Document Author: Matron - Minor Injury Units Date 17/10/2017. Clinical Director of Pharmacy

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1 Title: Ref No: 1954 Version: 2 Document Author: Matron - Minor Injury Units Date 17/10/2017 Ratified by: Care & Clinical Group Clinical Director of Pharmacy Date: 17/10/ /12/2017 Review date: 12 January Purpose of this document This clinical protocol provides a clear framework for nurse/paramedic practitioners employed by Torbay & South Devon NHS Foundation Trust when providing care to patients presenting with eye complaints and injuries. 2. Scope of the Policy This protocol is for the use by Minor Injury Unit (MIU) and Emergency Department (ED) practitioner employed by Torbay and South Devon NHS Foundation Trust who has achieved the agreed Trust clinical competencies to work under this protocol Exclusion/Red flag emergencies: severe eye pain. Severe eye pain with headache and/or nausea & vomiting (e.g. Iritis). Significant reduction or complete loss of vision. Major trauma. Visual disturbance e.g. flashers, floaters, black curtain descending and covering vision (retinal detachment), hypopyon (pus), hyphema (Blood). Deeply red eye with hazy cornea, mis-shaped and mildly dilated pupil (glaucoma) 3. Assessment 3.1. Presenting signs and symptoms; may include some of the following; Red eye, itchy eye. unilateral/bilateral symptoms, foreign body, laceration, pain, gritty sensation, watery eye, purulent discharge, crusting of eyelashes, swelling of eyelid or face, visual disturbances, loss of vision, severe headache, nausea, vomiting. 3.2 History: refer to protocol for History taking and Clinical Documentation. Specific History; Traumatic (direct/indirect), non traumatic Duration of symptoms, time of injury Visual loss, visual disturbances Mechanism of injury - type of exposure e.g. metal, wood, dust, chemical etc. Mechanism of injury - type of impact and force. Known allergens allergic conjunctivitis Headache, photophobia. Nausea/Vomiting Extreme sun exposure (UV sunbeds, skiing) Version 2 (January 2018) Page 1 of 9

2 Recent hammering. Welding, Occupation e.g. plasterer. Past medical eye conditions e.g. iritis, glaucoma Recent illness e.g. shingles. General medical history Medication, including any eye drops Allergies. First aid measures taken e.g. irrigation Patients normal vision, glasses, contact lenses 4. Clinical Examination: 4.1. Test Visual Acuity Test visual acuity of both eyes using Snellen Chart test in accordance to patients sight i.e. if patient wears glasses test with glasses on or use relevant pin hole technique 4.2. Look examination should include eye, eyelids, surrounding orbital area. Where possible examine eye without local anaesthetic. NB where patient is in pain, unable to open eye instil local anaesthetic eye drops oxybuprocaine or proxymetacaine according to Patient Group Direction. Observe eyelids for: redness, inflammation, crusting, cyst, pus filled area, foreign body (NB invert eyelid to complete examination) Observe eye for: redness, haemorrhage, discharge (watery/purulent), conjuntival swelling/cobbling, foreign body, abrasion, rust rings. Observe pupil for: size, shape, reaction, opacity. Hyphema. Observe orbital area for: swelling, oedema, redness, bruising. Repeat corneal (eye) examination using instilled Fluorescein 2% staining to determine presence of corneal abrasions or ulceration Special Tests Visual testing Snellen Chart Check PH of both eyes (normal PH is 7-8) chemical injuries Everting of eyelids observe for sub tarsal foreign bodies or abrasions. Staining of eye observe for uptake of stain. History of trauma and linear line/lines corneal abrasion. No specific history of trauma and uptake of stain dendritic in nature? ulceration refer for review by eye specialists. (eye unit) 5. Treatment 5.1 Viral Conjunctivitis Clinical findings: Thin, watery discharge and minor inflammation Advice: Remove contact lenses if worn until symptoms have completely resolved. Version 2 (January 2018) Page 2 of 9

3 Advise not to share towels, reduce hand/eye contact and wash hands after touching eyes. Over the counter ocular lubricants advised by chemist may be used to reduce discomfort To return or seek further medical advice if discharge becomes muco-purulent and/or inflammation worsens. 5.2 Bacterial Conjunctivitis Clinical Findings: Unilateral or bilateral, with purulent discharge, crusting of eyelashes and pruritus. Treatment & Advice: Infective conjunctivitis is a self-limiting illness that usually settles without treatment within 1-2 weeks. Wash hands regularly, particularly after touching infected discharge and avoid sharing pillows and towels. Remove contact lenses if worn until symptoms and signs of infection have completely resolved. Lubricant eye drops may reduce eye discomfort as available over the counter Treat with Chloramphenicol 0.5% eye drops or 1% ointment as per Patient Group Direction demonstrating application. Advise to clean away infected secretions from each eye (eyelids & lashes) separately with cotton wool/gauze soaked in boiled water. To seek further review if no improvement after 3-4 days or reoccurrence. 5.3 Allergic Conjunctivitis Clinical Findings: Bilaterally intense itch and red eye, clear discharge, pre-existing allergic rhinitis or hay fever, seasonal or perennial or contact with allergen. Swollen conjunctiva (cobblestone appearance) and lid swelling. Treatment and advice: Avoid if possible rubbing eyes Remove contact lenses if worn until symptoms resolve. Place cool compresses on affected eyes to ease symptoms. Give Chlorphenamine tablets as per Patient Group Direction or advise over the counter antihistamines. Where possible avoid exposure to the identified allergen. Where caused by cosmetics, symptoms should be resolved completely before trying an alternative product. Advise patient to seek advice from local chemist regarding over the counter eye drops which may aid recovery reduce discomfort. 5.4 Removal of Foreign body on the surface of the cornea If Foreign body is a chemical base such as plaster/cement check PH of eye. If FB visible remove from eye as below and continue treatment as for chemical injury Gently irrigate eye using 0.9% Sodium Chloride solution from medial to lateral aspect of eye. Remove Foreign body with Moistened swab remember to include everted eyelid. If unable to remove with moistened swab attempt removal with bevel of needle. If unable to remove discuss with ophthalmology. If Foreign body removed check for corneal abrasion using fluorescein eye drops as per Patient Group Direction. Version 2 (January 2018) Page 3 of 9

4 If Corneal abrasion treat as for corneal abrasion. Refer all patients with rust rings to the eye clinic. Advise patients if rust rings appear after discharge following removal of a foreign body to seek further assistance at the eye unit or return. 5.5 Corneal Abrasion Clinical findings: Uptake of stain following abrasion line Give Chloramphenicol eye ointment (or drops) single dose and TTA as per Patient Group Direction demonstrating application. If no improvement to seek further review at Eye unit. Advise over the counter analgesia such as paracetamol for mild eye pain. 5.6 Blepharitis Clinical findings: the margins of the eyelids are red and inflamed and may be crusted. Patients may present with eyelids burning, itching and stuck together. Symptoms are worse in the mornings. Both eyes are infected. Symptoms are often intermittent, with exacerbation and remission over long periods of time Treatment and advise: Advise eye hygiene If condition persists for more than 2 months or is reoccurring advise patient to seek advice from their General Practitioner. 5.7 Stye Clinical Findings: This is an infection around the base of the eye lash in the edge of the eyelid. It causes acute pain and tenderness, often with a yellow point of pus Treatment/Advice: Advise patient to apply a hot compress to the eyelid to encourage the localised selling to burst enabling the pus to drain. A stye should take 5-7 days to heal. 5.8 Meibomian cyst Clinical findings: Is a swelling in the eyelashes but not at the edge of the lid as a stye, may or may not be painful. Treatment/advice: To apply hot compresses and massage area 5.9 Chemical injury/splashes: NB Knowing what the exposure has been caused by is essential to the correct treatment of the injury; Lime based and alkali products are the worst wet plaster being the biggest problem Clinical findings: Exposure to irritant. Severe pain foreign body may be present if cement/plaster. Treatment Check PH of eyes if chemical unknown. Version 2 (January 2018) Page 4 of 9

5 Irrigate eye copiously with mls of sodium chloride solution. Where patient experiences pain instil local anaesthetic drops such as oxybuprocaine or proxymetacaine according to Patient Group Direction prior to irrigation. Repeat PH 10 15minutes later. Continue irrigation until PH returns to normal parameters. Where over 1.5litres of fluid is used and PH remains abnormal refer patient to eye unit for further urgent treatment. If confirmed alkali exposure refer patient to eye unit even if PH returns to normal. Alkali s continue to burn over a period of time. If unsure of chemical base use toxbase or phone poisons direct and follow treatment advice. Refer to Ophthalmology for advice re treatment and follow up/referral. For pepper spray or Police tear gas spray exposure to air is required. Ask patient to remain outdoors of unit. Give analgesia such as paracetamol for pain relief support as per patient group direction. Stronger analgesia is not required as exposure to air will reduce the symptoms of pain. Consider giving Give analgesia as per patient group directions Subconjunctival Haemorrhage Results from bleeding if the conjunctival or episcleral blood vessels into the subconjunctival space Check INR if on warfarin Check BP and history of trauma Treatment Discharge if no trauma/other concerns, otherwise refer to eye clinic Arc Eye History of UV light exposure without protective googles from welding, sunbed use or snowfields. Symptoms: start within 6-12 hours after exposure: may have a gritty sensation, pain or irritation, watering, photophobia and reduced visual acuity. There may be lid swelling and conjunctival redness. Severe cases may have a corneal haze. Treatment: Chloramphenicol as per PGD Advised regular analgesia ( not topical anaesthetic) If severe of concerns seek ophthalmic advice. 6. Documentation 6.1. Clinical records must be written in accordance with Torbay and Southern Devon Health & Care Trust History Taking and Clinical Documentation protocol, Nursing & Midwifery Council guidelines of records and record management (2009) or relevant registering body e.g. Health & care professional Council (HCPC) record keeping guidance. Version 2 (January 2018) Page 5 of 9

6 6.2. A summary letter of the MIU attendance and the care delivered must also be sent to the General practitioner and also health visitor if under 5yrs of age or school nurse if 5 16yrs of age to ensure the central medical record of the patient is accurate For patients being transferred to the Emergency department, ensure clinical records are completed in a timely manner on the shared symphony IT system. A summary letter will be sent to the General practitioner in the normal manner For patients seeing the General practitioner or specialist within the next 24 hours ensure the patient has a copy of the attendance record to take with them. A summary letter will be sent to the General practitioner in the normal manner. 7. Discharge information 7.1 Ensure those patients who have been referred for further acute intervention has appropriate transport to meet their needs, all relevant treatment has been prescribed and/or administered and correct information & documentation is given to the patient. 7.2 The patient /carer understand that if the condition deteriorates or they Have any further concerns to seek medical advice. 7.3 The patient and /or carer demonstrate understanding of advice given during consultation. 7.4 The patient/carer has been provided with written advice leaflet to reinforce advice given during consultation. 7.5 The patient/carer demonstrates and understanding of how to manage 8. Training and implementation: MIU Network meeting Cascade. All staff adhering to protocols must have agreed training and proven competence to work within protocol. Each protocol must be agreed and signed by line manager. 9. Monitoring tool Regular review of clinical practice to ensure individuals are adhering to clinical protocol. 10. References Accident & Emergency, theory into practice. Dolan B, Holt L Acute Medical Emergencies, a nursing guide. Harrison R, Daly L British National Formulary March 2015 British National Formulary for Children 2015 Differential Diagnosis. Rafley, A. Lim, E. 2 nd edition 2005 Guide to physical examination and History Taking. Bickley 2003 Nurse Practitioners, clinical skills & professional issues. Walsh M, Crumbie A, Reveley S NHS Devon Protocol for the management of eye complaints Minor Emergencies Splinters to fractures. Butteovolli P, Stair T 2000 Minor Injuries, A Clinical guide. Purcell D. 2 nd edition 2010 Version 2 (January 2018) Page 6 of 9

7 South & West Devon Joint Formulary Torbay Care Trust protocol for Eyes Version 2 (January 2018) Page 7 of 9

8 OPHTHALMOLOGY TRAIGE Ophthalmology management: A guide for ED Doctors, ENPs and MIUs Diagnosis Treatment Follow up Immediate Referrals: Speak to on call Ophthalmologist via and via switchboard after Chemical Burn Immediate washout, PH check Contact on-call ophthalmologist Globe perforation Systemic antibiotics Contact on-call ophthalmologist Corneal Laceration Acute glaucoma Post op pain/reduced vision / Endophthalmitis Giant Cell Arteritis Check pressures, analgesia, U&Es, IV access FBC, U&Es, LFTs, ESR, CRP, Urine dip, Refer to GCA pathway Contact on-call ophthalmologist Contact on-call ophthalmologist Contact on-call ophthalmologist Refer to medical Registrar on call bleep186 Retinal artery occlusion Consider O2 rebreathing If confirmed diagnosis refer to stroke team Sudden visual loss <6 hrs Orbital cellulitis Check for relevant afferent pupillary defect Sepsis screen, systemic antibiotics Contact on-call ophthalmologist Contact on-call ophthalmologist Appendix 1 For advice during contact on-call Ophthalmologist. During the hours refer to eye clinic and mark as urgent Orbital fracture CT facial bones Refer eye clinic and on-call maxillo- facial surgeon Corneal ulcer Iritis Flashes & floaters (? Retinal detachment) Refer eye clinic- discuss/mark urgent if concerned Refer eye clinic- discuss/mark urgent if concerned Refer eye clinic- discuss/mark urgent if concerned Lid laceration Check globe Refer eye clinic- discuss/mark urgent if concerned Version 2 (January 2018) Page 8 of 9

9 Other common A&E Ophthalmology presentations Arc eye Subtarsal foreign body Corneal abrasion Dentrtic ulcer Conjunctivitis Sub conjunctival haemorrhage Topical chloramphenicol TTA, Analgesia ( not topical anaesthesia) Remove FB Chloramphenicol TTA Chloramphenicol TTA OC Lacrilube Nocte 1/13 Topical Ganciclovir five times daily Swabs, if likely bacterial. chloramphenicol TTA Check INR, BP, History of trauma Discharge Discharge with eye clinic referral if concerned Discharge with eye clinic referral if concerned Refer eye clinic Discharge with eye clinic f/up if concerned Discharge if no Trauma/other concerns Refer eye clinic if concerns Eye clinic appointments bookings should be made through Symphony ENPS and MIU practitioners must only work within their level of competence and within PGD prescribing abilities. Issue Status Date Reason for Change Authorised 1 February 2013 Merger of Torbay Care Trust and NHS Devon Protocols for eyes 1 August 2015 Reviewed no clinical changes Documentation amendments reflect new symphony IT system. 2 Ratified 12 January Revised February 2018 Review date extended from 2 years to 3 years D Molloy D Molloy Care and Clinical Group Clinical Director of Pharmacy Version 2 (January 2018) Page 9 of 9

10 The Mental Capacity Act 2005 The Mental Capacity Act provides a statutory framework for people who lack capacity to make decisions for themselves, or who have capacity and want to make preparations for a time when they lack capacity in the future. It sets out who can take decisions, in which situations, and how they should go about this. It covers a wide range of decision making from health and welfare decisions to finance and property decisions Enshrined in the Mental Capacity Act is the principle that people must be assumed to have capacity unless it is established that they do not. This is an important aspect of law that all health and social care practitioners must implement when proposing to undertake any act in connection with care and treatment that requires consent. In circumstances where there is an element of doubt about a person s ability to make a decision due to an impairment of or disturbance in the functioning of the mind or brain the practitioner must implement the Mental Capacity Act. The legal framework provided by the Mental Capacity Act 2005 is supported by a Code of Practice, which provides guidance and information about how the Act works in practice. The Code of Practice has statutory force which means that health and social care practitioners have a legal duty to have regard to it when working with or caring for adults who may lack capacity to make decisions for themselves. The Act is intended to assist and support people who may lack capacity and to discourage anyone who is involved in caring for someone who lacks capacity from being overly restrictive or controlling. It aims to balance an individual s right to make decisions for themselves with their right to be protected from harm if they lack the capacity to make decisions to protect themselves. (3) All Trust workers can access the Code of Practice, Mental Capacity Act 2005 Policy, Mental Capacity Act 2005 Practice Guidance, information booklets and all assessment, checklists and Independent Mental Capacity Advocate referral forms on icare Infection Control All staff will have access to Infection Control Policies and comply with the standards within them in the work place. All staff will attend Infection Control Training annually as part of their mandatory training programme. The Mental Capacity Act Version 2 (January 2018) Page 1 of 1

11 Rapid (E)quality Impact Assessment (EqIA) (for use when writing policies) Policy Title (and number) Policy Author Version and Date An (e)quality impact assessment is a process designed to ensure that policies do not discriminate or disadvantage people whilst advancing equality. Consider the nature and extent of the impact, not the number of people affected. Who may be affected by this document? Patients/ Service Users Staff Other, please state Could the policy treat people from protected groups less favorably than the general population? PLEASE NOTE: Any Yes answers may trigger a full EIA and must be referred to the equality leads below Age Yes No Gender Reassignment Yes No Sexual Orientation Yes No Race Yes No Disability Yes No Religion/Belief (non) Yes No Gender Yes No Pregnancy/Maternity Yes No Marriage/ Civil Partnership Yes No Is it likely that the policy could affect particular Inclusion Health groups less favourably than Yes No the general population? (substance misuse; teenage mums; carers 1 ; travellers 2 ; homeless 3 ; convictions; social isolation 4 ; refugees) Please provide details for each protected group where you have indicated Yes. VISION AND VALUES: Policies must aim to remove unintentional barriers and promote inclusion Is inclusive language 5 used throughout? Yes No NA Are the services outlined in the policy fully accessible 6? Yes No NA Does the policy encourage individualised and person-centred care? Yes No NA Could there be an adverse impact on an individual s independence or autonomy 7? Yes No NA EXTERNAL FACTORS Is the policy a result of national legislation which cannot be modified in any way? Yes No What is the reason for writing this policy? (Is it a result in a change of legislation/ national research?) Who was consulted when drafting this policy? Patients/ Service Users Trade Unions Protected Groups (including Trust Equality Groups) Staff General Public Other, please state What were the recommendations/suggestions? Does this document require a service redesign or substantial amendments to an existing Yes No process? PLEASE NOTE: Yes may trigger a full EIA, please refer to the equality leads below ACTION PLAN: Please list all actions identified to address any impacts Action Person responsible Completion date AUTHORISATION: By signing below, I confirm that the named person responsible above is aware of the actions assigned to them Name of person completing the form Signature Validated by (line manager) Signature Please contact the Equalities team for guidance: For South Devon & Torbay CCG, please call or marisa.cockfield@nhs.net For Torbay and South Devon NHS Trusts, please call or pfd.sdhct@nhs.net This form should be published with the policy and a signed copy sent to your relevant organisation. Rapid Equality Impact Assessment Version 2 (January 2018) Page 1 of 1

12 Clinical and Non-Clinical Policies New Data Protection Regulation (NDPR) Torbay and South Devon NHS Foundation Trust (TSDFT) has a commitment to ensure that all policies and procedures developed act in accordance with all relevant data protection regulations and guidance. This policy has been designed with the EU New Data Protection Regulation (NDPR) in mind and therefore provides the reader with assurance of effective information governance practice. NDPR intends to strengthen and unify data protection for all persons; consequently, the rights of individuals have changed. It is assured that these rights have been considered throughout the development of this policy. Furthermore, NDPR requires that the Trust is open and transparent with its personal identifiable processing activities and this has a considerable effect on the way TSDFT holds, uses, and shares personal identifiable data. The most effective way of being open is through data mapping. Data mapping for NDPR was initially undertaken in November 2017 and must be completed on a triannual (every 3 years) basis to maintain compliance. This policy supports the data mapping requirement of the NDPR. For more information: Contact the Data Access and Disclosure Office on dataprotection.tsdft@nhs.net, See TSDFT s Data Protection & Access Policy, Visit our GDPR page on ICON. New Data Protection Regulation Version 2 (January 2018) Page 1 of 1