Keywords
after-hours eye surgeries - ocular trauma - operating room resources - clinician satisfaction
- survey - listserv
Training in the management of ocular trauma is an Accreditation Council for Graduate
Medical Education (ACGME) requirement for ophthalmology residency programs. Many residency
programs provide training in both adult and pediatric eye disease. In the United States,
approximately 2.4 million eye injuries occur per year.[1] Approximately one-third of eye-related emergency room complaints are for ocular
injuries.[2] Ocular and adnexal injuries often require emergent or urgent surgical intervention
within 24 or 72 hours, respectively. These include eyelid lacerations with canalicular
involvement, intraocular foreign bodies, full-thickness corneal-scleral lacerations
with or without uveal prolapse, and orbital fractures with extraocular muscle entrapment.
Many of these cases require surgical intervention after normal working hours due to
the urgency of surgical intervention or the availability of the surgeon and operating
rooms (ORs).
The specialized care needed for eye injuries and the availability of after-hours ophthalmological
services result in many of these cases being managed at hospitals affiliated with
ophthalmology training programs. These hospitals may or may not be level 1 trauma
centers. Minimum criteria of patient care resources at trauma centers in the United
States are typically mandated by the American College of Surgeons (ACS) or by state
trauma guidelines. However, in regard to ophthalmology services, the ACS guidelines
state that “Level 1 facilities are prepared to manage the most complex trauma patients
and must have available a full spectrum of surgical specialists, including … ophthalmology,”
but do not further specify minimum ophthalmology criteria.[3] Ophthalmology residency programs tend to have a wide range of resources available
for after-hours ophthalmic surgery, including on-call trainees, which may both promote
access and affect the quality and efficiency of care delivered. To date, no study
has attempted to evaluate the range of these resources available for ophthalmology
residency programs across the United States.
The purpose of this article is to determine the availability of resources for after-hours
eye surgeries at ACGME-accredited ophthalmology programs in the United States. We
also sought to quantify clinician satisfaction based on the availability of resources,
and to determine the most significant barrier to clinician satisfaction.
Methods
Institutional Review Board Approval
This project was a quality improvement study and was exempted from Institutional Review
Board review.
Data Collection
An anonymous online survey was constructed on Survey-Monkey ([Fig. 1]). The survey consisted of multiple-choice questions addressing the availability
of three resources considered essential to high-quality surgical management of eye
injuries: (1) OR staff specifically trained to assist in ocular cases, (2) a functional
operating microscope, and (3) adequate surgical supplies. Multiple-choice response
options regarding availability were “Almost always,” “Frequently,” “Infrequently,”
and “Almost never.” The survey also included one question regarding overall clinician
satisfaction with after-hours surgical management, and one question asking which resource
(or lack thereof) most affected clinician satisfaction. The initial survey was sent
in May 2017 to all ophthalmology residency program directors on an Association of
University Professors of Ophthalmology (AUPO) listserv (eyepd.net). Follow-up reminder
emails were then sent 1 and 3 weeks after the initial survey was sent.
Fig. 1 Study questionnaire.
Outcomes
The primary outcome measure was the availability of resources. Secondary outcomes
assessed the impact of available resources on clinician satisfaction. Satisfaction
was graded on a scale of 1 to 10. Predictors of clinician satisfaction (level 1 trauma
center, cases per month, access to a functional microscope, supplies, and eye-trained
OR nurses) were evaluated as dichotomous variables: frequently (“almost always” and
“frequently”) or infrequently (“infrequently or “almost never”), and cases were evaluated
as fewer or more than five cases per month.
Statistical Analysis
Statistical analysis was performed using Stata version 1 (StataCorp LP, College Station,
Texas, United States). Percentages were calculated with available resources. Median
and interquartile range (IQR) were reported for clinician satisfaction scores, and
p-values were calculated using the Wilcoxon rank-sum test. A generalized linear regression
model was used to evaluate the impact of available resources on clinician satisfaction
scores. The threshold for statistical significance was set at p ≤ 0.05.
Results
Access to Level 1 Trauma Services
Fifty-seven of the 116 programs (49%) completed the survey. Fifty-four of the 57 respondents
(95%) had access to either an adult or pediatric level 1 trauma, and forty-five (79%)
respondents had access to both adult and pediatric level 1 trauma hospitals. Seven
programs (12%) reported access to an adult level 1 trauma hospital only, while two
programs (4%) reported access to a pediatric level 1 trauma hospital only, and three
programs (5%) reported access to neither adult nor pediatric level 1 trauma hospitals.
The majority of programs (63%) performed more than five trauma cases per month.
Availability of Resources
Fifty-four of 57 (95%) respondents reported access to a functioning microscope almost
always or frequently, and 50 of 57 (88%) respondents reported access to adequate surgical
supplies almost always or frequently. However, 28 of 57 (49%) programs reported access
to eye-trained OR staff almost always or frequently. The remaining 29 of 57 (51%)
programs reported access to such OR staff either infrequently or almost never ([Fig. 2]).
Fig. 2 Percentage of programs with access to resources.
Clinician Satisfaction
The median satisfaction score among all programs was 6 (IQR: 5–8). Scores were significantly
higher among programs with frequent access to eye-trained OR staff compared with programs
with infrequent access to trained OR staff (p < 0.001). Similarly, scores were significantly higher for programs with access to
surgical supplies (p < 0.001) and a functional microscope (p = 0.021) than for programs without these resources ([Table 1]).
Table 1
A comparison of median clinician satisfaction scores by available resources
|
Resource
|
Yes[a]
|
No[a]
|
p-Value[b]
|
|
Access to eye-trained OR staff
|
8 (7–9)
|
5 (4–6)
|
< 0.001
|
|
Access to surgical supplies
|
7 (5–8)
|
4 (3–5)
|
< 0.001
|
|
Access to operating microscope
|
6.5 (5–8)
|
3 (1–5)
|
0.021
|
|
More than 5 cases/month
|
6 (5–8)
|
7 (5–8)
|
0.559
|
|
Access to level 1 trauma center[c]
|
6 (5–8)
|
9 (5–10)
|
0.194
|
Abbreviation: OR, operating room.
a Median (interquartile range) for satisfaction scores are reported.
b
p-Values were calculated using Wilcoxon's rank-sum.
c Either the pediatric or the adult facility was a level 1 trauma center.
Most programs had access to a functional microscope and adequate surgical supplies.
In contrast, only half had access to eye-trained OR staff. No program with access
to eye-trained OR staff lacked a microscope, and only one program with access to eye-trained
OR staff lacked surgical supplies. Adjusting for other factors, clinician satisfaction
scores were 2.62 times higher for programs with access to eye-trained OR staff (p < 0.001) comparted to programs without those trained staff ([Table 2]).
Table 2
Predictors of clinician satisfaction
|
Measure
|
Regression coefficient[a]
|
p-Value
|
Adjusted coefficient[b]
|
p-Value
|
|
Access to eye-trained OR staff
|
2.99
|
< 0.001
|
2.62
|
< 0.001
|
|
Access to surgical supplies
|
3.11
|
< 0.001
|
1.85
|
0.005
|
|
Access to operating microscope
|
3.00
|
0.006
|
1.01
|
0.285
|
|
More than 5 cases/month
|
−0.36
|
0.554
|
0.48
|
0.246
|
|
Access to level 1 trauma center[c]
|
−1.80
|
0.163
|
−1.17
|
0.181
|
Abbreviation: OR, operating room.
a
p-Values were calculated using generalized linear regression model.
b Adjusted for eye-trained OR staff, surgical supplies, microscope, cases per month,
and level 1 trauma center.
c Either the pediatric or the adult facility was a level 1 trauma center.
The most commonly perceived barrier to a higher clinician satisfaction was reported
as access to eye-trained OR staff (28/57, 49%), followed by none (19/57, 33%), then
access to proper materials and equipment (7/57, 12%), and finally access to a functional
microscope (2/57, 4%).
Discussion
The surgical management of ophthalmic injuries is complex and requires specialized
knowledge and equipment to be performed efficiently. However, national regulations
describing minimum criteria for adequate ophthalmological services at trauma centers
are vague. In our study, we sought to gain a better understanding of how many programs
have access to key resources during after-hours surgical cases, and how access to
these resources affect clinician satisfaction.
Surveys have been successfully utilized to gather data regarding national trends in
ophthalmology residency education,[4]
[5] as well as in trends in compensation of retinopathy of prematurity screening.[6] Ophthalmology listservs are a useful resource for distributing online surveys to
clinicians to quickly gather data.[4]
[5]
[6] To our knowledge, this is the first study to utilize an AUPO listserv surveying
ophthalmology program directors regarding access to surgical resources after hours.
This is also the first study to assess the relationship between clinician satisfaction
and access to ophthalmic surgical resources. The survey response rate in our study
was 57 out of 116, or 49%. This is comparable to the observed response rate in other
studies utilizing an AUPO listserv for survey distribution (44–51%).[5]
[6]
In this study, frequent access to trained OR staff in the emergency setting seems
to be the most important predictor of clinician satisfaction. Although access to eye-trained
OR staff, a functioning microscope, and surgical supplies were all predictive of significantly
higher clinician satisfaction scores, the majority of ophthalmology training programs
have access to a functional microscope and adequate materials and equipment, whereas
only half of all programs have after-hours access to OR staff with training to support
ocular cases. Therefore, the area in which there may be potential to improve after-hours
surgical infrastructure is the percentage of programs with access to such specialized
OR staff. Furthermore, nearly all residency programs are linked to either an adult
or pediatric level 1 trauma center, highlighting the importance of better defining
minimum ophthalmology trauma service requirements.
There is evidence in the literature that the presence of specialized OR staff who
are familiar with the surgical procedures being performed leads to improved outcomes.[7]
[8]
[9] Similarly, surgical teams who display effective communication and teamwork have
better surgical outcomes. A recent study by Mazzocco et al reported that teams that
infrequently exhibit cooperative behaviors (such as confirmation of surgical plans,
information sharing, inquiry for relevant information, mutual respect, and vigilance
and awareness) are 4.8 times more likely to have their patients experience death or
major complications.[7]
Literature from the nursing field also supports that OR nurses feel less safe working
with unfamiliar surgical procedures.[8]
[9] A recent survey conducted by a head OR nurse at the National University Hospital
in Reykjavik, Iceland, highlighted the importance of adequate background knowledge
during specialized procedures to anticipate proper resources and contribute to the
case.[8] In addition, a Finnish study interviewing OR nurses showed that when individuals
were assigned to unfamiliar cases or surgeons, they experienced decreased effective
communication and increased interpersonal conflict.[9]
Our study has several limitations: 49% of program directors completed the survey,
so our results are not completely representative of all ophthalmology training programs.
The decision to participate in the survey may be biased by self-selection. A multimodal
approach including post mail, email, telephone, and face-to-face encounters may have
resulted in a higher survey response rate. Second, much of the preparation for after-hours
surgical cases is done by residents and fellows, whereas the survey queried only residency
program directors. It is possible that trainee survey responses would differ based
on dissimilarities in responsibilities. Third, our survey included only three variables,
which were determined by an informal in-house survey at our own institution prior
to this study. Thus, there are likely to be additional barriers encountered by other
programs or individuals that we did not include in our survey. Including an “Other”
free comment section would have allowed us to identify additional barriers.
In conclusion, while all three resources surveyed are important for high-quality surgical
management, the vast majority of ophthalmology programs surveyed appear to have appropriate
access to adequate surgical materials or a functioning microscope after hours. Based
on our survey, increasing the availability of OR staff with the training to support
complex ophthalmic surgery could potentially improve management of after-hours eye
injuries at ophthalmology training programs. Further studies comparing clinical outcomes
of after-hours ophthalmic surgery with and without eye-trained OR teams may provide
further insight as to whether this resource should be considered a minimal requirement
for optimizing the environment in which urgent ocular surgery is conducted.
