A Description of a Paediatric Ophthalmology Shared Care Service in North Staffordshire and an Audit of the Service

Transcription

1 A Description of a Paediatric Ophthalmology Shared Care Service in North Staffordshire and an Audit of the Service BY C CARRICK, S BANSAL, K MATTHEWS, L JONES, A JOSEPH, RD BROWN Abstract Introduction The North Staffordshire paediatric ophthalmology shared care service (PSCS) was established to improve quality of service, reduce pressures on secondary care, reduce waiting times, increase patients choice and simplify referral pathways. The structure of this service is described. Method Referral letters over one month were reviewed to assess triage accuracy. Optometric prescribing over 12 months was scrutinised against guidelines. The effect of the introduction of an electronic referral system on waiting time was assessed. Data was examined to ascertain if referral route affected attendance. Results All 225 new referrals had correct triage decisions made. For 1,585 patients refracted by a PSCS optometrist, seven prescriptions fell outside the guidelines. The electronic referral management system resulted in a significant reduction in waiting times from 32 days to 25 days. Patients referred by the Choose and Book (CaB) system had the highest attendance rate. Conclusion The PSCS provides care in the community and has released capacity at the University Hospital of North Staffordshire (UHNS). The orthoptic referral triage system directs patients appropriately to PSCS or UHNS appointments. The refractive prescribing guidelines help to maintain a standardised quality of care. Electronic referral management reduces administrative error. Referral pathways affect attendance. Introduction Healthcare in the UK has recently undergone major changes; 2006 saw the introduction of the Department of Health White Paper which stated the intention to provide a greater range of services in settings that are more convenient and accessible to patients [1]. The Association of Optometrists has suggested that optometrists have the skills and resources to provide radical patient-centred eye care and so help healthcare commissioners to meet the requirements of the NHS Plan [2]. Achieving these requirements is dependent on agreed protocols for examination and treatment, these describe how and when information should be shared between practitioners [3]. The areas they felt lent themselves to shared care included paediatric ophthalmology [2]. Children in the North Staffordshire area with suspected eye problems were originally referred directly to the paediatric ophthalmologist at UHNS. The demand on the hospital eye service (HES) was too great to provide the treatment entirely within the paediatric ophthalmology department as there was insufficient capacity. A scheme of care in the community was put forward as a significant number of patients were identified as not requiring an ophthalmologist s input. Suitable patients would be co-managed by trained and accredited optometrists and orthoptists. An initial pilot scheme in 2001 using three optometrists who were already undertaking clinical sessions at UHNS was introduced. This allowed close supervision and permitted confidence to develop. Eligible patients for this pilot study had reduced vision only without any other significant orthoptic abnormality. This pilot was followed by an extended service in May 2004 using 10 optometrists in community practices over the North Staffordshire area. Patients were referred by the orthoptists from primary or secondary screening or from orthoptic follow up clinics again, these patients had reduced vision only. Patients diagnosed with a squint, abnormal fundus or media (following examination by the optometrist) or if the vision failed to improve were referred to UHNS. The service was further extended in May 2010 to the current system using 18 optometrists. Patients with more complex conditions are now managed in the community. This new system is designed to allow easy transfer of patients between the two services with the goal to have 80% of patients managed in community and 20% at UHNS. The benefits of the service are to: Further reduce waiting times for children with ophthalmology needs. Decrease pressure on secondary care capacity. Encourage joint working between secondary and primary care. Provide choice at the point of referral. Provide care closer to home in primary care setting. Reduce non-attendance. The objectives of this audit are to provide a comprehensive analysis of our PSCS by studying its effects and assess any need for change. This audit also investigates suitability and effectiveness of the prescribing guidelines and reports on the changes incorporated within the protocols from the start of the scheme to improve the PSCS for all service users. In 2006 the service received a local award for partnership working and a National Acorn award for service redesign. Selection of optometrists and training scheme for accreditation Currently 18 optometrists covering 20 community optometry practices are involved in the PSCS. A geographic selection process was applied by ensuring a balanced spread of optometric practices throughout the North Staffordshire area. The accredited optometrists work in community-based practices that have the same standardised basic equipment used in the hospital ophthalmology service. The normal equipment consists of a retinoscope and trial lenses as well as an indirect ophthalmoscope and appropriate lenses. Optometrists were accredited by UHNS ophthalmologists after attending clinics for training. Local PCTs undertook accreditation paperwork. Their clinical competency is biennially assessed by consultant paediatric ophthalmologists at UHNS. Orthoptist involvement The present system involves 10 orthoptists attending 22 community clinics within the North Staffordshire area.

2 Appendix 1: Referral Pathway Appendix 2 Appendix 3 Orthoptic referral letter triage All paediatric ophthalmology referrals via letter or choose and book (CaB) are triaged by the orthoptic team. The referrals are processed along the most appropriate route dependent on referral content either to: PSCS to be seen by an orthoptist and / or optometrist. Paediatric ophthalmologist at UHNS (Appendix 1). Patients can be referred from PSCS to UHNS if required and vice-versa. Electronic referral pathway Since February 2011, the PSCS has been supported by an electronic process management tool, called eworks (previously Metastorm BPM), making it a paperless service. It is used by North Staffordshire IT shared service to design business processes across local NHS Trusts. Orthoptists refer patients to the accredited optometrists through this new system and users are able to track the progress of their referral forms online electronically. Users can also identify the action stage it has reached and can review any activities associated with the referral. Choose and Book (CaB) is a national electronic referral service that gives patients a choice of place, date and time for their first outpatient appointment in a hospital or clinic [7]. Standard Protocol for prescribing for refractive error Guidelines regarding prescribing glasses in children have been devised by consultant ophthalmologists, UHNS orthoptists and the accredited PSCS optometrists. Two age appropriate guidelines (Appendix 2 and 3) were created to ensure consistency amongst practitioners and provide support in the community setting. These guidelines were created by reviewing current published literature and through joint collaboration of experience and knowledge [4-6]. The optometrists are able to contact the orthoptic department to discuss any variation from these guidelines. The optometrists' results are sent to the orthoptic department via eworks and an appropriate orthoptic follow up appointment is arranged. Patients are sent for repeat refraction as necessary or referred directly to the ophthalmologist if any concerns are raised by the optometrist or orthoptist. Standard protocol for referral Criteria for patients referred to PSCS are outlined in Table 1. All other conditions are referred to the UHNS Methodology To the best of our knowledge this was the first shared care service for managing children with eye problems. We are not

3 Table 1: Criteria for PSCS Unilateral or bilaterally reduced vision Concomitant strabismus Inferior oblique over actions Asymptomatic A, V, Y pattern ocular motility disorders Mild ptosis non pupil obscuring with normal pupils Convergence and accommodative insufficiency Specific learning difficulties Family history / parental concern Asthenopic symptoms Any others deemed appropriate by the paediatric ophthalmologist aware of any published standards. The study is retrospective, involving examination of notes, hospital waiting time information and inter-service referral data. Audit 1 All referral letters to UHNS paediatric ophthalmology service received in June 2011 were reviewed to assess the orthoptic referral triage process. These referrals were assessed to evaluate whether patients had been directed to the appropriate service and how many had to be redirected. Patient notes were reviewed to ascertain referring source and mode of referral. Audit 2 The notes of all patients sent for an optometric assessment within the PSCS between May 2010 and April 2011 were analysed to assess the adherence to recommended prescribing guidelines by participating optometrists. Audit 3 Waiting times for patients to be seen by a PSCS optometrist were calculated pre and post eworks implementation. Hospital appointment waiting times for patients were calculated. Audit 4 Attendance rates for different referral routes and transfer rate of patients between UHNS and the PSCS were also examined. Results Audit 1 The Orthoptic triage service A total of 225 new patients were referred to UHNS in June 2011 and were allocated appointments. Of these, 110 were male and 115 were female. The mean age of these patients was four years three months (range two months to 15 years one month). The referrals had correct triage decisions made in all cases according to the information provided in the referral letter. Of these patients, 196 (87.1%) were directed to the PSCS and 29 (12.9%) patients were directed to the paediatric ophthalmologists at UHNS. At this first appointment, 15 (6.7%) patients were transferred between community PSCS clinics and UHNS or vice versa. These 15 referrals contained incomplete information that influenced the triage decision and subsequently required redirection (Table 1). Audit 2 Paediatric shared care optometrist service A total of 1,783 patients were referred to PSCS optometrists from May 2010 to April Of these, 931 were male and 852 were female. The mean age of patients was five years one month (range five months to 13 years nine months), and 198 (11.1%) were not brought (WNB) to the optometrist appointment and were subsequently discharged. The 1,585 attendances were audited in accordance to the refractive error prescribing guidelines and there were only seven (0.4%) instances of non-adherence to these guidelines. In this 12 month period, optometrists requested 13 (0.8%) patients be transferred to UHNS for an ophthalmologist s opinion (Table 2). Audit 3 Effect of introducing eworks Samples of PSCS optometrists returns for three months prior to the introduction of eworks and three months after its introduction were taken. The mean time from referral by the orthoptist to an optometrist to be refracted before eworks was 32 days (391 patients) and post introduction of eworks was 25 days (339 patients). This difference in waiting times is Table 2: Examples of referrals between services Transferred from UHNS to PSCS Original referral Duane syndrome Jeune syndrome Surgery required Variable ptosis Reduced visions and suspicious deep cups Optician suggested myelinated nerve fibres and persistent reduced vision Slight conjunctival palpebral hyperaemia Reason for transfer (Outcomes) Requiring additional measurements of strabismus prior to surgery Non pupil obscuring, requires monitoring Deep cups of no concern recorded by ophthalmologist. Myelinated nerve fibres present but to continue with occlusion therapy for strabismic amblyopia No concern recorded by ophthalmologist. Transferred from PSCS to UHNS* Original referral Fast blinking, possible strabismus Possible strabismus, strong family history of eye problems Convergence weakness exophoria, no improvement with exercises Premature baby, possible esotropia Possible strabismus, patients father is partially sighted Family history of nystagmus, no nystagmus seen Patient notices one eye drifts up Parent requested ophthalmologist opinion as notices marked esotropia Reason for transfer (Outcomes) Trichiasis Manifest / latent nystagmus Surgery required Lid lump Orthoptically satisfactory, but pigment on iris Upbeat nystagmus Moderate inferior oblique overactions Slight esotropia and moderate epicanthus *All transfers from PSCS to UHNS required Paediatric Ophthalmologist opinion/input

4 Table 3: Patients referred to UHNS for consultant input following optometrist consultation Transferred from PSCS to UHNS following optometrist examination Structure Optic Disc Lens Retina Iris Lids Anomalies tilted, asymmetry, cupped, pale cataract, Cloquet's canal remnant mottled, haemorrhage, hypo-pigmented area, bear track pigmentation lump, skin tag significant p< Electronic referral has reduced delays encountered by loss of referrals and administrative errors or handling problems. Audit 4 Attendance rate and route of referral During the month audited, 225 referrals were received, 176 patients attended (23 UHNS, 153 PSCS), the combined overall attendance rate in June was 78.2%, with approximately equal attendance rates at UHNS (79.3%) and PSCS (78.1%). The waiting time for assessment was, at UHNS, 26.5 days (range days) and at PSCS, 28.3 days (range eight to 81 days). Following the extension of the PSCS, GPs were encouraged to refer patients via the CaB service. CaB referrals made up 13.8% of the referrals, in this group only one patient (3.2%) was not brought (WNB) to their appointment. From our data, patients who were referred by other routes were more likely not to attend their appointment, with a WNB rate of 32.9%. This suggests that the CaB system, where patients are consulted to agree a specific date and time, is much more likely to result in patients attending. Discussion In recent years the UK Department of Health (DH) has introduced strategies and targets in order to reduce waiting times and provide appropriate appointments to patients with more complex conditions [8]. The DH promotes delivering quality efficiently whilst maximising potential workforce [9]. These innovative ideas cover all eye care services designed to enable people to achieve and maintain good eye health and sight [1] and give health care professionals an opportunity to expand their clinical roles. Recent NHS policies have sought to strengthen the role of primary and community services by shifting the balance of care away from hospitals. The National Eye Care steering group has developed care pathways for cataract [10], glaucoma [11-14], lowvision and age-related macular degeneration to utilise the skills of trained and accredited optometrists to perform assessment of and co-manage these groups of patients. More recently the emphasis has been on glaucoma shared care schemes [11-14]. Despite this recent government drive to encourage shared care programmes, the area of paediatric ophthalmology seems not to have been addressed. The North Staffordshire PSCS offers a strategic innovative solution to address capacity, quality, efficiency and effectiveness. It aims to bring basic eye health care as close as possible to where people live and work, giving them a choice of clinics and providing a multidisciplinary approach to children s eye care. It has reduced the demand on secondary care, enabling those who need to be seen in the hospital eye service to obtain an appointment within an appropriate time. Our PSCS has successfully involved community optometrists in the HES. This audit concluded that all referrals were triaged correctly against the referral pathway. The ease of transfer between the two systems provides a seamless service for patients. A total of 6.7% orthoptist triaged referrals had to be re-directed. These referrals had correct triage decisions made according to the information on the referral but later were appropriately transferred. Only 0.8% of patients in the PSCS needed transferring for an ophthalmologist's input. Patients were not penalised for entering either service as overall waiting times for each service are similar, showing equality throughout the ophthalmology service, ensuring diagnosis and treatment in a timely manner. Our results demonstrate the current guidelines for prescribing refractive errors are sufficient to allow PSCS optometrists to provide a consistent and safe clinical practice. Patients are being seen quickly with support of the eworks system and waiting times have been reduced. Referrals not using CaB had the highest non-attendance rates. To overcome this, it is felt that a process similar to the CaB system should be introduced, as this has shown to increase the likelihood of attendance. Currently, GPs are the only referral source who can utilise CaB. In the absence of such a system for other referrers, we aim to improve our attendance rates by contacting patients to book a convenient appointment with them. If a patient has no refractive error, is orthoptically satisfactory and has an acceptable level of visual acuity, optometrists are able to discharge the patient. Procedures have been developed to facilitate and monitor this and it has been running successfully since November The success of this PSCS is a direct consequence of excellent communication within and between the teams involved, as well as the design of the service and supporting pathways. The structure in place supports high quality clinical management by all involved in the process. Our PSCS has successfully involved optometrists based in this particular community and has a number of key functions; supporting visual screening, promoting choice for parents and patients, delivering treatment in a community, supporting care management and supporting visual rehabilitation. It helps to improve patient care without compromising patient safety. The introduction of a scheme similar to the one described in this study requires highly committed staff members at every level of patient care, including clinical, administration and management teams. It also requires careful consideration of the costs and local circumstances, including geographical access and the existing organisation of paediatric ophthalmology care within the HES. The current prescribing guidelines are satisfactory, but will be updated in line with research developments. The PSCS is growing locally, by providing available care and treatment services integrated within the UHNS ophthalmology service. The triage process has shown that it can reduce the numbers of referrals attending the paediatric HES. Although the service has diversified, the responsibility of every PSCS patient still lies with the consultant ophthalmologist. Patients within PSCS are not being penalised in receiving treatment from UHNS or community accredited optometrists. Excellent communication, regular training and audit will enable service providers to maintain all aspects of competency and deliver a high quality of care.

5 Conclusion Our PSCS has proven to provide high quality consistent care to paediatric patients within the community. It has been demonstrated to be an effective and efficient model to deal with the increasing number of referrals to the paediatric ophthalmology service. The model requires a skilled team of orthoptists, community optometrists with special interests and consultant ophthalmologists. Claire Carrick, Orthoptist BSc (hons), University Hospital of North Staffordshire, Orthoptic Department, Eye Unit, Stoke-on-Trent, UK. References 1. Topic: National Health Service: policy-areas/nhs/. Accessed April Primary eye care in the community what optometrists can offer healthcare commissioners and patients. Association of Optometrists. December Classé JG, Alexander LJ. Protocols for comanagement. Optom Clin 1994;4(2): O Connor A. Hypermetropia in childhood: a review of research relating to clinical management. British and Irish Orthoptic Journal 2008;5: Donahue SP. Prescribing spectacles in children: a pediatric ophthalmologist's approach. Optom Vis Sci 2007;84(2): Leat SJ. To prescribe or not to prescribe? Guidelines for spectacle prescribing in infants and children. Clinical and experimental Optometry 2011;94(6): Choose and book: Accessed April Peter NM, Khooshabeh R. Nurse-led oculoplastic clinics innovative, safe and cost effective. Eye News 2012;18(6): Delivering quality efficiently: alias= Accessed April Booth A, Walters G, Cassels-Brown A, et al. Shared care postoperative management of cataract patients. Br J Ophthalmol 1998;82(3): Syam P, Rughani K, Vardy SJ, et al. The Peterborough scheme for community specialist optometrists in glaucoma: a feasibility study. Eye 2010;24(7): Bourne RRA, French KA, Chang L, et al. Can a community-based referral refinement scheme reduce false-positive glaucoma hospital referrals without compromising care? The community and hospital allied network glaucoma evaluation scheme (CHANGES). Eye 2012;24(5): Mandalos A, Bourne R, French K, et al. Shared care of patients with ocular hypertension in the community and Community and Hospital Allied Network Glaucoma Evaluation Scheme (CHANGES). Eye 2012;26(4): Gray SF, Spry PGD, Brookes ST, et al. The Bristol shared care glaucoma study: outcome at follow up at 2 years. Br J Ophthalmol 2000;84(5): Sandeep Bansal, Orthoptist BSc (hons), University Hospital of North Staffordshire, Orthoptic Department, Eye Unit, Stoke-on-Trent, UK. Karen Matthews, DBO BSc (hons), Lynval Jones, MMedSc, FRCSEd, Mrs Annie Joseph, FRCOphth, Mr Raymond Brown, FRCOphth, University Hospital of North Staffordshire, Orthoptic Department, Eye Unit, Stoke-on-Trent, UK. Correspondence: Mrs Claire Carrick University Hospital of North Staffordshire Orthoptic Department, Eye Unit, Main Building, Newcastle Road, Stoke-on-Trent, Staffordshire, ST4 6QG, UK. claire.carrick@uhns.nhs.uk Acknowledgements The authors would like to thank Malcolm Gray, former Chairman of Staffordshire LOC, in assisting the initiation of the PSCS service and all the PSCS optometrists who are providing a dedicated standardised optical service throughout the North Staffordshire area. We also thank the Orthoptic Department and the administration staff at UHNS for their hard work in collecting patient documents. Declaration of competing interest: none declared