OSS (Day 3)

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half of your precious stop early morning to attend this course so i am doctor jude pahadelio and with me is kabel and we will be your moderators for today so before we start uh just a recap on our last day two discussions we had approximately 100 more than 120 participants and we had very nice presentations and discussions about the operating room covid protocols and about the model employee so for today day three we will be focusing on [Music] the outpatient department which is uh comprised of the opidli the eye instrument center and uh we will have discussions on uh some administrative matters as well as uh the basic of the history in my exam so before we start uh maybe request that everyone use their microphones and not in use and for the open forum or questions you can use the chat box or you can raise your hand and we highly appreciate questions so please feel free to ask may we also request everyone to fill up the evaluation forms first speaker so that we can improve on the course on uh maybe next year again so attendance sheets will be posted at the end of the last speaker until 10 minutes thereafter and certificates will be provided to those who attended all three sessions we will also give you copies of the lectures of all speakers so it's 8 59 we will start on time without further ado [Music] thank you sir so to start off our first lecture i would like to introduce our first speaker she is a graduate of our lady of fatima university and she took her residency training here at itrmc and she is also the past chief president of our department she is a recent diplomate of the philippine board of offshore biology so she will be discussing about ophthalmic history taking and eye examination so without further ado i would like to call on our first speaker dr carmela gabrilio doctora good morning good morning thank you dr cabell so i will be discussing about uh basic uh ophthalmology history taking and and examination so um for ophthalmologic history taking an eye examination i'm i'm carmella gabriel [Music] so this is the objective of my report is to know and how to take the basic of talmudic history until and to know the basic of technology examination for history taking history taking is gathering information process from the patient guided by an educated and active mind selective guided and progressive elicitation and recognition of significant information history by skilled person can arrive at the proper diagnosis in 90 of the patient history thinking is composed of history of present illness ocular past ocular history ocular medications general uh ocular medication general general medical and surgical history surgic uh systemic and ocular medications allergies social history and family history so for the chief company this is the patient's own word onwards or non-technical paraphrasing of patients patients will example a redness or blurring of vision or flashes of light history oppression illness is the detailed description of the chief complaint to understand the symptoms and curse of the disorder listen and question then write down orderly sequence that makes sense to you so as the time time sequence when and how fast what order did even occur frequency or intermittency location laterality severity associated symptoms or documentation or all the record of the patient or photos still under the history of present illness we have some example of disturbances of vision such as blurred or decreased centralization decreased peripheral vision which is seen in patients with glaucoma alter altered image size diploma or double division [Music] or flashes of light and iridescent vision or halos or rainbows ocular pain and discomfort examples are foreign body sensation cellular pain photophobia headache and asthenophia or ice stream abnormal ocular secretion like lac cremation or excessive tearing and an epiphora or uh spilling of tears onto the face and dryness and discharge for abnormal appearance uh examples are doses or drooping of the eyelid proptosis or acceptance misalignment of the eye redness opacities masses and anisoqurius for the past ocular history it is important to ask the use of eyeglasses or contact lens use of ocular medication in the past ocular surgery ocular trauma and history of amblyopia ocular medication is asked to know how the patient responded prior to therapy or present a recent medication can affect the patient's presence tattoos general medical and surgical history many of ocular diseases or manifestation are associated with systemic diseases like hypertension diabetes rtb or thyroid thyroid disease and for ophthalmologic examination a va measure visual equity measurement is a fundamental element of basic eye examination it should be performed prior to any manipulation of the eye ensure that the visual equity chart is well illuminated [Music] visual active testing is usually performed with the aid of snelling chart each eye should be tested separately both with and without correction or spectacle test test is performed at a distance of 6 meters or 20 feet [Music] so if the patient cannot uh if the patient is unable to read the largest letter uh move the patient closer to the chart if the patient cannot read the biggest letter at one meter or three feet proceed with counting finger if the patient patient is unable to count the extended finger correctly up to one foot then next is hand movement determine if the patient can distinguish the presence or absence of hand movement like perception if the patient is unable to correctly identify the direction of light source and no light perception if the presence of light cannot correctly detected by the patient when taking the distance of visual activity we need we need thus we need a snelling chart uh plain occluder pinhole occluder and flashlight fill uh equity testing is if the patient visual equity improved by two lines or more then we consider error of reflection we used a jager chart in near visual activity testing it is performed at 14 inches distance it assessed the ability of the patient to see clearly at a normal reading distance near visual equity usually recorded both the size and distance of of the smallest uh that the patient can read correctly example uh j5 at 14 inches for pupil examination assess the size size and shape of the pupil the reaction to of the pupil to near and light and swinging flashlight test for a pupil exam it is usually examined in a dark dark room and ask the patient to fix it at a distant target and shine a light on both eyes and observe for the size of the pupil the normal size of the pupil is two to four millimeter if the if there is a size difference of two millimeter in pupil size it should uh it is considered abnormal an adhesion between the iris and balance or synicia can lead to abnormalities in your shape reaction too near to evaluate the commoditive ability of the pupil observe the size of the pupil as the patient shifu goes from a distant to a near object so the normal response is the pupil will constipate with accommodation for light reflex tests we test for direct pupillary reaction there uh there is a risk constriction of the pupil upon shining of light directly on the patient's eye and for consensual pupillary reaction there is a risk constriction of the contralateral eye for swinging flashlight test it is performed by shining in light on one eye then swinging the light to the opposite eye so swinging flashlight test is to use to evaluate the for relative after apparent pupillary defect or repd if there is positive retd which we think of optic nerve lesion on the side of the dilating pupil for the normal pupil findings are recorded as equal and bristly reactive to light or pupil equal round reacting to light and accommodation and if there is presence of or absence of repd for the external eye examination check for the skin if there is erythema no jewels or vesicles and for eyelid if there is two c's entropion or ethropian and for the lacrimal system if there is a lachlan mass [Music] ocular motility testing examination of eye movement begin with extermination of ocular alignment in the primary position or straight gaze so the simplest method is is to observe for the position of corneal light reflex so instruct the patient to look at look straight and fix it at a distant target while light is shown toward both eyes a reflection of light should appear at the center of the pupil in both eyes and if there is misalignment of the eye there is the corneal corneal light reflex ears outside the center of the pupil example if the patient has isotropia or the eye turned inward the corneal light reflex is displaced temporarily for ocular utility testing instruct the patient to keep immobile as he or he or she follows your finger use a very light or small target with his or her eyes as you place the letter h or a6 arm style for intraocular pressure we use the application tonometer tonometry and it remains the world standard for iop measurements so iop is considered normal if it's it falls within the range of 10 to 21 millimeter mercury or if the difference between two eyes does not exceed two millimeter at two millimeter mercury slit lamb biomicroscope it facilitates examination of the anterior and posterior sediment of the eye which includes the eyelid sclera iris lens and cornea for fundus examination we use direct and in the and indirect of calmuscus to to assess the posterior segment of the eye especially in patients with systemic illness that can affect the retina such as hypertension and diabetes so there are five structures that should be observed in a systematic fundus examination the ocular media the optic disk the retinal vessels and retinal background and macula so for ocular media check for or observe for the presence of ror or red orange reflex ror indicates the clarity of the media the ocular media the cornea the lens the eqs and vitreous rumor and condition of the retina for the optic please take note for the color shape and margin so this is a photo of a normal disk showing a helping neural retinal rim with distinct this border with up this ratio 0.3 and this is a photo of a tilted this scene in myopic patient and this is uh optic this with neovascularization seen in diabetic retinopathy and this is a picture of this with dirt margin or optic disc edema and in glaucoma there is an enlargement of the cup it is seen in glaucoma for and it is important to evaluate the course the caliber of the retinal vessels note for pigmentation lesions or abnormal hemorrhage exudates in the retina and macula or if she had a testing it she had a testing it is a color perception test for red green color deficiency we use ishihara plates for full tests it consists of 38 plates and lastly the ansler grid amsler grid is is a square-shaped grid used to detect or monitor metamorphism involving the central vision and for summary acquiring the skills to be able to perform the basic eye history and atomic examination will allow physician and allied health workers to recognize potential uh vision threatening conditions and that's all thank you thank you very much doctor gabriel for that very informative lecture so for any questions you may type it in our chat box below and we will be answering them at the end of the program or at the end of all the lectures so also reminding everyone to please fill up the speaker evaluation form on the chat box now to introduce our next speaker may i call on dr sir thank you paula so far our next speaker is a graduate of the saint louis university in med school now i think with honors and he's a resident a graduate of itrmc she was actually the first uh graduate of iprmc to have a fellowship at the upc pgh pediatric ophthalmology and strabismus she is currently the presidency training officer and chief of the pediatric service so maybe welcome everyone for ruth pena and her topic will be on appears for an efficient opd consultation no audio thank you excuse me disable young participants can you make okay thank you [Music] okay good morning so my topic would be pearls for an efficient outpatient consultation treatment patient so if you have a efficient or fast doctor the opd flow would be fast but if you have an efficient staff mass mobilization okay so there are three parts of the three parts of the outpatient consultation the outpatient reception the consultation proper and the disposition okay so for the outpatient reception so this would involve the staff and the patient okay so what are the roles of the assist to facilitate the consultation the reception okay so first is to [Music] determine the patient data completely occupation occupation regarding the case of the patient next we have to complete the vital signs la lunas an important thing to do is to note the chief complaint so by the name of the staff would have an idea on what to prepare in tapagnakita young chief complaint how to go about the consultation so for the chief complaint the determinant of my history of trauma by my pain tearing my redness patient by the time of instilling anesthetic drops okay so anesthetic drops the most common anesthetic drops used philippines so when we instill the drops [Music] so the patient has to close the eyes for 10 to 15 seconds [Music] the next thing to take is the visual acuity as lectured by dr gabriel so i think we need to know so this is the visual activity test one i at the time is tested and usually distance visual connectivity so for the outpatient consultation [Music] consultation so what is the role of the assist first is to check the materials and the equipment okay so first is to check the slip lamp light so this is the sleep lab planting equipment ophthalmologist next is to prepare the cotton buds tissue um other things to prepare are the lenses in the indirect ophthalmoscope usually [Music] [Music] okay so after checking the materials and equipment you should position the patient at the state lab so yeah just lying chairs clean sleep lamp you should check for the height of the chair new patient or hindi man and you have to place the chin in the forehead lateral foreign should be aligned with the marker so this is the lateral tantrus the next role of the assist is to know the eye drops the preparedness aside so these are the anesthetic drops most commonly used proparacane this is the dye or the fluorescein strips or italian [Music] this fluorescent strips or the dye is used to look for abrasions or defects a cornea okay and these are the dilating drops this is the most commonly used so this is used to dilate the pupil when the doctor would examine the retina okay so for the outpatient consultation we have to know the common outpatient procedures so that we could assist the doctor and maybe needed equipment materials so first got a first common uh measuring procedure is measuring the intraocular pressure so nasa chief complaint glucose [Applause] [Music] so another common procedure is the is the removal of a foreign body okay so yeah [Music] grinder or nagwelding but you need to prepare you will need anesthetic on your eyes other materials needed would be cotton buds okay so efficient assist in the gum galloping patient that was a procedure so another outpatient procedure would be the dilated examination so we don't dilated exam [Music] okay so this is what we see inside the eye dilated pupil okay so how do we dilate the patient so we have to instill tropicamide tropicamaejos and mid one drop every five to fifteen minutes until pupils are diluted after 11 minutes fully dilated or malachi on maximum angulation yeah one drop every five to 15 minutes times three doses 30 minutes 40 minutes so what do we prepare for the dilated exam the dilating drops attack and the materials needed would be the condensing lenses so for the indirect ophthalmoscope this would need this big one this big lens here the 20b lens or the 28d lens okay so this is usually done in dim lights and this can be done while the patient is sitting or lying down sitting down examinations [Music] okay so for the outpatient disposition the personal consultation what is the role of the assist it is to check the prescription in the instructions regarding the explain the prescription instructions and it is also the road of the assist to check for the completeness of the chart or the record site rmc double complete on record so what to do if the opd closes again variant opd you have to advise the patients to look for itrmc online consulta internet okay yankee hana so they would click on this link so it on online dot www.doctor.igrmconline.com so magandana is a patient [Music] online consultant so to click on this link in thailand okay so what are the iprnc on online consulta tips for patients so we don't roll them staff okay and you so what are the tips uh for the patient for uploading the eye picture so bhagavan patience is take the shot from in front of the eye flashlights aside and the details of the eye should be seen so that i'm lashes okay so this is my last slide thanks uh thank you ruth for that very you know very clear concise and very practical a week for your meal reward oh okay thank you ruth so uh we're reminding the audience to fill up the speaker evaluation form we will entertain your questions at the end of the program thank you sir so for our next speaker he is a graduate of the university of the philippines college of medicine and he took his residency training in ophthalmology at the uppgh department of offal emulsion visual science he had his fellowship in medical and surgical retina at ubpgh and rotterdam a hospital in netherlands he is the vice chair for research and is currently our retina service head consultant and a former chair here in itrmc ophthalmology he's also a clinical associate professor and a vitriol retinol consultant at ubpgh he is also a board member of the vitriol retina society of the philippines and a member of the philippine academy of ophthalmology and pao northern western luzon chapter so his topic is all about overview of the ipr mci center so i'd like to call on again dr jun pajarillio for the next lecture sir thank you paula for the introduction so good morning again everyone uh can you hear me and can you see my slides yes okay so i will be talking about the iprmc ambulatory ice and internal as you can see there are three components of the eye sensor you have the opd that's the surgical center and the eye instrument center all of these areas are integral to our goal to be an end referral center meaning we manage excuse me the most diverse and most complex of cases in ipr and by far the eic is the most expensive part of the eye center [Music] [Music] eic or the eye instrument center has a vast array of services now just like a menu where you can pick what what you want to eat the services offered range ranges from different highly specialized diagnostic tests the research laser procedures as well as ancillary tests all these tests are used for the care of the patient the objectives of my talk is not to teach you how to use all these machines but just to give an overview on what these machines are used for what they look like and probably some practical tips just in case you will be assigned to this area so this is the current pic so it's a it's an open big open space area with all our toys around shown here is a mom eyes on isobel our one and only autonomic technician so she is in charge of all these instruments so you can just uh uh imagine how demanding her work is so she works both uh with the full lights on and sometimes in the dark mode using this different machine okay so uh wait i will begin by again after this the overview i will begin my talk with the case i won't be focusing on details about disease and management but i will try to make you appreciate the role and relevance of the eic in the patient's journey so we have here a slight turn of movie uh a 56 year old female government worker diabetes hypertensive complained at the obd in our opd malabu as you can see here uh she has a picture mature cataract and the plan was to remove the cataract and uh but before that we need to do an ultrasound as well as biometry and keratometry so this is this is these are the things that i don't know this was the menu presented a while ago and we have both all these tests uh for the ocular ultrasound or b scan so uh why do we need this for aling nelly's case so it's it's used to evaluate the which use in retina in cases of opaque media in in alignment so we need to evaluate the retina and literals to determine if there are any problems not before doing cataract surgery so the principle of ocular ultrasound is basically differential echogenicity so sound waves reflecting back to the probe to the machine this is usually done by the ophthalmologist and not the authentic assistant or the technician and on your right is the machine showing this is our machine at idrmc and below is a sample of the scan so what should i prepare uh i think this will be discussed further later but uh just showing you what we need during an ocular ultrasound and usually the best way is for the patient to be supine patient and you see the probe and the uh synology is not in front of this screen so for ease of use that's the best position for the moving kind of filter ultrasound okay so ali nelly uh uh underwent an ultrasound and results were normal and we proceeded with cataract surgery but before doing cataract surgery we will need a biometry and as well as a atomic so just a review no for for us to have good vision the light refracted should fall on the retinal surface no exactly at the phobia so pass or cool on so in the same way if we replace the normal crystalline lens with an intraocular lens will be precisely on the surface of the retina so we specific power for each individual iol be computed so biometry or return because a scan is used to calculate the power needed for intraocular lens implantation so the principle is uh just like a ocular ultrasound it uses ultrasonic or sound grades but newer models uses light so it measures distances between the eye so this is usually done by a trained technician or an ophthalmologist you see here above is the optical barometer and below is the ultrasound diameter and this is the formula we use to calculate for the power of the lens p is the power so one part here in the yellow a pink circle is labeled as l that's the length for the actual length of the eye which you can measure using the biometry so this is just an example of a biometric scan on the right this is what we get and these are the things that we should prepare for keratometry this is the best friend of your biometry knowledge you will need a therapometer so this is used to measure cardinal curvature needed for io calculation as you can see here know the srk2 formula make a generic value so you will need to plug this in to get the power of that intraocular lens shown below on your right is the two this these are the machines that i see this is a keratometer an ancient keratometer manual keratometer and this is an automated keratometer so both will work fine so alignally underwent an event full take by emulsification of one day after the ends however host of vision was not good as you can see it's only 2 400. we examined the [Music] we examined the retina we examine the retina and what we see here is numerous uh hemorrhages and exudates so we diagnose her to have a diabetic retinopathy so she will need another test uh well two tests per scene and geography and optical coherence tomography but luckily we have this test at the eye instrument center and for fluid scene and geography you can see here at the photos we inject dye fluorescein dye through a vein usually anti-cubital area that die will go to the eye and will take photos so that's the usual procedure for this and uh this is used to evaluate the retina and parietal vessels usually in cases of diabetic retinopathy amd or retinal gain occlusion so it uses dye which progresses wherein we can see the retinal vessels more clearly so this is usually done by the technician but the dye is injected by the nerves or the md so just some warnings or some precautions when you do fluorescein and geography there is a very small risk for fluorescein anaphylaxis meaning you need to do a skin test there should be stand by ecard and be ready to call an md but not your imdb [Music] emergency again so call your i am or uh who is nearby number two be wary of pregnant patients as well as patients with kidney failure and be make sure to uh tell your patient that the skin can or your brain can turn yellow they can they can feel pain from the needle break and some would have nausea and pain so we need an informed consent form to before we do this procedure okay this is an example of a fluorescein geography so these are some just some tips to get excellent fa images so what's important here is those in pink we have to have maximal dilation and you have to know the photographic sequence and timing so this is a time procedure very important in time uh you'll have only a few minutes to complete the entire examination otherwise the dye is already gone you won't see anything so but only i don't know how to take necessary photos need more trigger happy because it's already lost in flashing lights okay for machila oct optical coherence tomography just a review the machine is located at the center of the retina it's just a small portion here in the yellow big yellow circle so oct is used to evaluate the histologic macula this is used for diseases usually due to macular edema of various process the principle is using lightner instead of sound waves and this is done by a technician so this is just an example above upper left is the h e is the logic section and below is your ocd scan so it's very very remarkable you know you don't need to cut the eye open to get histologic sections of the retina so we have this at igrmc this is just an example of a scan using our heidelberg oct and the most uh the important thing is to incorporate or input the accurate age of the patient the values here are page match so we have to input the correct age but most of the functions are automated unlike your fa where you need so many preparations for oct it's pretty much simple so after the test ali nelly was diagnosed with proliferative type meaning there's cleo vascularization and she is readily available in our eye instrument center this is what we have this is a light med 5-3 nanometer laser so the indications for doing laser is for primarily for neovascularization as an ischemia and other indications as well as as seen here the principle is using thermal energy usually at the 5 32 nanometer range or sometimes at the 810 nanometer range and this is done by the ophthalmologist or the retina specialist so this is a video not showing the procedure so just uh what a few wirings or precautions again this this the levers are harmful so there's backscatter you can see the green light so you have to make sure that the area is shielded and for those inside the room they should wear goggles the procedure is also painful and after the procedure patients would complain of a temporary visual impairment and also uh the last was to take care of the lenses because the lenses are very expensive so what should i prepare this is in pink is the most important the icf you have to dilate so remember procedures which you need to dilate and which other procedures you need to constrict and you have to prepare the field health requirements okay so alignment underwent prp and anti-injection [Music] the disc looks large and very shallow anterior chamber as you can see in the slit lamp so she was diagnosed to have anger closer glaucoma and would need the following test again perimetry oct and would undergo laser irregular to me so well we have all these machines to do all these procedures so alignment is quite lucky so this is just an example of a perimetry we do it under dark dark uh illumination and this is a visual field so it's used to map out deficits in the field of vision uses for glaucoma and we project lights at various areas not to map out areas which are compromised so this is done by technicians technicians well so in producing reliable visual fields we need in in pink and the most important we have to have a manifest refraction and make sure to do not violate the initiating that directing the public on some other days so this is an example of an optic nerve head uh o3p scan using our heidelberg uh it's basically the same concept as your machela oct for young iridotomy this is our machine i'm not sure it's light med so it's used to create an iris hole uh indication is for narrow angle narrow angles or close angles just like how uh alinelli and it uses the so this is another laser that we have in our eic so this is usually done by the ophthalmologist or the welcome specialist this is a photo of a young hole a hole done using a react laser and we have to constrict patients unlike your prp you will need to dilate and again prepare your iacf and your field health forms so alinelli underwent laser iridotomy pressure was controlled you went back to vehicle and was lost to palpato up until again suffered from during the vision as you can see on the right photo this is an after catheter or a pco posterior capsular opacity so again feeling helpless undergoing other procedures eic so this is the same machine used for young yuri so we call the procedure young capsulotomy basically to create a hole at the capsular opacity to clear the the visual axis indications as i've said or after catera and the same machine is used and it can be formed by any any eye doctor so what we need to prepare uh as we illuminated here this is the lens that we use when we compare it to the other lens this is the one the lens we use for iridectomy so elevate [Music] so a few more slides of three or five slides so maximizing the life of equipment so you have to read the manual request for a product demonstration maybe observe experienced technicians you have to follow preventive maintenance schedules and avail of service contracts so there are service construction economy on how much you will spend for for maintenance as well as repairs of course you have to check the warranty so you have to ensure stable electricity use high-end ups and downs in upstate [Music] and you have to immediately report problems to document the error message you can take photos and inform the technician supplier and try not to do too much troubleshooting these are very expensive equipment and do utmost care in handling cleaning and scaring this equipment okay so for assisting during laser procedures probably this will be discussed later so in short line you have to document fill up the icf and the field head forms you have to prepare the patient know when to dilate know when to constrict and you have to time it medications i have to prepare the machine so some machines would require warming up booty which will take time i have to prepare the needs depending on the procedure and you have to immediately record malfunctions and you have to know who to and for laser beware of backscatter so you use protective goggles close the door place danger signs around the area and work with a sense of urgency so the last two slides so our eye instruments enter is actually a heavyweight one we we are complete we can manage a vast array of diseases the patient does not have to go out of the of iprmc so we're very lucky the administration is very supportive and we've accumulated all these machines through years by business through the years but behind this is the brains okay so we are a very small uh department uh it's still very important knowing even if you have the most sophisticated machines we need someone to use them properly and we are a leader man and we need all the help that we can get especially for the eic okay that's my last slide uh if you have any questions you can ask it for the thank you thank you thank you very much sir for giving us giving us an overview of the eye center instrument is centered so again reminding everyone to kindly fill up the evaluation forms for each speaker on the link provided below so for any questions again you may type them in the chat box and we will answer them at the end of the program so i'm going to introduce our next speaker may i again call on dr paharidio thank you paula so for our next speaker she's a graduate of the yup college of medicine took his residency and glaucoma fellowship at the uppgh as well and is currently a glocoma service consultant at iit rmc and he's a part of the hospital research team so without further ado patricia concepcion will be talking about eic workflows and pearls in maximizing efficiency all right trisha morning good morning can you see my slide yes slide therapy okay so good morning again everyone and thank you for all those who have been attending the ophthalmic support staff course and again i'm dr patricia and concepcion today i will be talking about the workflow of the itrmci instrument center or the eic and how we can maximize efficiency so the eic is essential to any eye center aside from being able to help in the diagnosis and management of the patients it is also a large contributor to the revenue of any eye center so it's important that we utilize our diagnostic and laser machines so i have no financial interests in any of the products shown in this presentation and these are the objectives of this discussion okay so i won't be discussing the all of the laser machines but uh dr parrilli was able to show them earlier but first it's important to be familiar with the machine so we have um the diagnostic machines and the laser machines the diagnostic machines are usually accompanied by computer screens as you can see here and they can be used by the support staff or the doctors but they should have been adequately trained they should have been adequately created to use them now and most of the time but most of the time it is the support staff that gets the training to operate the diagnostic machines and then here are examples of the laser machines and they look like slip lamps with attached consoles that these are where the settings for the laser will be placed and these on the other hand are for therapeutic purposes therefore only the doctors use them but it's also the role of the optanic support staff to have the needs for the procedure ready and to assist the doctor if required so when you know the machines you know the procedures everything is set and good to go there should be a workflow in place to ensure fast turnover of the patients and streamline processes okay so here's the general workflow in the itrmci instrument center so our lovely often nurse mom isobel schedules three to four patients for procedures per day depending on her availability and then on arrival the patient is registered as an outpatient in the hospital system and given an opd blotter and then vital signs uh visual equity and a brief history of the patient are also taken so while the patient is being prepared for any procedure needs paperwork is also being prepared especially if the procedure is covered by phil health so the companion is asked to bring the papers to the field health portal or counter and while the patient is undergoing the procedure processing of the paperwork continue and the bill is given to the companion and a copy is attached to that chart so if the procedure is not covered by by fail health a charge slip is issued after the procedure and payment is made at a cashier or if financial assistance is requested they are referred to the medical social service upon getting back the receipt the patient is given post-procedure instructors if there are any and then discharged and given an appointment for follow-up so let's discuss uh some of the ways that we can maximize efficiency in each step so for scheduling scheduling is very important in maximizing efficiency because of the nature of the procedures in the eye instrument center the procedures can actually be time-consuming it's not as fast as blood extraction so procedures like fluorescein and geography or visual field testing can take as long as 20 minutes per patient depending also on the on how to operate the patient so the procedures require utmost corporate cooperation from the patient since they have to keep a certain eye position or focus on a target to obtain accurate or optimal results and sometimes the first timers my first time undergoing tests they would take a longer time to test than the repeat performers and then the procedures are also operator dependent so that's also another factor to consider uh your familiarity or your expertise on it with the machines and the procedures and then if you're a staff member dedicated to the instrument center then you can schedule more patients however if you have other tasks in the eye center like um isobel you have to limit scheduling so considering all of these it might be best to schedule longer procedures on a day when you are more free and easier or faster procedures on the tighter days okay then uh for registration so since patients are scheduled you are expected to be prepared for the patient and for the procedure so these are things that should be done prior to the patient's arrival ideally the patient's initial charts or their consultation charts should be present and ready so it will be easy to confirm the diagnosis and the procedure to be done hindi and then fill health covered procedures require more paperwork than those that are not but the paperwork is usually standard including the informed consent or or record or technique cf2 charge slip so they should be ready to be attached to the chart once the patient gets his or her opd daughters who don't wait for the patient to arrive tapas so have the sets of papers already prepared beforehand and then the cf4 is encoded by the resident on jupiter so use templates if necessary or if allowed to speed up things okay and then when the patient arrives after creating their open opd blotter the vital signs and the visual activity are taken and in after we were taught that taking the visual equity before doing anything else is very important so it's a very important skill that authentic support staff members should they're in so visual equity testing this was mentioned by doctor gabrillo already earlier but i would just like to reiterate because that's how important va is so visual equity or va is the measurement of the smallest object a person can identify at a given distance from the eye so we usually take the distance v8 which is expressed as a ratio or fraction that compares the patient's performance against an agreed upon standards with the numerator the number on top or the first number is uh the distance at which the test was performed or the distance of the patient from the eye chart and the denominator or the second number is the distance at which a person with normal activity can read the same line of letters from the stellan chart which is commonly used uh okay so for example a visual equity of 2070 indicates that the patient can recognize at 20 feet the line of the letters that a person would with normal equity can recognize at 70 feet so for the support staff it's not really about how it gives you a clue on what the patient's problem is but knowing the baseline visual equity is actually a form of protection for everyone because you should know how well or how bad the eye can see before you do anything just in case a patient complains of having any change in their vision after the procedure okay and then some diagnostic tests and laser procedures need some pre-procedure preparation so first of all again it's uh your role to ensure that needs are ready near the machine whether it's you or the doctor who will be doing the procedure so for laser procedures you prepare the key to the machine your topical anesthetic and then if the machine looks like a slit lap again it's fairly sir the doctor uses a contact laser lens such as this and this uses an eye gel and also prepare some tissue and an elbow rest may also be helpful for the doctor and for diagnostics the procedure that need the most preparation probably would be fluorescein and geography and uh you should be prepared with the needs like a butterfly iv set for intravenous injection and the fluorescein die and then know which procedures need pharmacologic dilatation or constriction of the people because uh as mentioned earlier uh pharmacological dilatation or constriction actually take time so procedure again again must start you the day late or constrict and then again you have to know the procedure because the machine itself cannot be the basis for this because a single machine may be used for multiple purposes so for example the nd yag laser can be used for capsulotomy in which case the patient needs to be dilated and it can also be used for iridotomy in which case the patient needs to have a constricted repel so this is what we use commonly used for uh dilatation jung sandman and the pilocarpens would be used for constriction and also know which procedures need the patient's refraction doctor mentioned this earlier but some would need proper correction of the patient's error of refraction to obtain reliable results such as in visual field testing okay and then what about the procedure itself how can we maximize efficiency first make sure you are with the correct patient it's just like uh dealing with antibiotics by your correct patient correct meds correct those so uh same with uh diagnostic or laser procedures make sure you are with the correct patient and then give clear instructions to the patient uh you can get the procedures require utmost cooperation of the patient so make sure that the patient understands what he or she needs to do during the test especially if there's an expected learning curve and of course do the correct procedure properly after the procedure if a patient requires observation take note of the time that the patient needs to be re-examined so that and make sure that everything uh that needs to be processed is accomplished during this waiting time and just like the fill of papers it's best to have standard or template discharge papers ready and you can proceed with the next patient then for the companion the companion should be asked to handle the paperwork and payment concurrently while the patient is undergoing preparation and the procedure itself so aside from the patient with them to the eic uh the companion also uh would be asked to handle paperwork while the patient is undergoing the procedure so clearly instruct them on what to do and where to go and if possible to be more efficient create a checklist or a numbered procedure on a small piece of paper that you can print and attach to that chart and all uh all the papers to avoid any confusion in the hat go in a step by step you can put it in a piece of paper tarp nummy procedures on how the processes go and then what else can we do to maximize efficiency in the eic so make sure that all procedures are properly documented it may be a good practice to document start and end times for the steps in the workflow especially for beginning centers wherein you would like to find out where the process can get slow and later on having a proper census on the procedures can help in identifying which machines and procedures had been the most utilized and this information can be used to further develop the eye center then release results in a timely manner so that may be out of your hands already but go ahead and follow up those doctors who need to give you those reports so that you can release your results on time and know how to properly care for your equipment read the manuals machines that are well maintained will of course give you less problems and also include how to disinfect the lenses so sometimes the doctors uh forget to disinfect the lens so you should be able to help them and disinfect the lenses as well so i'll say it now it's not recommended to use alcohol to clean the lenses it's the easiest to reach uh this infection along with alcohol so it's not really recommended it's better but to disinfect them with the mild or diluted dishwashing solution and uh this was mentioned by dr earlier about troubleshooting so learn just at least the basic basic knowing the troubleshooting so at least uh for example in the middle from the patient it's in the middle of a test there arises a problem so if if these are simple errors then maybe you would be able to fix them as long as they're in the instruction manual you should stop tinkering with the machine and if all else fails you should know who to contact immediately in case that the machine needs to be serviced and of course uh always be kind and gorgeous to the patient so when the environment when the ice instrument center is pleasant and conducive that would make you less likely to commit errors and that would make the patient more cooperative and make them go back to you so thank you that ends my presentation i hope this lecture had been helpful thank you dr trisha i'm sure this is a this was a very helpful lecture not very many practical tips we all learned from your from your talk note so i will not use alcohol anymore for our ladies okay so thank you again dr trisha may we remind everyone to fill out the speaker evaluation forms for dr atricia's lecture and uh the next lecture will be introduced by bakara yes sir so for our next speaker so our next speaker uh he is a graduate of saint louis university school of medicine and took uh his residency training here in the local australian regional medical center so he is currently the head of the optics refraction service here in our department so without further ado i may call on dr charles angelo young to talk about the optimal ophthalmology ward workflows and for us in maximizing efficiency sir okay hello paula hello everyone good morning thank you so uh yeah can you see my screen i shared it yes sir all right so most of you at the hospital probably uh know me already so i just say good morning to everyone and i would like to congratulate all the previous speakers for um for a very informative and i think a very concise and useful uh talk no that each of them delivered so this is the last lecture so basically we will be tackling um pearls for an efficient workflow within the ophthalmology world so so this is the outline of my short short talk this is a 15 minute talk so first we will be discussing uh preparing the patient for surgery followed by tips for post-operative care and then basic eye nursing care and lastly one of the bottlenecks for our services patients in facilitating the billing hic papers and discharge so we will start with preparing the patient for surgery so again the the overall flow for work in the eye center is very similar to what you do in your other words uh with a few special uh steps because uh we are a specialized eye center and also the first thing that uh all of you should all look look out for are the doctors orders including the cp clearances so although most of our surgeries will be done under local anesthesia most of them are still seniors and most of them have co-morbid so please do not forget to check this ep cleanliness of the patients to make sure that all of the recommendations of the cleaning physician have been followed also follow the doctor's orders on time so one of the biggest bottlenecks for surgery that we have encountered over the past few years with the involved pre-op dilation of our cataract patients mostly so they come into the operating room the pupils are not dilated surgery is delayed productivity is delayed basically so these are the bullets here are basically some of the things that we should double check before sending the patient down into the operating room so number one make sure that the patient has been dilated sufficiently for cataract patients and also for our retina patients um if the patient has a special cases that may need the intraocular pressure to be decreased make sure that the anti-glucoma drugs have been given so either your manitol or your acetazolamide just make sure that they have been given pre-op at the proper timing check the iv lines and other special precautions that uh your subspecialty clinics may require um double check the paperwork to facilitate the discharge later on so make sure that the rt pcr results have been attached for cataract patients again make sure that the biometry measurements have been attached as well so um for i tell you imaging results for special cases orbit cases so if a ct scan is needed or an mris needed make sure that the plates are also sent down with the patient in the operating room some patients will be required to be put in npo please uh make sure that it's been followed la la la manga general anesthesia we do not want to give our anesthesiologist friends uh a headache as well and um as mentioned by dr concepcion earlier in these procedures here always check for laterality make sure that you're deleting the right eye but you're giving the proper pre-op meds on the right eye so uh other than that we also noticed that uh the supplies are sometimes late or incomplete so make sure that the pre-op drop the post-op drops of the patient as well as the pre-op drops are all complete so this would usually include the antibiotic drops the steroid drops and when available a topical anesthetic and other miscellaneous supplies including your iv line should be complete before you send the patient down to the operating theater okay so you know a lot of you have not rotated in ophthalmology words so these are just the common drugs that we use to dilate the patients uh i did surgery yesterday and the other day and my uh impatient indiana daily but anyway ion uh sand meter in tropical microscopy leveling is something we use very commonly that's what it looks like so you know and in general any any eye dropper with a red cover is a mediatek regulator so it could be tropicamite plain or phenylephrine sometimes there's atropine or cyclopentylate but you don't usually use that for surgery okay uh drops of the green cobra are well we don't use it too often but i think our glaucoma cases might need it prior to trap so if you need to constrict the pupil you can make sure that they're constricted so beyond just two straps yeah standard or protocol should also be followed to avoid any bottlenecks in surgery so make sure that the nail polish is removed this has been a recurring frustration for a lot of us the delay surgery because we could not find any nail polish remover and it could have been avoided if the patient has been checked before being sent down to the or all cosmetics powder little eyeliners make sure that the face faces have been cleaned before being sent down to our dentures will remove jewelry and underwear in some cases please uh just double check all of that um the fourth point here is something i feel is very important make sure that the patient uses the bathroom before you they're sent to the theater um have them uh empty their bladders so they're not straining during the surgery so a lot of complications can actually be um avoided by simply asking them to empty their bladders before going into the theater okay so i think those are the most important um pointers or pearls for us to remember when preparing a patient for the theater okay post operatively uh again it's usually basically a standard procedure for per hour of the patients um some patients will be required to maintain a certain position so check your doctor's orders and make sure that the patient follows that flat under bed or a moderate high back rest for some cases uh just double check on that diet restrictions uh if uh we are able to determine their one um cancel their npo uh or if the iv fluids are have run dry just uh double check and remove them already and make sure that the antibiotics and steroid drops are given on time most of our drops are given during waking hours only so when the patient is asleep you don't need to bother them what else also look out for sub-specialty orders such as uh patients that have undergone a nucleation may require compression dressings i'll just check on the dressings that they are not too soaked you can actually ask the residents to one to address the problem of a faulty compression dressing ocular hypotensives when needed in a complicated cases uh some some uh some cases will also require post-op mediatic uh madriatics or deleters so just double check on the doctor's orders basically and of course in laterality you have to check okay basic eye nursing care again there's really nothing out of the ordinary for uh for our patients um one thing i would like all of you to remember is to maintain your minimum health precautions when you are working with the patients don't forget your gloves if you can don't forget your face masks and also don't forget to have your patients wear their face masks when you are caring for their eyes so other than uh the usual eye drops i think uh two things that i've seen in the world that may need a little guidance would be our eye patching and the use of eye shields so [Music] then this church around the eyes just clean them with a damp piece of cotton avoid wiping into the globe so for eye patching yes i have two pictures here no i have seen a lot of patients that uh have had their eye patches plastered in a haphazard manner so this will not be this will kind of reflect the care that we give to our patients uh negatively as well the one on the right you mentioned diagonal that's the proper way of plastering your eye patches so we're going to have a h vertical horizontal direction so we want to apply the plaster in such a way that the patient won't be in too much discomfort okay eye shields yeah in cases of eye trauma we use eye shields that's what it looks like a plastic thing so you will notice that uh the more pointed and is uh directed nasally the plaster is also applied diagonally so eon [Music] for the last part of this short talk facilitating billing phic and discharge so a lot of our patients are delayed with their discharge because of incomplete papers basically so as with the other uh segments and other lectures uh if we are able to check everything as soon as the patient arrives we're able to discharge them quicker so a quicker turnover will reflect our efficiency and also will increase the productivity of the center which is our overall goal so number one uh we still follow the stand standard field health requirements so uh the mdr the proof of payments the pbf are things that we could actually check as the patient is being admitted now for cataract patients this is something very important right now for our claims with phil health make sure that the cataract pre-surgical approval is actually attached and not expired okay double check on the laterality as well make sure that the surgical approval matches the eye that has been scheduled for surgery post op and we check for the signatures so the patient has to sign this as well as the surgeon um then charting the or records and or techniques are all pretty standard our nurses are very familiar with this already so just check that as well make sure that everything has been attached and all the signatures have been affixed cf3 and cf4 forms are also pretty standard you're all familiar with this the cf4 uh the residents do this on the computer already so what you can do seguro is to remind our residents to complete the cf4 already once the patient has been wheeled into the theater so as soon as the patient is brought back out we can facilitate the discharge quicker do not forget your tagatagon billing and your discharge instructions as well again double check the laterality of the eyes and the timing of the drops so and unless specially indicated by the attending physician you can tell the patients to just use the drops as well during waking hours lastly for the private patients we have we will be having a few private patients as well uh make sure that the phil health either professional fee forms have been filled out and signed as well so again this is uh these are all just very short pointers of things that you already know with a few reminders long for uh the of the workflow and just make sure always make sure that the eyes that you're dropping the meds on are correct make sure that the paperwork is complete and our patients will be the the discharge of our patients will be facilitated quicker uh inland if you have any questions just feel free to ask any of us or the residents i guess that that's it if there are any questions [Music] yes sir thank you so thank you so much dr young for that very practical and informative lecture so again reminding everyone to please fill up the evaluation forms on our link below on the chat box so again for any questions kindly i'll feel free to type them below so may i call on dr june again to please introduce our next speaker thank you so we have two more uh actually dr charles is like the last uh speaker we have two more uh we invited two more speakers the tech speaker would actually have an overlap with dr charles lecture a while ago but this will be on their own point of view and this will cover probably also not only the word but also the or the eye instruments center which all utilizes uh we need to build patients and we need to discharge them as well so for our next speaker we we have he graduated bis accountancy at the slu and is a cpa currently is an account on three at iprmc and he will talk about facilitating patient billing and discharge so please welcome let us welcome mr john chico sir hello good morning good morning good morning and we are very [Music] very much humble that we are invited in this forum so [Music] i would just like to share my screen [Music] yes slicer okay okay so let me start so i would like to introduce the the team first before i discuss uh the flow of the pv and game section so and again john benedict at the head of the building section the section is subdivided into three units the billing the covet testing claims and the ph ic claims and each usb unit also has its its unit is divided also in its subunits so the building has aph ic building and an mph icb link for the public testing and we all know that this is now the bread and butter of the hospital since the pandemic that is generating cigarettes 70 of the revenue for the whole hospital and the phi 6 names the regular claims this is composed of the previous generation the planes processing transmitter end rth and the night planes so let's start first admission and patient and this is the first process so a checking of the eligibility and generation of the people upon admission but nothing uh the first thing let me establish another patients [Music] patient go forward [Music] pbf form and phil has number a member information and the patient information eligible [Music] [Music] foreign for another is the young non-compensable procedures for model students the listed case rates and transferred to hospital of choice for medical cases [Music] within 90 days and then another admit within 90 days transferred to hospital choice at the same time within 90 days autonomous processing of patients final statement of account for ph i situations still have so from to start uh if you forward less attendance the billions section that will have uh you have billing it will receive not a new um your face sheet and also check the home fitness of cf4 lab and radio resource and other needed documents so um results or incompetencies or so california um so [Music] we briefly discussed current processing and transmitter of claims so after my discharge initiation you calculate the hit documents and prepare abstract report and then you will verify and segregate all the hic forms and then if you check them out you may claim form one two three through e claims papers and i discuss you have circulars related to ophthalmology claims pc2016-014 annex ii list of procedures case rate and supplementary guidelines for all case rates hellcat package guidelines and the diagnosis and management of uncomplicated etc in adults and lisa procedures and case rates and supplementary guidelines for all case rates um [Music] [Music] for hci 39 young cornyal 65772 relaxing incision for correction of surgically induced astigmatism um [Music] procedures with additional condition for claiming the investment um six seven zero one zero removal of nitrous anterior approach open sky technique or limbal incision subtotal removal of mechanical etractomy so it cannot be claimed unless done in combination with penetrating serratoplasty any of the following rbs food spo you know six five seven ten six five six five seven thirty six five seven fifty six five seven five five tap was six five zero zero five removal of vectors under approach open sky technique or uh limbal instinction partially mobile lumbosa so uh for rbs codes six seven zero ten years five seven ten seven thirty seven fifty seven cannot be claimed as second history procedures [Music] language so six five zero nine one that is that is a deceleration of ocular contents without implant point um six five zero nine three a deceleration of ocular [Music] [Music] uh eight five zero eight five two nine two zero nine three zero nine four zero nine eight two eight

2021-12-11 21:26

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