As the senior at the LBVA you will largely focus on cataract surgery and other sub-specialty surgery while also helping your co-residents in clinic on your non-operative days and after surgery. Given the higher surgical volume and the opportunity to operate two days of the week, you will need to be very familiar with how to place CPRS orders for surgery and how to facilitate getting your patient into the OR with all the necessary equipment and supplies. Several of the most common steps necessary to getting into the OR are outlined below for review.
What steps to take when signing a patient up for surgery
Obtain consent
Place request for surgery (RFS) on CPRS (Make sure to list Amy Delfin as "Attention"
If a patient has minimal PMHx, a Request for Cataract Surgery (RFCS) can be placed, and patient does not require further work-up
In order to qualify for RFCS patients cannot have a pacemaker and cannot require oxygen at baseline
If there is any suspicion that a patient would not be cleared for surgery without pre-op work-up; a formal RFS should be placed with subsequent work-up as listed below.
FOR RFS PATIENTS --- Order CXR/EKG/Labs
FOR RFS PATIENTS --- Send patient for E-screening with clinic technicians
Order pre-op Drops
Send patient info to Amy Delfin for scheduling
How to access the surgical schedule
Star icon on desktop “VA Shortcuts” > left panel “This PC” > (W:) Workgroups drive > Surgical shared folder > Surgical CASES Being SCHEDULED > “Eye OR Cases CURRENT Scheduled Calendar”
If you do not have access, Teams Amy Delfin and Jorge Sarimiento
If planning for Glaucoma surgery
Update the Glaucoma Excel sheet
Consider if other medications are needed and order (MMC must be ordered 1 week in advance and if TDOS changes, an updated order needs to be placed)
How to order intraoperative medications
Most commonly for MMC for Trabeculectomy cases
To order intraop medicine such as MMC or 5FU --> SDS orders --> Ophthalmology --> Medications --> MMC or 5FU
If planning for Retina surgery
Discuss pertinent findings with fellow (Lens status, PVD status, etc)
Take indirect to OR from clinic for pre-op exam
Take Cryo to OR from clinic if needed intraop
If anything is taken from clinic, please let clinic team (Liz or other technicians) know that you are taking it
How to order tissue and special order surgical implants (IOLs) --> Order on CPRS through the following steps
Consults
Surgery
Request for Implant
Can order corneal tissue as well as special order IOLs
Must also message the implant coordinator (Jason Sriongpol (spelling?) or Sohelia Akbarian)
Must also message Alcon (Ann Pham) /J&J rep for IOLs for expedited delivery if needed with quick turnaround
LAL Planning
Ensure patient is a good candidate for LAL
Good dilation (>7mm)
Willing to wear UV protecting glasses and return for multiple treatments
Patient understands that this is largely a mono-focal lens with some range
Often helpful in post-refractive patients who want very specific refractive outcome
Patient needs pre-op refraction
When completing IOL calcs
Consider aim
Typically can aim -0.5 to -1.0 because LAL can be adjusted roughly +2 to -2 D
Discuss with attending regarding a "starting" aim that can then be adjusted with post-op treatments
Contact Rep and place Request for Implant (RFI) as outline above on CPRS
What to do the day before surgery
Place H&P Note (SDS History and Physical)
Place orders for pre-op drops if necessary
Ensure that notes and orders are listed under the OR context --- LB SDS Reception
Review consent
Review IOL calcs and make sure all lenses are on site at the VA if applicable
What to do the day of surgery
Get to OR (5th floor) 45 minutes prior to first case start
Ensure patient in marked, consented, and drops are ordered if needed
Review anesthesia plan with OR nurse/Anesthesia staff
Almost always MAC for Cataracts
Most often MAC +/- Block for retina/Glaucoma
Mixed anesthesia for plastics
Get IOLs for the day from implant room and leave in OR1
Check room
Ensure scrub tech has all necessary equipment/sutures/intra-operative medications
Write patient/case info on OR whiteboard
Draw up block if necessary
Plan timing for Pre Verification (PV)
Prior to surgery, a safety check, or PV, will be completed for each cases with the attending present
For cataract surgery, PV can be done in the OR
For all other surgeries, PV must be done in the pre-op holding area after which the patient will be taken to OR
After surgery, several orders/notes are needed
Brief Op Note
Op Note in surgery tab (to be completed by resident or fellow dependent on case)
Dicharge orders --> SDS Orders --> Post-op Orders --> DC IV when stable, DC patient, Re-start Diet
RTC Orders
Discharge instructions note (SDS General Discharge Instructions )
Special consideration for POD0 cataracts
List follow-up time for post-op follow-up on discharge instructions note.
Inform the patient and the PACU nurse that the patient will be going to Ophthalmology clinic for POD0 visit
If patient presents to clinic before 330, clinic staff can help check them in/work up. However, if patient will be seen after 330, plan to receive patient from waiting room yourself
How to place Beneficiary Travel Note
Make a new note: BENEFICIARY TRAVEL (BT) NEW
Special mode transportation select yes to continue to special mode justification; visual impairment.
Select “Visual impairment, without private transport assistance, with inability to use public transportation safely”,
No IFT
Type of transport: Wheelchair Van/Ambulette
Wheelchair type: N/a
Other mobility type: Ambulatory with supervision
Travel date is to commence: Place current date
Estimated time frame veteran will require transportation = 6 months
Locations: To and from all visits
Round trip
Click finish, then select SMT one last time
Sign the note, then go to ORDERS and sign the order.
How to use CPRS Booster
The CPRS is an add-on software to run with CPRS that allows you to create "smartphrase" like shortcuts as well as other shortcuts to use CPRS more efficiently
To run CPRS Booster
First open CPRS
Open booster through VA shortcuts (Rocket icon)
Follow prompts for different shortcut options
Transport
Travel USA "Freddie" - 562-336-8187
Call Operator and ask for the "AOD" for assistance with transport of patients home after hours