BLOG: Building an in-office surgery suite for intraocular refractive procedures
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Our growing practice specializes in refractive surgery, and several years ago, we made the decision to build our own facility and customize it to our vision of a modern facility with a spa-like atmosphere.
As we met with the architect, the building was quickly reimagined from a single story to a two-story building. I pondered the idea of building an ASC on the first floor and my practice on the second floor. I thought I could perform cataract surgery there, as well as a slew of elective procedures, not to mention the added convenience for both our patients and our practice. Texas is not a certificate of need state, so the approval and certification hurdles that many states face were not an issue.
My biggest concern was cost, volume of surgery and staffing. I quickly realized that I was very happy at the ASC where I performed my insurance-based procedures like cataract removal. I was already a major partner in a very efficient ASC that specializes in ophthalmic procedures, and I had a great working relationship with them.
A fair number of patients seeking refractive surgery are presbyopic and hyperopic. In many cases, refractive lens exchange (RLE) is a better option than LASIK. However, in the past, when given the RLE option, the vast majority of patients declined this viable option secondary to the cost of performing those procedures at the ASC. The same held true for implantable Collamer lenses (ICLs) and cosmetic blepharoplasty procedures. The cost was intimidating for cataract and pterygium patients who did not have insurance. The ASC and anesthesia fees for these elective procedures were also passed down to the patient, making the surgery unaffordable and burdensome.
When we were still in the conceptual architectural phases of the buildout, I thought about the possibility of having an in-office surgery room. I was inspired by a peer-reviewed study that showed the safety of performing cataract surgery in an in-office procedure room and by other articles discussing the possibility that, one day, ophthalmologists might be able to perform in-office cataract surgery, and surgeons would be able to bill Medicare or other insurance carriers for a (reduced) surgery center fee. I understood that there were arguments from both sides, especially about patient safety.
Because LASIK has always been a big part of our practice, we had already planned to build out a modern refractive surgery suite that holds multiple femtosecond and excimer lasers. I also decided to build an in-office surgery room for elective procedures. There were several additional reasons that inspired my decision to incorporate an on-site surgery suite in my practice. The most important factor for me was that I wanted to be able to handle elective cases, especially refractive cases, the way I thought would be best for the patient, making the cost of the procedure manageable for the patient and on par with other procedures like LASIK.
This way, we are able to provide the most appropriate procedure for our patients at a reasonable cost, while keeping patient safety as our primary concern. Another benefit is that the patients prefer the convenience of our office vs. an ASC or hospital. I had a few patients who have had cataract surgery for their first eye in an ASC and ended up having the second eye done in our office because of insurance reasons. These patients always praised having surgery in our office vs. an ASC. Our office has a relaxing spa-like atmosphere, with soothing music and a more personalized, intimate setting with an emphasis on patient needs. It is convenient, comfortable and inviting.
Patient safety has always been my top priority. We are a Class A ambulatory surgery facility, certified by the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF). During the design phase, care was taken to adhere to or exceed AAAASF guidelines. The design, setup and surgical protocols meet the standards of a modern ASC, from the type of seamless flooring and non-tiled ceilings, to the ventilation and HEPA system. This in-office surgery room has a modern phacoemulsification unit, ophthalmic patient bed, surgical microscope, and all necessary equipment and instrumentation needed for intraocular, anterior segment and oculoplastic surgery.
Patients are prepped and draped in the usual sterile ophthalmic fashion. The surgeon and staff are dressed and gowned in a similar fashion to an ASC or hospital operating room setting. Preoperative and postoperative protocols, similar to ASC protocols, are followed. Oxygen is administered at low flow by nasal cannula, and patient vitals are monitored during the procedure. There is a crash cart in the facility. In case of a life-threatening emergency, there are transfer agreements to a nearby emergency room and hospital. Our malpractice insurance carrier has been onboard with the new addition to our office. Some of the office staff are both certified scrub technicians and ophthalmic technicians. This allows us the ability to have the same staff for clinic on clinic days and for surgery on surgical days without added cost of extra staffing. We invest in training and certification. The staff hold certifications in Basic Life Support, while I hold certification in Advanced Cardiovascular Life Support from the American Heart Association. Going into our fifth year, the office-based surgery suite has had an excellent safety record similar to or even better than the ASC where I perform intraocular procedures. Thankfully, there have been no cases of vitreous loss or endophthalmitis.
We perform procedures on a scheduled weekly basis in our in-office surgery suite. All surgical procedures are performed under level 1 anesthesia. Typical procedures are RLEs, ICLs, eyelid procedures, and uninsured cataracts and pterygia. I do not perform any complex cases that have a higher risk of complications at the office suite, like complex mature cataracts with miotic pupils or nanophthalmic eyes. I will schedule those cases at the ASC under intravenous sedation. The surgical suite has also been invaluable in situations like a retained nuclear chip after cataract surgery, limbal relaxing incisions and suturing a flap.
ASCs are a necessity for eye surgeons. However, if you perform elective procedures such as RLEs, ICLs or blepharoplasties, you might want to consider having an in-office surgery room. Patients will find having surgery at your office cost-effective, convenient and relaxing, and it will make their experience more personalized and tranquil. Happy patients share their experience with their family and friends!
Visit Dr. Iskander’s blog to learn more about Refractive Procedures.
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