laterality done in succession  Availability of equipment & instruments  Allocation of appropriate amount of time

Efficiency = Cost-Effectiveness  Procedure time for

various surgeries

 Room turn over time (2 rooms?)

 Verify surgical site in advance

 Average cataract is 8-10 minutes

 Average is 3-5 minutes

 Prevents delays and saves times

Time Management  Prepare – avoid preventable delays  Speed, accuracy, thoroughness  Unexpected cancellations

The Patient’s Experience  Fear and/or anxiety  Embarrassment  Cold environment

 Making a better experience   Explanations, reassurance, comfort   “Vocal anesthesia” and therapeutic touch   Warm blanket, soothing music

Preparation  OR team: surgeon, circulator, scrub,

anesthesia  Surgeon preference cards   Instruments, medications, equipment  Special order items

  High power lens   Mitomycin C   Special instruments   Custom packs

Validate Documents  Consent(s)  H&P  Labs/other testing  Preop checklist

Staffing and Stocking  Appropriate numbers and mix of staff  Adequate supplies & equipment

Toxic Anterior Segment Syndrome (TASS)  Acute, noninfectious endophthalmitis  Anterior segment inflammation  Complication of anterior segment surgery

TASS  Contaminants on surgical instruments from

improper or inadequate cleaning  Products introduced into eye during

surgery   Irrigating solutions   Ophthalmic medications   Other substances

 Topical ointments or antiseptic agents  Talc from surgical gloves

TASS  Typical presentation

  Develops within 24 hours of surgery   Corneal edema   Accumulation of white cells in anterior

chamber

 Treatment – topical steroids, NSAIDs or both

Prevention of TASS  Product recalls and/or communication  Compounding alerts  Appropriate management of intraocular

surgical instruments

Surgical Instrument Care Recommendations 1-5  Adequate time for cleaning/sterilization  Follow manufacturers’ directions  Not allowing viscoelastic solutions to dry

on instruments  Transport opened instruments from OR in

closed container for immediate cleaning  Use disposable cannulas and tubing

whenever possible

Surgical Instrument Care Recommendations 6-10  Do not re-use devices labeled for single-use  Clean intraocular instruments separately from

non-intraocular instruments  Use detergents properly and rinse instruments

thoroughly after cleaning/final rinse with sterile distilled or deionized water

 Proper use of ultrasonic cleaner (when used)  Appropriate manual cleaning processes

Surgical Instrument Care Recommendations 11- 17  Appropriate rinsing processes  Dry instruments with lumens after rinsing

with forced or compressed air  Follow special instructions for phaco & I/A

handpiece, I/A tips, & inserters  Use proper processes for reusing woven

materials  Verify cleanliness & integrity of instruments  Use appropriate sterilization methods/

processes

Surgical Instrument Care Recommendation 17

  Implement administrative controls: a) written policies & procedures, b)purchase of adequate numbers of instruments sets, & c) provision of appropriate education on all recommendations

Recommended practices for cleaning and sterilizing intraocular surgical instruments (2007). The Journal of Cataract and Refractive Surgery, 33, 1096-1100.

E L E T H I A D E A N , R N , M B A , P H D P A T R I C I A A . L A M B R N , M N , C N S , C R N O

Discharge to Home

© 2012 ASC Compliance, LLC

Disclosures

  We have no financial or other conflicts of interest relevant to this presentation.

  We do not discuss off-label use of any commercial product in this presentation.


DISCHARGE PLANNING

  Discharge planning begins when surgery is scheduled.

  Identify patient education needs and implement resources as needed (home care, social services referrals, etc.)

  Inform the patient and family   Prepare them as events unfold   What to expect at each step


Peri Operative Care

  Begins before the patient arrives (admission), pre-operative area, surgical event, postop care, discharge planning & discharge

  Considerations:   Elderly adults are at greater surgical risk   Preoperative meds may or may not be reordered   Identify postoperative needs (responsible adult

postoperatively)


Vital Information for Discharge

  Care of the wound, incision, dressing

  Medication reconciliation:

  Actions and possible reactions of medications

  Should patient resume all preoperative medications

  Follow-up appointment

  Activities allowed - when and what •  Exercise, sexual activity, driving the car, return to work, •  leisure activities


More Vital Information

  Emergency phone numbers

  What to expect in the first few days or hours postoperatively

  Verbal and written discharge instructions


More Vital Information

  Remember that communication breakdowns cause 75% of problems

  “The biggest problem in communication is the illusion that it has taken place.”

- George Bernard Shaw


Regulatory Standards

  Be familiar with applicable state, federal and accreditation regulations

  Policies & procedures should reflect current practice

  Remember…if it is written it must be done!


Questions ? Discussion?


Kate Goldblum, CFNP Albuquerque, New Mexico · Evaluation for Cataract Surgery Visual acuity –...

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