Who is responsible for obtaining informed consent before surgery?

The surgeon (physician) is responsible for obtaining informed consent. The physician must explain the procedure, risks, benefits, and alternatives. The CPO or other staff may witness the patient's signature on the consent form or verify it is present in the chart, but cannot obtain consent on the physician's behalf.

What are the three components of the Universal Protocol?

The Universal Protocol has three steps: (1) Pre-procedure verification, confirming the correct patient, procedure, and site using two patient identifiers; (2) Surgical site marking, where the surgeon marks the operative site directly on the patient; and (3) Surgical time-out, a team pause immediately before incision to verbally confirm all three elements. Every team member is expected to participate.

Should a CPO tell a patient to stop taking aspirin before cataract surgery?

No. A CPO should never advise a patient to stop any medication, including aspirin, without an explicit physician order. The decision to discontinue blood thinners before ophthalmic surgery is a medical decision made by the surgeon, often in coordination with the patient's internist or cardiologist. Many cataract surgeries proceed safely with the patient still on aspirin.

What post-op symptoms should prompt a patient to call the office immediately after eye surgery?

Patients should contact the office immediately for sudden decrease in vision, severe or worsening eye pain not controlled by prescribed pain medication, significant increase in redness or discharge after the first post-op day, new onset of flashes or floaters, or a curtain blocking part of their vision. These may indicate complications such as endophthalmitis, elevated IOP, or retinal detachment.

When must informed consent be obtained relative to the procedure?

Informed consent must be obtained before any sedative, anxiolytic, or anesthetic medication is administered. Once a patient is sedated, they cannot give truly informed consent. Consent should be documented in the pre-operative holding area or at a pre-op appointment, while the patient is alert and able to understand and ask questions.

Pre-Op & Post-Op Care for the CPO Exam

Surgical procedures in ophthalmology require meticulous preparation before the patient enters the operating room and careful monitoring after they leave it. As a CPO, you are a critical member of this safety chain. Understanding pre-operative and post-operative care is not only testable content but a core clinical responsibility.

Pre-Operative Care

Blood Thinner Management

Patients on anticoagulants and antiplatelet agents (commonly called blood thinners) require specific management before surgery to reduce bleeding risk. Common agents include warfarin (Coumadin), aspirin, clopidogrel (Plavix), and the newer direct oral anticoagulants such as rivaroxaban and apixaban.

The decision to stop or continue these medications is made by the surgeon in consultation with the patient's prescribing physician. Do not instruct a patient to stop blood thinners without a physician's order. For many ophthalmic procedures performed under local or topical anesthesia, blood thinners may not need to be stopped at all, particularly for cataract surgery.

Never advise a patient to stop blood thinners without explicit physician instruction. Stopping anticoagulation can lead to serious cardiovascular events. The ophthalmologist coordinates with the patient's cardiologist or internist.

Informed Consent

Informed consent is a legal and ethical requirement before any surgical procedure. The surgeon is responsible for explaining the procedure, its risks, benefits, and alternatives, and then obtaining the patient's signature. Your role as a CPO may include witnessing the signature or confirming the consent form is complete in the chart, but you do not obtain the consent itself.

Consent must be obtained when the patient is calm, awake, and able to understand the information, not after sedation has been given. If a patient has questions after the physician has explained the procedure, notify the physician rather than answering medical questions yourself.

Surgical Site Marking and the Universal Protocol

The Universal Protocol was developed by The Joint Commission to prevent wrong-site, wrong-procedure, and wrong-patient surgical errors. It has three key components:

Pre-procedure verification: Confirm the correct patient, correct procedure, and correct site using two patient identifiers (name and date of birth, or name and medical record number).
Surgical site marking: The surgeon marks the operative site with their initials before the patient enters the operating room, directly on the patient. For eye surgery, the surgeon marks the correct eye (right or left) or the correct eyelid.
Surgical time-out: Immediately before incision, the entire surgical team pauses to verbally confirm the patient identity, procedure, and site. Everyone must agree before the procedure begins.

The surgical time-out is a team activity, not just the surgeon's responsibility. As a CPO in the OR, you are expected to participate and speak up if something does not match.

Post-Operative Care

Post-Op Instructions

After surgery, patients receive both verbal and written post-operative instructions. Key topics typically include:

Prescribed eye drop schedule (frequency, order of instillation, duration)
Activity restrictions (no swimming, no heavy lifting, no rubbing the eye)
When to expect normal symptoms (mild redness, blurred vision initially)
What symptoms require immediate contact with the office
Follow-up appointment schedule

As a CPO, you may be responsible for reviewing these instructions with the patient and ensuring they understand them before discharge. Confirm the patient has a responsible adult to drive them home if they received sedation or dilation.

Recognizing Post-Op Complications

Patients should be educated to recognize warning signs that require urgent evaluation:

Sudden decrease in vision at any point after surgery
Severe pain not relieved by prescribed analgesics
Increasing redness or discharge after the first day
Flashes of light or a curtain in the visual field (possible retinal detachment)

Post-cataract endophthalmitis (infection inside the eye) is rare but vision-threatening. Onset within 1 to 7 days post-op with pain, redness, and cloudy vision requires same-day evaluation.

Key Takeaways

Blood thinner management before surgery requires physician-directed guidance; do not advise patients to stop medications without an order.
Informed consent is the surgeon's responsibility; the CPO may witness the signature but does not obtain consent.
The Universal Protocol (verification, site marking, time-out) prevents wrong-site surgical errors and requires team participation.
Post-op instructions must be given verbally and in writing; confirm patient understanding before discharge.
Educate patients on warning signs that require urgent post-op contact: sudden vision loss, severe pain, increasing redness, or flashes and curtains.