Monitoring Cataract Surgical Outcomes: ‘Hand Written’ Registration Method

Colin Cook MBChB FCS(Ophth)SA FRCOphth
KwaZulu-Natal Blindness Prevention Programme, PO Box 899, Hilton 3245, South Africa

Introduction

The purpose of this hand written method of monitoring cataract surgery outcomes is to provide a practical method, assisting cataract surgeons and programme managers to monitor qualitatively the results of their cataract surgery. Such monitoring is the key to improving the quality and results of our cataract surgery.

The hand registered method is quick, simple, and friendly to use!

LINKS TO PICTURES

The Process

At discharge

Before the patient is discharged, the Snellen visual acuity (VA) in the oper-ated eye is tested and is recorded in the case notes
If the VA is less than (<) 6/60, it is rechecked, both with and without a pin-hole
If the VA is <6/60, the eye is carefully examined to determine the cause of the poor vision
The details for each patient are recorded on form A
The discharge is only authorised once this has happened.

At 8 week follow-up

At 8 week or more follow-up, the Snellen visual acuity with the spectacles that the patient has or will be wearing is tested and is recorded in the case notes
If the VA is <6/60, the eye is carefully examined to determine the cause of the poor vision
The details for each patient are recorded on form B.

How to Complete Form A: Discharge Visual Acuity

Form A is completed at discharge
It should be completed for all patients who have had a cataract operation except those under the age of 20 years and those cases of cataract due to trauma
One row of the form is completed for each cataract operated eye
Each form has space for 20 cataract operations.

IOL - record ‘yes’ if an IOL was implanted and ‘no’ if an IOL was not used.
Surgical complications - record any surgical complications.
Discharge VA (good, borderline, poor) - tick one of the 3 columns, depending on the measured visual acuity.
Cause of poor outcome (selection, surgery, spectacles) - if the VA is recorded as less than 6/60, the reason should be recorded in the appropriate column.
- This should only be done if the VA is <6/60.
- Only one column should be filled.
- If there is more than one cause for the poor outcome, the clinically most significant cause should be identified.
- Selection (co-existent disease or pathology causing poor vision) - specify the disease or pathology.
- Surgery (intra-operative complication(s)) - specify the complication(s).
- Spectacles (uncorrected refractive error) - tick this column if the VA improves to 6/60 or more with a pinhole, or with spectacles which the patient does not have. ‘No IOL’ operations should be checked with +10.0D spectacles

How to Complete Form B: Follow-up Visual Acuity

Form B is completed at follow-up at least 8 weeks after surgery
It should be completed for all patients who have had a cataract operation except those under the age of 20 years and those cases of cataract due to trauma
One row of the form is completed for each cataract operated eye, which is seen at 8 weeks or more
Each form has space for 20 cataract operations.

Follow-up VA (good, borderline, poor) - tick one of the 3 columns, depending on the measured visual acuity.
Cause of poor outcome (selection, surgery, spectacles, sequelae) - if the VA is recorded as less than 6/60, the reason should be recorded in the appropriate column.
- This should only be done if the VA is <6/60.
- Only one column should be filled.
- If there is more than one cause for the poor outcome, the clinically most (ignificant cause should be identified.
- Selection (co-existent disease or pathology causing poor vision) - specify the disease or pathology.
- Surgery (intra-operative complication(s)) - specify the complication(s).
- Spectacles (uncorrected refractive error) - tick this column if the VA improves to 6/60 or better with a pinhole or with spectacles which are not available to the patient.
- Sequelae (post-operative complication(s)) - specify the complication(s).

Analysis of the Data

The analysis should be done for every 100 cases, and compared with previous results
It can be done either for the department as a whole, or for individual surgeons, or both. You need to decide which option is most suitable for your situation
Add up the entries in each column on forms A and B and calculate the percentages.
It should only take about 10 minutes!

Using the Results to Monitor Performance and Improve

The analysis is a tool to help improve the quality of surgery. This is its purpose.

It is used to compare past results with present results.

It is not to be used to compare one surgeon with another, or one hospital with another.

The aim is:

Reduce surgical complications
Increase percentage with good outcome
Decrease percentage with poor outcome due to surgery or need for spectacles.

What if the Results are Not Good?

Action to improve results is advisable if:

IOLs

The percentage of cases receiving an IOL is less than 95%.

Take action to improve the availability and affordability of IOLs.

Surgical complications

The posterior capsule rupture rate is more than 5%
The vitreous loss rate is more than 5%
The discharge uncorrected visual acuity is poor (<6/60) in more than 10% of cases.

Take action to improve the surgical technique by asking for advice from a good, experienced cataract surgeon.

Visual outcome

The week 8 visual acuity with available correction is more than 5% poor outcome (<6/60)
The week 8 visual acuity with available correction is less than 85% good outcome (6/6-6/18).

Analyse whether the major cause of poor vision is surgical problems or correction of refractive errors.

Take action to improve the surgery as above.

Take action to provide at least best spherical correction spectacles at an affordable price.

Trends over time

The trend over time is static outside the recommended limits
The trend over time is worsening.

Carefully analyse the reasons for lack of improvement and take action to deal with the identified problems.

Questions and Answers: Dr Hans Limburg asks Dr Colin Cook

Why use the manual tally sheet system?
Monitoring of cataract surgical outcomes is a tool that is guaranteed to ensure that we always continue to improve the quality and outcome of our cataract surgery. The manual tally method is a simple, quick, and inexpensive method of doing this. It is suitable for use in any hospital that does not have access to a sophisticated computer system.
What are the experiences in Edendale Hospital?
The system has been used in our hospital since July 2000. It is an integral part of the clinical routine. The data analysis takes about 10 minutes each month. The results are reported and discussed at staff meetings each month. The system facilitates a positive culture of quality control and accountability amongst the staff, with everyone committed to improving results and outcome whenever possible.
What are the results in Edendale Hospital?
Because many of our patients have to travel considerable distances for follow-up, fewer than 30% attend for any follow-up. We, therefore, only monitor the day one visual acuities before patients are discharged. We are particularly interested in seeing that <5% of poor outcome (VA <6/60) on day one is due to surgical complication. We are also particularly interested in identifying and discussing the causes of poor outcome due to surgery.
How many other hospitals in the region use the manual tally sheet system?
We have encouraged the use of the manual tally system in a number of hospitals in the Southern Africa region. Each of the hospitals has been advised to modify the system to best suit their own situations. We have not monitored their results, only whether they are or are not monitoring. In the planning and development of our Vision 2020 programmes, the manual monitoring of our cataract surgery outcomes is something that can be immediately and simply implemented.