G. Natchiar, MD; Alan L. Robin, MD; Ravilla D. Thulasiraj, MBA; Senthil Krishnaswamy, MD
|
|
|
|
|
|
| Attacking the Backlog of India's Curable Blind | |
|
The Aravind Eye Hospital Model G. Natchiar, MD; Alan L. Robin, MD; Ravilla D. Thulasiraj, MBA; Senthil Krishnaswamy, MD |
|
|
The number of individuals in developing nations with preventable blindness from cataract and other disorders is increasing. New programs incorporating local customs and efficiently using available resources must be created to prevent the escalation of blindness and to rehabilitate patients already disabled with cataracts. We describe a system of highquality, high-volume, cost-effective cataract surgery, using screening eye camps and a resident hospital.
There are many reasons for this ever-increasing number of eyes with curable cataract blindness. The first major barrier is the patient (Table 1). To decrease the number of patients with cataract blindness, many human factors, including illiteracy, basic knowlege about eye diseases, and fear, must be overcome. The training, organization, and management of physicians in the mass treatment of large patient volumes is another deterrent to the elimination of cataract blindness. Presently, only one third of the approximate 7500 ophthalmologists in India are actually involved in performing cataract surgery at the community level. Despite the increasing backlog of cataract blindness, poor organizational skills prevent most ophthalmologists from doing more than an average of 150 operations yearly. The distribution of ophthalmologists between rural and urban locales further increases the barriers to eliminating cataract blindness. Although three quarters of India's population live in rural areas, three quarters of India's ophthalmologists live in urban areas.
The Aravind Eye Hospital, Madurai, India, started as a lO bed hospital in 1976 and has today grown into a large ophthalmic institution. Sixty percent of the hospital's services are community oriented and free. Staffing consists of30 medical officers, 47 residents and fellows, 308 paramedical staff, and 304 ancillary staff. These include administrators, receptionists, housekeepers, sanitary workers, and security staff. The total bed capacity is 1400. Nine hundred beds are devoted to patients who are given totally free care. These "free patients" pay nothing for their diagnostic examination, any ophthalmic surgery, or postoperative care. In addition, free food is provided during their hospitalizations. Surgeons at the Aravind Eye Hospital currently perform more than 69 000 surgical procedures annually (Table 2).
* ICCE indicates intracapsular cataract extraction; ECCe, extracapsular cataract extraction; PC, posterior chamber; and IOL, intraocular lens. + Extracapsular cataract surgery with the insertion of a posterior chamber intraocular lens. We believe that the following are necessary to perform large volume surgeryina developing nation. An institution must be capable of marketing its surgical "product," knowing the target population, and motivating the community. Community awareness and involvement are vital to the success of any program dealing with large volumes of patients. Nongovernmental volunteer organizations and voluntary agencies playa vital role linking Aravind to the community. Aravind receives most of its marketing through screening eye camps. The population serviced through the screening eye camps ranges between 17 and 20 million people. All are within a 240-km radius of the hospital. A unique aspect of Aravind's design is that it has two separate hospital buildings. The first is a paying hospital serving clients who can afford payment for at least part of their eye care. The other is a free hospital, serving the poor. In the free hospital, all services are provided without cost. Patients from screening eye camps are served herein. This hospital not only helps treat patients from the disadvantaged section of society, but its success acts as a catalyst, bringing wealthier patients from various communities to the payinghospital. Patients who are satisfied with their visual outcomes and happy with the hospital's care become advocates of the hospital and educate potential patients about the virtues of cataract surgery. An additional benefit of an eye camp is that it increases the awareness of eye diseases, their treatment, and their avoidance. It also enhances the concept of Aravind's caring attitude and efficiency. This sense of awareness not only promotes the eye camp per se, but it also promotes better general eye care. These organizations later become a link and referral center for Aravind. Patient recruitment is necessary for the hospital to function at full capacity and run efficiently. Without this, Aravind's ability to perform surgery expediently and inexpensively would be greatly diminished. We use two primary methods of recruiting patients. These involve admissions from both walk-in clinics and screening eye camps. Walk-in clinics service patients who come to the hospital on their own. On arrival, the patient decides to go to either the free or paying clinics, depending on finances. There are no strict financial criteria for admission to the free hospital. Here patients must make their own arrangements for food. However, those who cannot afford even that are given it free. Most patients who come to these clinics have heard of Aravind through previously operated on patients, publicity, or visitors who visit inpatients. Screening eye camps are an integral part of our "marketing" strategy for increasing patient awareness of our hospital. These are regularly conducted at the community level. We conduct approximately 16 camps weekly. Patients who are screened and are found to have surgically treatable eye abnormalities are transported on the same day that they are screened, free of charge, back to the Aravind Eye Hospital. They receive intracapsular cataract surgery and meals without cost. All patients receive free postoperative medications and care. At the time of hospital discharge, they are given free + 10-diopter spherical glasses. Patients who desire an intraocular lens can obtain one by paying Rs 500 (US $16) toward the cost of both the implant and postoperative medications. In patients in whom intraocular lens implantation is indicated because of occupational demands or clinical reasons, the lens is provided free if the patient cannot afford the price. From a marketing perspective, it is crucial that patients not wait during their initial processing when they arrive at the hospital. During registration we perform routine procedures quickly, efficiently, and carefully. We expedite the entire process and treat each patient as a "most valued" customer. Proper planning of each screening eye camp ensures that the maximum number of patients will benefit from each outreach program. We use two axioms in the organization of the camps: maximum community awareness, or marketing, of the eye camp; and a joint participation, or teamwork, between workers in the community and the Aravind Eye Hospital staff. The Aravind Eye Hospital has developed a system that integrally involves the community around the chosen camp site so that the community as a whole is motivated to conduct the screening camp. This community involvement maximizes the chances of those requiring treatment being brought to the camp. Recruiting sponsors and volunteers living within the community is the first step in organizing a screening eye camp. These individuals are important because they minimize the burdens of finances, logistics, and manpower when the eye camp is actually conducted. The Aravind eye camp organizer, a full-time paid Aravind employee, approaches local service (eg, Lions Clubs, Jaycees, and Rotary) and religious organizations to discuss their involvement in the camp. Several different sponsors often combine their efforts and resources, increasing the camp's outreach within the community. These local sponsors market the eye camp and orchestrate details such as the camp's date, locale, and the necessary equipment and furniture. They ensure that the location is accessible to patients and that there are adequate facilities and rooms for the various examination stations. A convenient site, such as a large school building, is required so that rooms are adequate (eg, 7 m in length for vision testing). The eye camp date is chosen jointly, allowing for appropriate planning and publicity. Sponsors then recruit other local community volunteers. The number of volunteers needed is dependent on the projected number of patients to be screened. The use of local volunteers is an efficient utilization of appropriate manpower. They accomplish many nontechnical but extremely necessary jobs that are crucial to the treatment of a large volume of patients. Volunteers clean the camp site, set up the camp furniture, help with publicity, manage the crowds, and register patients. They can also be trained to assist in various diagnostic procedures and help escorting patients to different examination rooms. Prior to the eye camp's beginning, approximately seven volunteers clean the site and arrange the furniture. The furnishings required (Table 3) and the number of personnel needed (Table 4) are both functions of the volume of patients anticipated.
Publicity is an important aspect of eye camp planning. This crucial factor helps determine the turnout and the ultimate success of the camp. The goal of effective publicity is not only making people aware of the eye camp but, more important, convincing patients with eye diseases to attend the camp and accept treatment if an abnormality is detected. These are the very patients we want to target. Various visual methods of publicity are used, such as wall posters, handbills, cloth banners, and newspaper advertisements. In the rural areas of India, the most effective type of publicity is through audio media. Sponsors use techniques such as microphones and loudspeakers on the street and the radio to announce an upcoming camp. These aural techniques attract the attention of visually disabled and illiterate patients, who might otherwise not attend. The major goal of screening is the identification of individuals with cataract blindness, since cataract is the leading cause of reversible blindness and has vast economic and social implications. We also attempt to see all school-aged children so that we can detect refractive errors, strabismus, amblyopia, and nutritional deficiencies. We commonly find many with uncorrected refractive errors. Presbyopia also may present as a disabling problem. The prescription of glasses for refractive errors becomes an integral part of the eye camp. We strive to detect glaucoma using tonometry and ophthalmoscopy. We evaluate other eye diseases that may require additional diagnostic or therapeutic management (ie, diabetic retinopathy, pterygium, dacryocystitis, corneal ulcers, and retinal detachments). These patients are referred back to the Aravind Eye Hospital. The final goal, and probably the most important from a long-term perspective, is educating the community on proper eye care. Part of this education is informing subjects that appropriate eye care is available. We encourage people to return to the Aravind Eye Hospital if additional eye problems develop. This prevents needless blindness through appropriate intervention. To increase the camp's efficiency, we extensively use paramedical personnel who are part of the medical team from the Aravind Eye Hospital. These ophthalmic assistants are usually young women, from rural areas, with at least a high school education. They receive training in basic nursing, followed by intense training in a specifc area in ophthalmic diagnosis and care. They perform preliminary screening and diagnostic tests. Their strategic use reduces the need for ophthalmologists. The patient flow through the eye camp is well organized, ensuring an efficient utilization of manpower and facilities. We set up a series of record-keeping and diagnostic stations. Patients travel through these in a inidirectional manner. The flow of patients is streamlined. As all patients may not require testing at all stations, the examination process ensures that patients attend only necessary stations (ie, it would be wasteful ro have a young patient with 6/6 visual acuity attend the refraction station). The first step is patient registration. Volunteers record patient names, ages, and addresses onto case sheets. These volunteers must have legible handwriting and are usually teachers who are involved in their community. They are well acquainted with both patients and their medical and social histories. Patients are next given identity cards. These cards will be retained for any future follow-up. Patients procedd to the first diagnostic station. Here, preliminary vision testing is conducted by ophthalmic assistants and they are aided by volunteers. Vision charts,such as the Snellen chart in the local language and illiterate E type charts, are used to determine each patient's visual acuity. At the second diagnostic station, residents and fellows perform a preliminary examination. They use flashlights and ophthalmoscopes, examining the eternal eye and fundus. They use a dimly lit room with a desk, chairs, and two functioning electrical outlets. If there is no electricity, the physicians use battery-operated instruments. In countries like India, batteries are expensive, so it is more economical to use electrical instruments. This preliminary examination is the first step in the screening protoval in which each patient is triaged and his or her care streamlined, depending on the examination's results. Patients with external eye diseases such as chalazions, blepharitis, malnutrition, and conceal ulcers are promptly advised about therapeutic modalities and necessary are promptly advised about therapeutic modalities and necessary medications are prescribed. Patients with incurable blindness are advised of it at this time. The remainder go beyond this step to the other diagnostic stations as indicated and to the final examination. Next is the evalutoon of intracular pressure and tearduct function. The intraocular pressure is measured and the lacrimal passages' patency is evaluated, whenever indicated. Care is taken to provide adequate lighting by locating this station near a window. One or two trained ophthalmic assistants, with the help of two to four community volunteers, conduct the examinations. The physical requirements are two benches for patients to lie down on and adequate additional benches for waiting patients. The volunteers administer topical anesthetic drops and explain procedures. The volunteers also help the patients lie down on the benches and instruct them to extend one of their arms and focus on their thumb during Schiotz tonometry. Tonometry is performed on all candidates for cataract surgery, patients with suspected or identified glaucoma, and as glaucoma screening in patients over the age of 40 years. The ophthalmic assistants measure the intraocular pressure of each eye with Schiotz tonometers. Patients with a history of watering eyes or discharge, patients with suspected lacrimal sac infection, and candidates for cataract surgery have the patency of their nasolacrimal ducts tested by ophthalmic assistants. Distilled water is gently irrigated through the lower punctum and canaliculus. The cannula and tonometer are sterilized with an alcohol lamp after each patient.  Schematic of the diagnostic stations and staff required for a screening eye camp. The refraction room is next. Herein, patients with complaints of defective vision due possibly to simple refractive errors, patients with presbyopia, patients who want to change their glasses, and aphakic patients are examined. This room is equipped with one or more foldaway partitions to create refraction cubicles, trial lens sets, and mirrors. Well-trained ophthalmic technicians refract while volunteers help and control the patient flow. Most refractions are accomplished without dilation, but young children and some adults receive cycloplegia. There are adjoining waiting rooms for dilation. The results of these examinations are evaluated at the critical step in patient flow, the final examination by senior physicians. On rare occasions, if the senior physician decides that a crucial examination has been overlooked, he or she can return the patient to the proper diagnostic station. However, in most cases, the senior physician reviews the patient's record, makes the final diagnosis, and prescribes treatment. Based on the findings of the previous diagnostic examinations, the senior physician can prescribe glasses, medicine, or advise the patient to undergo surgery. Those patients scheduled for surgery are registered, counseled, and transported at the termination of the eye camp to Aravind Eye Hospital. These patients receive surgery, postoperative care, meals, and round-trip transportation. In this system, the ophthalmologist is relieved of the mundane chores of performing all the necessary steps in patient examination by the work of well-t-rained volunteers, ophthalmic assistants, and residents. Thus, the care of patients is streamlined into an orderly, efficient flow that allows one senior ophthalmologist to treat hundreds of patients ata given camp. The recommended numbers of staff for a given size of screening eye camp are given (Table 4). The various roles of the physicians and ophthalmic assistants, as well as the volunteers, in each of the steps of the screening procedure are diagrammed (Figure). An emphasis on quality control, at all levels, is a major contributing factor in our success and increasing patient volume. We closely monitor the needs of all patients beginning with recruitment. Since patie~ts must interact with all levels of staff, the staff is constantly expected to be polite and give accurate information. There is continuous feedback from the patients regarding their views, whether be their outpatient or inpatient care. There is a management team, consisting of deparunental administrative heads (eg, housekeeping and maintenance). The administrator heads a team meeting weekly, reviewing suggestions and the functioning of the institution at various levels. All applicable suggestions are implemented, improving the services offered to the customer (patient). There are similar clinical quality of care meetings. Classes and training sessions are held regularly for ophthalmologists and paramedical staff. Constant monitoring of the staffs performance is essential.
With the proper infrastructure and utilization of operating room personnel a surgeon can easily do eight to 10 intracapsular cataract extractions per hour (Table 5) .It is possible to perform 200 intracapsular cataract operations without intraocular lens insertion within 5 hours, by four surgeons, with the help of 15 supporting staff. The senior surgeon makes the corneal-scleral incision, does a peripheral iridectomy, delivers the lens with a cryoprobe, and places the first corneal-scleral suture. He or she then goes to the next operating table. The remaining sutures in the first patient are placed by the resident or fellow. This not only makes the senior surgeon more efficient, using his or her talents most appropriately, it also gives the resident or fellow practice and confidence. Additionally, a sense of teamwork is created. Each senior surgeon is responsible for three contiguous operating tables and an adequate number of instrument sets. He or she is assisted by three scrub nurses, one orderly, one circulating nurse, and one nurse to sterilize the instruments. Likewise, one surgeon can perform approximately five extracapsular cataract extractions with the insertion of posterior chamber intraocular lenses per hour (Table 6). The sterilization process is handled with great care and efficiency. With Posterior Chamber Intraocular Lens Insertion
To expedite matters, a room adjacent to the operating room is used for both lid and retrobulbar injections. To increase the efficiency of this room, we use four nurses, one physician, two orderlies, and one person monitoring the patient flow. Patients walk into the operating rooms and also walk out to the wards following surgery. The flow of patients from the wards to operating room and back is well organized. Efficient patient handling results in minimal time loss. According to the workload, other paramedical staff such as circulating nurses and nursing staff are required in the rooms where retrobulbar blocks are given. When patients are admitted to the hospital, we both welcome them and give them preoperative instructions. These instructions make them aware of the surgical procedure and what to expect both intraoperatively and following surgery. This reduces their fears. Following surgery, the patients receive instructions in postoperative care. They are told the hospital's rules and regulations, what to expect during their hospitalization, and are given some basic education in general health and basic ocular hygiene. Following surgery, patients are followed up and their eyes are dressed daily during their postoperative stay of to 5 days. They receive topical corticosteroids, antibiotics, and cycloplegics, at least once daily (once every 4 hours for patients undergoing intraocular lens implantation). Trained patient counselors look after patients' comforts. The use of patient counselors keeps trained nursing staff to a minimum. The services of nurses are used exclusively for direct patient care. This increases the quality of nursing care. At the time of hospital discharge, patients are given both instructions and return appointments. They are asked to inform others of the facilities offered in the hospital when they get home, so that those who need them can also take advantage of Aravind's facilities. The most cost-effective method of reducing the cataract backlog is a passive process in which patients come directly to the hospital without the need for active recruitment or transportation provided by the hospital. Although this is the least expe~ive, it is also the least common way for patients to be introduced to Aravind. Other active approaches of patient recruitment are required to decrease the backlog of cataract blind. These active endeavors involve screening eye camps or a resident hospital approach where patients commute to the hospital and back to receive care. In a resident hospital, high-volume surgery is done under hygienic conditions. Accommodations are provided with just basic amenities (ie, toilets). Once surgery is completed, the higher-trained staff are used to serve other patients needing their skilled services. The staff is efficiently used, mainly performing tasks that demand their level of training. Patients desiring more luxurious services go from the eye camps to the paying hospital. They can choose from variety of amenities depending on their tastes and finances. Thus, the community, through the paying patients, generates more than enough revenue for the hospital and also serves the community by paying for the services of patients treated without charge. The revenue that is generated by the paying hospital, after deducting running costs, is used toward the free services provided at the hospital. Surplus medications, injectable antibiotics, corticosteroids, needles, and sutures purchased by the paying patients are used in the free hospitals. This method of sharing medications helps reduce cost. The large volume of operations brings down the cost. The answer to the backlog of cataract blindness in India has many possible solutions that may differ in various locations. Our model stresses community involvement at every step of patient care. We begin with coordination of our outreach programs with local service groups. We use their volunteers to help bring patients, who might otherwise not come, to our screening eye camps. This involvement helps ensure that most patients return to the base hospital for any needed ophthalmic care. The patient becomes an important aspect in determining the quality of care. Finally, the satisfied patient returns to the community and markets ophthalmic education and the base hospital. Patients who are aware of the institution come on their own. These same patients promote the institution to friends. Aravind is accessible if complications arise. Even in India, many people prefer to be seen by the same physician they are used to, as this encourages faith, trust, and confidence. We have developed a system that efficiently deals with screening patients with ophthalmic abnormalities ranging from presbyopia to cataract. We use individuals to their fullest potential. Both the medical and paramedical staffs are efficiently used so that they mainly perform tasks that demand their level of training. When possible and appropriate, we employ community volunteers, who are well motivated and often know the patients' needs best. Our efficiency is based on a spirit of teamwork and pride in our accomplishments. A base hospital approach, such as Aravind's, has many potential advantages. It allows for the luxury of multispeciaIty clinics. A high volume of patient encounters facilitates a greater mastery of patient care skills for all involved. Centralized care allows for both more productive and cost-efficient operations. The principal solution to the backlog of cataract blind is performing cataract operations on a large scale. The same situation prevails in almost all developing countries. The basic problems and the barriers are similar. We have found that these strategies are profitable while treating large quantities of patients. We ensure that we make optimum use of the existing ophthalmic manpower and hospital facilities through appropriate management strategies. We encourage new and innovative approaches to existing problems. We use resident hospitals that are able to perform large volumes of surgery. Limited bed availability prevents large-volume cataract operations in other hospitals. Eye camps provide opportunities for large-volume surgery, but facilities are not available throughout the year. At a resident hospital, space is available to conduct large-volume surgery. It is possible to maintaina "factorylike" efficiency with this approach. The services are of the highest quality and the manpower can be used optimally and efficiently in a cost-effective manner. Many aspects of our Aravind model for health care are innovative and have stood the test of time. We believe that community involvement, proper social marketing; and the appropriate utilization of human and other resources are probably the cornerstones of any health care organization. Some specific aspec;ts of this model could be duplicated in other developing areas. However, there are some features that would be more difficult to duplicate and may not be appropriate for other areas. It may be impossible in some areas of Africa and South America to have multispecialty clinics. It may also be difficult to raise the necessary funds to pay for salary support and obtain the necessary equpipment. References
|
|
|