4.

DOCUMENTED PROCESS FLOW FOR PROVISION OF CLINICAL SERVICES IN

NOVO EYE CARE CLINIC INC.

Purpose
This document outlines the processes and staffing necessary to ensure safe and efficient
ophthalmic surgery, adhering to local anesthesia guidelines for cataract surgery. It describes the
steps that take place once the clinician and patient have mutually decided to proceed with
surgery.

a. Pre-Operative Phase

Consent
It is considered best practice to obtain consent before the surgery day, except in emergency or
minor operations. On the day of surgery, consent should be reconfirmed and signed again by
the patient. Consent forms or ASC record sheets must document the discussions and risks;
procedure-specific forms are useful but must be customized to fit each patient’s unique needs
and risk profile.
Consent must be obtained with full knowledge of the risks associated with the surgery and
anesthesia. The individual administering anesthesia is responsible for discussing potential
complications. While a separate consent form for anesthesia is not required, it is recommended
to record the discussion in the patient’s medical records.

Pre-Operative Assessment
General medical records should be available for pre-operative assessment, and if pertinent
information is missing, the surgery should be deferred.
The results of the pre-assessment should be documented on a checklist.
o Pre-operative assessments should typically be performed by specialist nurses or trained
ophthalmic healthcare professionals, with medical or anesthetic input as needed.
o Specific checks must confirm the patient’s suitability for surgery. Living alone is not a
contraindication, but arrangements for post-operative care, particularly with eye drop
administration, must be ensured.
o Some patients may need assistance from a relative, friend, carer, or community nursing
team for transportation or post-surgical care.
 o Suitability for the planned anesthesia must be confirmed.
o Concerns regarding mental capacity, ability to lie flat during the procedure, and
communication difficulties should be addressed.
Medical History and Clinical Assessment
o The pre-operative assessment should cover:
o Past illnesses: Present illness and symptoms, categorized by system (e.g., cardiovascular,
respiratory, neurological, renal, psychiatric).
o Medications: Record all current medications, especially anticoagulants, antiplatelets,
and alpha-blockers (e.g., tamsulosin, doxazosin).
o Allergies and sensitivities: Document any allergies or sensitivities to drugs.
o Surgical history: Note past surgeries and any complications.
o Anesthetic history: Include any past anesthetic procedures and complications.
o Communicable diseases: Identify any viral status or isolation requirements as per local
protocols.
Physical Examination
o The following should be examined:
o Vital signs: Pulse rate, rhythm, and blood pressure (repeated if abnormal).
o Additional checks: Hearing, comprehension, cooperation, tremors, and abnormal
movements.
o Infection control: Perform screening tests like RT-PCR as per local protocols.

Additional checks if indicated:

o For patients showing signs of respiratory distress or breathlessness, measure respiratory
rate and oxygen saturation. If necessary, consult a doctor or anesthetist.
o Assess the patient’s ability to lie flat and still during the operation.
o Conduct non-ocular sepsis checks.
o Perform slit lamp examination, e.g., for blepharitis.

Routine tests:
o A clotting profile for patients on anticoagulants like warfarin (based on local protocols).
o Electrolytes for patients on dialysis.
o Blood glucose and HbA1C levels for diabetic patients.
o Protocols should be in place for managing patients with high blood pressure, diabetes,
and those using anticoagulants before ophthalmic surgery.
o There is no strict guideline on the maximum time between the full pre-operative eye
examination and surgery. In most cases, patients will undergo surgery within the
recommended referral to treatment time (RTT), minimizing the risk of significant
 changes (e.g., new glaucoma onset). If there is a significant delay, reassessment in the
eye clinic should be considered.

Pre-Operative Information
1. Though consent may have already been obtained, the pre-operative assessment
provides an opportunity to share important information with the patient and their
family or carers.
2. Provide comprehensive information about the surgery and anesthesia using verbal,
written, audio, or video formats.
3. Discuss the day of surgery, including what to expect during the procedure.
4. Cover transport, attire, arrival and discharge times, food and drink restrictions, the use
of dentures and hearing aids during surgery, and the need to remain still during the
procedure.
5. Discuss post-operative care, including eye drop administration and any required training
or community nursing services.
6. Ensure that patients receiving adult social care have adequate post-discharge care
arrangements. Reassure the patient regarding their care throughout the surgical
process.

b. Intra-Operative Phase

On Admission
Patients should arrive at the surgical unit with enough time to complete necessary formalities.
Staggered arrival times can be convenient for patients and reduce overall time in the surgical
process. However, for cases involving general anesthesia (GA) and sedation, this may be
challenging as the anesthetist needs to review all patients before the list begins.
For local anesthesia (LA) procedures, the effectiveness of staggered arrivals depends on surgical
staffing. If only one surgeon or professional is available to perform pre-operative checks,
stepping out of the OR to assess late arrivals may slow down the surgery schedule.

 For ophthalmic surgery without sedation, fasting is unnecessary, and patients should
take their regular medications on the day of surgery.
 Nurses or healthcare assistants (HCAs), supervised by nurses, should complete pre-
operative preparation in the ward or waiting areas. The results of pre-assessment and
the following should be recorded on a checklist:
o Confirm the patient’s identity and attach a name band to their wrist.
o Ensure next-of-kin details are updated in the patient’s medical records.
 o Confirm that the patient has remained well since the pre-assessment and has no
new illness, such as an upper respiratory infection.
o Verify that the patient has taken their medication.
o Confirm allergy status, as this may affect the surgery order (e.g., Type I latex
allergy).
o Ensure post-surgical arrangements for the patient’s safe return home.
o Check BP, pulse, temperature, and oxygen saturation.
o Confirm that the consent form has been signed and rechecked on the day of
surgery.
o Ensure pre-operative medications, including eye drops or inserts, have been
administered.
 Any changes in the patient’s condition or therapy since pre-operative assessment, or
concerns from the current assessments, should be communicated to the surgeon and
anesthetist, if applicable.
 The findings of the pre-operative assessment must be reviewed by the ophthalmologist
and, where appropriate, the anesthetist.
 Privacy must be ensured for examinations, and the operating surgeon and anesthetist (if
applicable) should verify the findings from the outpatient clinic or pre-operative
assessment.
 The eye and adnexae should be examined to rule out acute inflammation or infection
and rechecked for any factors that could affect the safety of local anesthesia or surgery.

Pre-Operative Marking

 Surgical site marking is mandatory for all procedures where applicable. The site must be
marked shortly before the procedure, but not in the anesthetic room or OR.
 Marking should be done by the surgeon or assistant surgeon who will be present during
the procedure. It is the surgeon’s responsibility to ensure the correct eye or side is
operated on.
 Confirm the patient’s identity through active confirmation (e.g., asking for their name
and date of birth).
 Verify the nature of the operation and the correct side or site.
 Clearly mark the eye or side to be operated on with an indelible mark that remains
visible after surgical cleaning and draping.
 Never mark the non-operative side, even with statements like "not this side."

Handover to Procedure Teams

A formal handover from the ward or admission team to the OR team is required.

 The handover should verify:

o Patient identification (name, date of birth, active confirmation) against the
identity band.
o Allergy status.
o The procedure and the correct site.
 o Surgical site marking.
o Presence of plates, pins, or metal implants if monopolar diathermy will be used.
o Fasting status.
o Relevant clinical details (e.g., blood sugar for diabetic patients, INR for patients
on anticoagulants).
o A completed patient record.
o A properly signed consent form.
o Biometry sheet (if applicable).
 Any discrepancies, omissions, or uncertainties must be resolved before proceeding with
the next stage of the patient pathway (i.e., sign-in).

Staffing
Certain principles should guide the OR team:

 The surgical clinic must identify the necessary workforce (number and skill mix) for
efficient and safe ophthalmic surgery. This should be developed in consultation with
appropriate staff representatives. Job plans should account for time to set up
equipment, perform safety checks, and engage in key safety protocols such as briefings
and debriefings.
 Staffing plans must accommodate the expected duration of surgery, including protocols
for team members leaving or joining during a procedure. Handover processes must be
clear in such instances.
 The surgeon should be supported by a consistent, well-trained team to maximize
efficiency and ensure patient safety.
 All OR staff should receive regular updates and professional development relevant to
their roles.
 The head nurse (or equivalent) must verify the availability of the necessary workforce
before starting any surgical list. If surgery proceeds without the agreed staffing levels,
the head nurse must be confident that the team can support safe patient care and
report the incident if necessary.

For LA ophthalmic surgeries, the minimum acceptable OR team includes:

 Scrub Nurses: Typically, two nurses are required—one for the current case and another
for preparing instruments for the next. These nurses should have ophthalmic or OR
training and sufficient experience to handle both routine and unexpected complications.
 Runner: A nursing assistant or similar role responsible for providing the scrub nurse with
necessary equipment, setting up phaco devices, positioning the patient and microscope,
adjusting lighting, and assisting with other essential tasks. This role is crucial for
maintaining the efficiency of the surgical list.

Patient Monitoring
For patients undergoing GA, standard GA monitoring procedures apply.
For patients under LA:
  Continuous monitoring should begin before the administration of LA and continue
throughout the operation. Minimum monitoring includes clinical observation,
communication, and pulse oximetry.
 ECG and BP should be monitored in sedated patients, those at risk of cardiovascular
issues (e.g., hypertensives, diabetics, pacemaker patients), or when high-risk situations
arise, such as strabismus surgery or the use of sympathomimetic agents (e.g.,
phenylephrine).
 Non-invasive BP measurements should be minimized to reduce discomfort during
surgery.
 A trained individual must monitor the patient throughout the procedure. This person
could be an anesthetist, nurse, or nursing assistant trained in basic life support (BLS),
capable of detecting adverse events and initiating appropriate treatment. The ultimate
responsibility for the patient lies with the operating surgeon and anesthetist (if present).

Anaesthetists and Resuscitation

 Each clinic must have an identified anesthetist responsible for overseeing ophthalmic
anesthetic services.
 The availability of an anesthetist for all ophthalmic cases depends on local staffing. An
anesthetist is not required when topical, sub-conjunctival, or sub-tenon’s techniques are
used without sedation.
 All OR staff must receive regular BLS training and be familiar with resuscitation
procedures. A resuscitation trolley should be readily available.
 A formal policy for medical emergencies must be in place, particularly in isolated units
or procedures conducted outside of main OR complexes. Clear protocols must enable
prompt access to advanced medical care when necessary.
 In clinics without immediate access to a cardiac arrest team, at least one staff member
must be trained in Advanced Life Support (ALS).
 Ideally, an anesthetist should be available in the OR, particularly when sharp needle
blocks (e.g., peribulbar, retrobulbar) or complex, long procedures are performed.
 If an anesthetist is not present, the ophthalmologist assumes full responsibility for
patient management, including resuscitation skills.

5 Steps to Safer Surgery

1. Safety Briefing (Team Brief):
A safety briefing should be conducted at the start of all surgical sessions, whether elective,
unscheduled, or emergency. This briefing can be done on a case-by-case basis if key team
members change during the session.
 Minimize noise and interruptions during the briefing.
 Conduct the briefing in a private location before the first patient arrives in the OR.
  The briefing must involve as many team members as possible, including the surgeon and
anaesthetist who have seen and consented the patients.
 Any team member can lead the briefing, and everyone should introduce themselves.
The names and roles of each team member should be listed and visible throughout the
session.
 The discussion for each patient should cover aspects like the procedure, site and side,
implant availability, allergies, co-morbidities, infection risks, patient positioning,
equipment needs, and anticipated challenges.
 Any issues raised must be documented and addressed with local governance systems if
relevant to other patients.
2. Sign In:
On arrival at the procedure area, all patients must undergo safety checks as the first part of the
WHO Surgical Safety Checklist.
 For cataract surgery, use a specific ophthalmic checklist; for other ocular surgeries,
either the WHO or an ophthalmic-specific checklist is appropriate.
 Noise and interruptions should be minimized, and the sign-in must be performed by at
least two team members, including the anaesthetist if involved.
 The patient's active participation should be encouraged when possible.
 All discrepancies or uncertainties must be resolved before completing the sign-in.
 Checks should include patient identity, consent, surgical site marking, anaesthetic
safety, allergies, and aspiration risk.
 Before any anaesthetic block, the anaesthetist must confirm the surgical site and side.
3. Time Out:
Immediately before the procedure begins, a second set of safety checks must be performed.
 Minimize noise and interruptions, and encourage patient involvement when possible.
 The time-out should resolve any issues identified during sign-in.
 Any member of the procedure team can lead the time-out, and all team members
should participate.
 This step should include checks on the patient’s identity, procedure, surgical site
marking, necessary equipment, and any critical concerns.
 Special considerations should be discussed for anesthesia, sterility, and postoperative
care.
  Any discrepancies must be resolved before starting the procedure.
4. Avoiding Retained Items:
Ensure that no items are unintentionally retained in the patient’s body by accounting for all
items used during the procedure.
 Periodically assess and standardize instrument sets and swabs.
 Equipment trays must have a comprehensive list of instruments for checking before and
after use, and disassembled equipment should be clearly documented.
 The same two team members should perform item counts before closing body cavities
and before final closure.
 If any item is missing, it must be investigated and documented immediately, with X-rays
if necessary.
 If there are any unresolved discrepancies, the entire team must be certain that no items
are left in the patient.
5. Sign Out:
After the procedure and before handing over to post-procedure care, a final set of safety checks
must be performed.
 Noise and interruptions should be minimized, and all team members should participate
in the sign-out.
 Confirm the procedure performed, ensure all instruments and swabs are accounted for,
and confirm proper labeling of specimens.
 Post-procedural care and equipment problems should be discussed and documented.
Records and Documentation:
 Medical notes, including any surgical or procedural documentation, must be available
on the day of surgery.
 Ensure all safety checks, procedures, and postoperative instructions are recorded in
standard documentation.
 Paper and electronic records must be aligned to avoid inconsistencies.
Debrief:
After each list, a team debriefing should be conducted to review the session.
 All team members should participate, and the surgeon and anaesthetist must be
present.anesthetist
  The debrief should cover what went well, any equipment issues, and areas for
improvement.
 A record of the debrief, including an action log, should be kept, and any patient care
concerns must be noted in the patient’s records.

Post-Procedure Handovers

A formal handover must be conducted between the procedure team and the post-procedure care
area, such as recovery or day case units. The handover should include, where relevant:

 The patient's name, verified against their identity band.

 Any relevant comorbidities.
 Known allergies.
 The planned and actual procedure(s) performed, including the site and side.
 Any surgical complications and corrective interventions.
 Relevant intraoperative medications, such as opioids, anti-emetics, and antibiotics.
 Expected recovery course and any potential complications.
 The postoperative management plan, including pain relief measures.
 National early warning scores, if applicable.
 Information provided to the patient regarding the procedure or plans for post-procedure
communication.
 Details of anaesthetic care, including any complications or interventions, as well as
airway issues.
 Inpatient drug charts, if the patient requires overnight admission.
 Contact details and instructions for the responsible clinician if a next-day review is
planned.

c. Post-Operative Phase

 Discharge Criteria: Clear discharge criteria must be established and met, including any
necessary assessments like vital signs and the condition of the eye, depending on the
specific case.
 Pain Management: Pain should be properly assessed and managed before discharge.
 Patient Condition: The patient should feel well with stable vital signs before discharge.
 Urination (for General Anaesthesia): Patients who have undergone general anaesthesia
must pass urine before being discharged.
 Safety Arrangements: Ensure the patient's return home is safe, with confirmation of
available support. It is recommended that all patients, especially frail and elderly
individuals, have a friend or relative accompany them both to and from surgery.
  Post-Operative Information: Provide both verbal and written information regarding
post-operative recovery, such as instructions, medication advice, follow-up
appointments, and what to expect during recovery.
 Contact for Complications: Give written instructions on what to do and whom to
contact in case of complications, particularly signs of post-op infections such as
endophthalmitis.

Organizing Surgical Cases

 Patient Safety: Safe surgery depends on thorough preparation, accurate scheduling, and
effective management of case lists.
 Standards and Communication: Organizations must develop clear standards for
scheduling both elective and emergency procedures. Key patient and procedure
information should be communicated using standardized data sets.
 Clear Communication: Use unambiguous language when scheduling and listing
procedures. Laterality (e.g., left or right) must be written in full, and abbreviations
should be minimized.
 Procedure Information: Scheduling should include patient name, identification
numbers, date of birth, gender, planned procedure, site and side, comorbidities,
allergies, infection risks, and special equipment requirements.
 Order of Procedures: The clinical team should prioritize procedures based on clinical
criteria such as urgency, age, allergies, and medical conditions. Routine scheduling rules
can be delegated to administrative staff.
 Efficient OR Use: Efforts should be made to maximize operating room (OR) efficiency by
starting on time and using flexible scheduling. OR utilization should be audited regularly.
 Case Scheduling: Consider factors like team briefing, anaesthetic time, patient
positioning, equipment preparation, and the experience of the procedure team.
Reviewing OR usage records can help determine time requirements for common
procedures.
 Avoiding Late Changes: Changes to the case list should be minimized, and clear
processes for case management should be in place to avoid multiple versions of the
same case list.

Patient Safety and Clinical Governance

 Handling Complications: OR staff must be prepared to handle unexpected complications

by having the necessary instruments and equipment readily available.
 Team Training: Training should be multidisciplinary and include human factors and non-
technical skills. Teams should practice and review local OR procedures together.
 Incident Reporting: All patient safety incidents and near misses should be reported
through a standardized process, investigated, and analyzed, with feedback given to staff
for continuous improvement.
 Transparency: The organization should promote openness and transparency when near
misses or incidents occur.
  Feedback and Governance: Each team should have a designated member responsible
for briefing and debriefing documentation. Issues should be escalated as needed for
service safety.
 Clinical Governance Meetings: Regular multidisciplinary meetings should be scheduled
for training, incident analysis, safety audits, and team development. These may be
termed "Morbidity and Mortality" or "Audit" meetings.

Workload and Productivity in the OR

 Factors Affecting Throughput: Patient throughput is influenced by surgeon experience,

OR staffing, anaesthetic support, OR design, record-keeping, technical support, case
complexity, and OR session duration.
 Training and Teaching: Ophthalmic units, particularly those focused on cataract surgery,
should manage teaching demands by scheduling dedicated teaching lists and allowing
flexibility for trainee needs.
 Improving OR Productivity: Key factors include collaboration between clinicians and
managers, data-driven decision-making, minimizing cancellations and delays, optimizing
turnaround times, and improving team efficiency. Regular data analysis on OR use and
case complexity can help identify areas for improvement.
 Avoid Complications: Through proper pre-op assessments, patient education, and risk
management protocols, complications can be minimized.
 Extended Roles for Staff: Consider expanding non-medical roles in OR processes and
streamlining workflows to improve efficiency.
 Surgical Technique and Instrumentation: Techniques and instrument handling can be
refined to reduce time, with specific focus on preparation and draping.
 Training Through Observation: For slower surgeons, consider recording their
procedures and preparation to identify areas for improvement.