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 Able to accommodate adult patients with an American Society of Anesthesiology (ASA) classification of I-III.

 Can be established to provide all levels of anesthesia but it is most practical to only provide anesthetic options i-iv.

 CPSO standards and inspection programs now exist to regulate such facilities.  High volume centres can easily make use of an Anesthesia Care Team model with

multiple simultaneous ophthalmology rooms; an appropriate number of rooms will be required to make this cost-effective.

 Surgeon-directed sedation, either intravenous or oral, is also appropriate in such a setting.

 If eye blocks are used, need to have a plan in place to manage brainstem anesthesia or failed intraoperative block.

 May have linkages with Academic Health Science Centre for more complex ophthalmology case referral and dealing with complications.

Anesthesia Care Team models employ Anesthesia Assistants to administer and monitor patients receiving sedation. These models are currently in practice across numerous facilities. The Anesthesia Care Team model allows one anesthesiologist to supervise numerous Anesthesia Assistants covering multiple procedure rooms.

Other centres employ ophthalmologist-directed oral sedation or no sedation at all. In fact, the vast majority of cataract procedures in the British NHS are performed without any sedation.19

RECOMMENDATIONS Planning for ophthalmology services must be done in concert with planning for anesthesia to ensure that an appropriate model is available, affordable, and funded.

One-on-one anesthesiologist services (services that require one

Anesthesiologist for each patient) must be funded at a rate that matches low intensity general anesthesia services.

Centers planning to use an Anesthesia Care Team model must ensure that there is sufficient volume and funding to make cost effective use of both the anesthesiologist and the anesthesia assistant.

Ophthalmologists are encouraged to liaise with a hospital Department of Anesthesiology to ensure the viability of the anesthetic portion of their plan.

19 _{Royal College of Anaesthetists and the Royal College of Ophthalmologists. (2012). Local anaesthesia for} ophthalmic surgery. p. 9.

MODELS OF ORGANIZATIONAL EFFICIENCY

Consideration was given to developing volume targets and guidelines to support the modeling and system planning for ophthalmology services. Given the variability across the province in terms of patient needs, provider capacity, and LHIN geography, we could not conclude that there is in fact a minimum volume target needed for a hospital or facility to reach in order to be efficient.

That said, there are organizations throughout the province that can be seen as aspirational models in the efficient delivery of ophthalmology services. The following section highlights three of these high performing ophthalmology centres in Ontario. All three centres described below operate as ambulatory care centres and have been able to attain efficiencies through the design of their care model.

THE OTTAWA HOSPITAL – RIVERSIDE CAMPUS

The Riverside campus of the Ottawa Hospital focuses only on ambulatory diagnostic, therapeutic

radiation, surgical and medical care including dialysis, endocrinology, arthritis, women’s health as well as a family health team. Day surgery programs are offered include ophthalmology, urology, general

surgery, endoscopy and plastics. It is a teaching site of the University of Ottawa Opthalmology Department.

The Riverside Eye Care Centre is a state of the art dedicated eye surgical suite for cataract surgery, retina, corneal, glaucoma, oculoplastic and trauma surgery. The program does all types of minor procedures, has a full complement of lasers and provides intravitreal injections as well as ophthalmology diagnostic testing including intravenous fluorescein angiography, A- and B-scans as well as OCT . Over 14, 834 eye care surgical cases are performed annually.

The ambulatory eye care centre has 2.5 eye procedure rooms, diagnostics and clinics all on one dedicated Eye floor. The eye surgical suite is staffed by anesthesia assistant, RPN and operating room technicians appropriate for low risk eye surgery services. This compares to enhanced staffing in the main operating rooms at the General site where the more complex eye surgeries are done. The number of staff per room is also significantly lower at the Riverside site as compared to the main operating rooms.

The main operating rooms at the Ottawa Hospital site are focused on dozens of types of surgical procedures. The OR staff support multiple surgical disciplines. Anesthesia models support higher risk procedures that are predominantly performed under general anesthesia. Elective cases can be bumped by emergency procedures.

These realities of running busy OR surgical programs can be reduced if not eliminated in dedicated eye suites in separate, purpose-built ambulatory care centres. Here best practice models and patient flow suitable for lower acuity day patients can be established.

Ottawa is currently exploring the possible gains in efficiency by standardizing the number of cataract cases per room per day (targeting 12-15 eye cases per day; and completing 10,384 cases per year).

Other considerations include operating for 12 hours, 5 days a week versus 8 hours, 6 days a week, as well as considering other staffing mixes, all in an effort to improve efficiency and lower costs per procedure.

Average Direct Cost Per

Cataract Case (2011-12) $426

THE IVEY EYE INSTITUTE – ST. JOSEPH’S HEALTH CENTRE, LONDON

St. Joseph’s Hospital in London is an ambulatory teaching hospital focused on expanding the boundaries of ambulatory care in multiple disciplines. It is one of 5 sites of St. Joseph’s Health Care Centre, London. St. Joseph’s Hospital provides short stay (< 48 hours, 19 beds total) and day surgery, ambulatory

treatments of complex medical and chronic disease, illness prevention, research and education. Interdisciplinary teams provide comprehensive assessment, diagnosis, treatment and follow up care through specialty programs including urology, diabetes, rheumatology, pain management, osteoporosis, hand and upper limb orthopedics, eye care, lung disease, ear nose and throat, head and neck surgery, dentistry, gastroenterology/ endoscopy, plastics and breast surgery. A full range of diagnostic services including medical imaging and lab services support these programs as well as the urgent care centre. The Ivey Eye Institute is a comprehensive model of Ambulatory Ophthalmology. It operates 2 cataract surgical suites for low acuity patients and 2 dedicated operating rooms with capacity to carry out general anesthesia. It provides all adult routine and urgent eye care for London and area as well as subspecialty ophthalmology for the region and offers 24 hour eye access for assessment and medical and surgical treatment. Subspecialty areas include retina, pediatric, general/ocular plastics,

cornea/anterior segment, low vision clinic, glaucoma, screening and visual rehabilitation, with optometry and orthoptics provided as well.

Comprehensive diagnostic eye facilities are on site as well as the practices of 16 adult and pediatric subspecialists and general Ophthalmologists. There are over 90,000 eye patient visits per year. The Ivey Eye Institute has been able to deliver efficiencies in cataract services using anesthesia

assistants, RPNs and operating room technicians. The number of cataract cases has been standardized at 14 cases per room per day (4,595 cataract cases per year).

Average Direct Cost Per

KENSINGTON EYE INSTITUTE, TORONTO

Kensington Eye Institute is a state-of-the-art ambulatory eye surgery centre of excellence located in Toronto. It is a not-for profit, charitable organization governed by a volunteer Board of Directors and licensed by the Ministry of Health and Long-Term Care as an Independent Health Facility. KEI is accredited by the Canadian Council of Health Facilities and is a fully affiliated teaching site of the Department of Ophthalmology at University of Toronto.

The Executive Leadership Team is accountable to the board for quality, standards of care, cost

effectiveness and efficiency of operations. All appointments to the medical staff must be approved by the board. A Professional Advisory Committee reports to both the board and the medical staff. Quality assurance metrics have consistently demonstrated a high level of patient satisfaction as well as surgeon and staff satisfaction.

Kensington Eye Institute is a purpose-built dedicated ambulatory eye surgery centre having 3 dedicated cataract rooms and 1 mixed procedures room for corneal transplants, glaucoma and retinal day surgery. KEI has its own dedicated nursing and support staff though the anesthesia assistants are employees of UHN and rotate through KEI and Toronto Western/General Hospitals.

There are 50 ophthalmologists on staff at KEI with 85% of the surgeons on staff at UHN, Mt. Sinai, Sunnybrook or St. Michael’s Hospital where they also provide on call and emergency coverage, consultation and surgical services. The remaining surgeons are all on staff at University of Toronto community affiliated hospitals. Similarly, the anesthetists who practice at KEI are also on staff at one of the four Toronto teaching hospitals.

KEI opened in 2006 with 3 cataract rooms and 6700 cataracts. As per CPSO, only ASA 1-3 cataracts can be done at KEI, while ASA 4 cataracts must remain in hospital. When KEI was formed, the four Toronto teaching hospitals agreed to shift their low risk cataract surgery to KEI and foregoing receipt of new MOHLTC wait time funding for cataracts. As agreed by MOHLTC, the hospitals were able to reinvest the dollars saved from reducing cataracts into more specialized ophthalmology services which also had long wait lists.

KEI with these same 3 cataract rooms are now completing 9880 cataracts per year. Each eye room is staffed with 1 RN and 1 RPN with an anesthesia assistant and an onsite anesthetist. All SPD procedures are done on site by 2 SPD technicians. There are approximately 16 to 18 cataract procedures per room per day. KEI gains efficiency by using standard packs and surgical trays and turning over the procedure rooms in 7 minutes between cases.

More recently, KEI has also been funded by MOHLTC to provide 400 corneal transplants, 600 retinal procedures and 800 glaucoma procedures per year, with the capacity to provide an additional 200 corneal transplants per year. These will be done in the dedicated fourth operating room specifically for non-cataract cases. Future plans include establishing more comprehensive diagnostics on site.

Average Direct Cost Per

PROVINCIAL SOURCING OF SUPPLIES

In an effort to find further operating efficiencies, implementation of provincial sourcing model for ophthalmology surgical supplies should be explored to complement the approaches already in use by the nine Shared Service Organizations for Hospital Purchasing. In particular, intraocular lenses and surgical phaco packs were identified as potential opportunity areas for provincial joint purchasing.

RECOMMENDATIONS Ontario’s nine hospital Shared Services Organizations should coordinate efforts to develop a provincial joint sourcing model for ophthalmology supplies.