Review of local guidelines Contributes to CQC Fundamental Standard 9, 12

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1 Eye Care for Adults and Children on the Burns ICU (BICU), including eye care techniques Clinical Guideline Register No: Status: Public Developed in response to: Best practice Review of local guidelines Contributes to CQC Fundamental Standard 9, 12 Consulted with Post/Committee/Group Date Teresa Tredoux Lead Nurse, BICU 2016 Niall Martin Consultant Surgeon, BICU 2016 Peter Berry Consultant Anaesthetist, BICU 2016 Ian Stafford Matron, Ophthalmology 2016 Professionally approved by Rebecca Martin Consultant Anaesthetist, BICU 2016 Version Number 1.0 Issuing Directorate Burns and Plastics Ratified by: DRAG Chairmans Action Ratified on: 18 th July 2016 Executive Management Board Sign Off Date August 2016 Implementation Date 26 th July 2016 Next Review Date July 2019 Author/Contact for Information Niall Martin, Consultant Burns Surgeon Policy to be followed by (target staff) Medical and Nursing staff, BICU Distribution Method Intranet, Burns Reference Folder in Metavision (EPR), Staff meetings and Related Trust Policies Infection Control (to be read in conjunction with) Document Review History Version Number Authored/Reviewed by Active Date 1.0 Dr Niall Martin, Consultant Burns Surgeon 26 July

2 INDEX 1. Purpose 2. Equality and Diversity 3. Scope 4. Staffing & Training 6. Infection Control 6. Eye Care in Critically Ill Patients 7. Breach Reporting 8. Audit 9. References Appendix 1 Eye Care Algorithm for Burns ICU Appendix 2 Examination of the eyes using fluorescein Appendix 3 Prevention of conjunctival adhesions Appendix 4 Irrigation of the eyes with Diphoterine solution 2

3 1. Purpose 1.1 The purpose of this clinical guideline is to facilitate optimal protection of the eyes for burn-injured patients and those with medical skin loss conditions to ensure that their future vision is not compromised by their admission to the Burns ICU. 1.2 To provide a clear description of simple eye care techniques, including the lysis of adhesions between the bulbar and palpebral conjunctiva using a glass rod. 2. Equality & Diversity 2.1 The Trust is committed to the provision of a service that is fair, accessible and meets the needs of all individuals. 2.2 An Equality Impact Assessment is not required. 3. Scope 3.1 This clinical guideline is applicable to adults and children admitted to the Burns ICU (E220) with burn injury or medical skin loss conditions. 3.2 Burn-injured patients may have sustained eye damage at the time of their injury but are also at risk of further damage and infections while in a critical care environment. Initial management is focussed on treating the multi-organ dysfunction and profound systemic inflammatory response. Eye care is part of the minimum standard of care for burn-injured patients because missed eye damage can result in permanent disability, including blindness. 3.3 These guidelines are based on current evidence to assist healthcare professionals in their decision making process. 4. Staffing & Training 4.1 This clinical guideline is to be used by all registered medical and nursing personnel working within the Burns ICU that are involved with direct patient care. 4.2 Training will be provided for all staff at induction and refreshed on an annual basis, or as needed if requested by individual members of staff. 4.3 Supplementary teaching and advice can be provided by Matron for Ophthalmology Clinics and Theatres, or a designated representative, for specific patients or the basis of individual staff training needs. 5. Infection Control 5.1 All secretions around the eye represent a potential biohazard. Staff should refer to the Trust Policy for Standard Infection Prevention Precautions and treat all ocular fluids as potentially high risk. 5.2 Routine microbiological samples may be taken by Burns ICU staff but specialist sampling techniques, such as scrapings, must only be performed by an ophthalmologist. 3

4 6. Eye Care in Critically Ill Patients 6.1 Patients on the Burns ICU have a greater risk of ocular complications because they are usually unconscious, sedated and/or paralysed, or have a reduced Glasgow Coma Scale. Alternatively, the risk is conferred by the mechanism of injury, such as flash burn, explosion, or chemical exposure. It may also be conferred in patients with medical skin loss conditions. Patients may also have burns to the eyelids or periorbital skin, which further increases their risk of ocular complications. 6.2 Critically ill patients frequently have poor eyelid closure and a reduced blink reflex that prevents the normal flow of the preocular tear film into the lacrimal sac. The eyelids offer mechanical and physical protection while the tear film is a natural barrier to infection. Corneal exposure results in dry eyes, which increases the risk of corneal keratopathy and epithelial erosion. 6.3 Current evidence suggests that the use of moisture chambers and lubricating ointments (or artificial tears ) effectively reduces dryness and maintains normal tear function. Moisture chambers and hydrogel sheet dressings, such as Geliperm, are used in many ICUs as adjuncts to lubricating drops and ointments. However, in a Burns ICU environment, moisture chambers and hydrogel sheet dressings increase the risk of infection, particularly with Pseudomonas, and must not be used. This is true for all burns and not just those with facial involvement. 6.4 Taping the eyelids shut is another recognised method of maintaining the preocular tear film. Adhesive tape should not be used to close the eyelids because it does not adhere well to burn-injured patients and may cause further damage to the fragile periorbital skin. 6.5 An eye care algorithm is described in Appendix 1. Any patient with facial burns, or a history of explosion, blast or engulfment in flames, exposure to liquid or vaporised chemical agent, or a significant medical skin loss condition, must be considered to have a corneal abrasion until proved otherwise. These patients must be examined using fluorescein. The technique is described in Appendix Any patient with confirmed or suspected corneal injury should be referred for an urgent ophthalmology review. This must be performed as soon as possible because subsequent periorbital oedema will impair the assessment. The management plan must be clearly documented on MetaVision. 6.7 All sedated or paralysed patients, or those with periorbital burns, must have their eyelids closed and simple lubricating ointment applied every 2-4 hours. The technique is described in Appendix 1. Antibiotic ointment should be applied to the eyes for all facial burns but should otherwise only be used in high risk cases after discussion with the ophthalmologists. 6.8 Conjunctival oedema or ventilator eye is caused by positive pressure ventilation, which reduces venous return and ocular tissue blood flow, leading to increased oedema. The incidence can be prevented by checking that endotracheal tube ties are not too tight and that the patient is nursed in a head down position. A number of medications can also exacerbate conjunctival oedema and should be considered if the problem persists. 4

5 6.9 Symblepharon is the partial or complete adhesion of the palpebral conjunctiva of the eyelid to the bulbar conjunctiva of the eyeball. It can be caused by any disease or trauma that causes acute conjunctival injury. Separating the raw surfaces using a glass rod for one to two weeks can prevent adhesions becoming established while re-epithelialisation occurs. The technique is described in Appendix Chemical burns to the eye, especially alkali burns, must be irrigated immediately with Diphoterine solution. Diphoterine solution is an emergency decontamination solution that terminates the chemical process without causing further damage to the tissues. It is not a treatment for confirmed chemical injuries. The technique is described in Appendix Breach Reporting 7.1 A risk event form ( Datix ) should be submitted to the Risk Management Department for non-compliance with this guideline. Any ocular surface complication that arises as a result of iatrogenic injury, or despite following the clinical guideline fully, should be reported using a Datix form for internal investigation. 7.2 The significance of each event will be assessed by the Reporting Officer. Relevant breaches or complications will be escalated to the monthly Burns (or Directorate) Mortality and Morbidity meeting for further discussion. Learning points will be disseminated to the Burns Care Team via an appropriate method. Serious events will also be escalated to the annual Burns Network Audit Meeting for peer review and comment. 7.3 Any events not resolved in this manner will be discussed with senior ophthalmology colleagues for expert advice and learning points disseminated to the team. 8. Audit 8.1 The use of this guideline will be monitored by review of any reported incidents and annual audit. 8.2 Any incidents will be reviewed at the monthly Burns Mortality and Morbidity meeting and the minutes disseminated to the wider Burns Care Team. 9. References Bunker DJ, George RJ, Kleinschmidt A, Kumar RJ, Maitz P. Alkali-related ocular burns: a case series and review. J Burn Care Res. 2014;35(3): Kaufman HE, Thomas EL. Prevention and treatment of symblepharon. Am J Ophthalmol. 1979;88(3): Mahar PD, Wasiak J, Hii B, Cleland H, Watters DA, Gin D, Spinks AB. A systematic review of the management and outcome of toxic epidermal necrolysis treated in burns centres. Burns. 2014;40(7): Radford CF, Rauz S, Williams GP, Saw VP, Dart JK. Incidence, presenting features, and diagnosis of cicatrising conjunctivitis in the UK. Eye (Lond). 2012;26(9):

6 Appendix 1 Eye Care Algorithm for Burns ICU All patients presenting to the Burns Admission Room and then intubated and ventilated in the Burns ICU Examine the eyes carefully Perform a fluorescein stain Examination must include eye movements, pupil reaction to light and visual acuity where possible Consider microbiology swab if needed See Appendix 2 Is there evidence of a corneal abrasion? Yes No No Is the face burned? Yes Apply simple eye drops every 6 hours to both eyes (consider simple eye ointment overnight) Apply chloramphenicol 1% ointment every 6 hours to both eyes (use a separate tube for each eye) Assess eyes daily Refer for urgent ophthalmology review Do the eyelids close? Tarsorraphy, or other protective interventions, may be required within 24 hours of admission No Consider early surgical tarsorraphy and apply eye drops or ointments as directed by burns MDT Yes Apply simple eye drops every 2-3 hours to both eyes (consider simple eye ointment overnight) Refer for routine ophthalmology review Assess eyes at least every 6 hours 6

7 Notes on the use of the Eye Care Algorithm for Burns ICU 1. Application of simple eye drops/ointment 1.1 Simple eye drops/ointment should be administered every six hours to both eyes unless there is an indication to use antimicrobial agents. 1.2 Wash hands and use appropriate personal protective equipment. Use sterile saline solution to clean the periorbital skin and flush the upper and lower eyelids. Gentle traction should be applied to the lower eyelid and 1-2 drops, or a small amount of ointment, should be applied to the conjunctiva (see Diagram 1). The eyelid should be released and both eyelids closed together. Gentle massage of the closed eyelids from medial to lateral helps to spread the agent around the eye. Diagram 1: Application of simple eye drops/ointment 2. Microbiological swabs 2.1 Microbiological swabs of the eyes should not be taken routinely as there is a risk of damage to the conjunctiva if there is no indication for the procedure. 2.2 If there is evidence of gross contamination of the eyes, microbiological swabs should only be performed by the ophthalmologists under direct vision as there is a risk of causing corneal abrasions and scarring if performed incorrectly. 2.3 Microbiological swabs may be taken when pus is visible and can be retrieved easily without risk to the eyes. 7

8 Appendix 2 Examination of the eyes using fluorescein 1. Purpose 1.1 The corneal epithelium is richly innervated with sensory pain fibres so corneal injury is painful. Patients admitted to the Burns ICU may be unable to provide a history of their injury or ocular pain. Examination of the eyes is mandatory for all patients. 1.2 This Appendix describes fluorescein as an adjunct to external eye examination. 2. Corneal abrasions 2.1 Corneal abrasion is probably the most common eye injury but also one of the most neglected. It occurs because of a disruption in the integrity of the corneal epithelium or because the corneal surface has been scraped away or denuded as a result of external physical forces. Fluorescein stains the exposed basement membrane and appears yellow-green when exposed to blue light. 2.2 The prognosis is usually excellent, with prompt treatment resulting in full recovery of vision. However, untreated corneal abrasions can lead to corneal ulcers and blindness. Essentially all corneal ulcers begin with an abrasion. 2.3 Minor corneal abrasions should heal within hours, but extensive or deep abrasions may take more than a week to heal. 3. Equipment 3.1 Minimum equipment includes ophthalmoscope with blue lamp, 10ml sterile saline drops, 0.5ml fluorescein sodium 1% eye drops, and sterile gauze 4. Technique 4.1 Check equipment and ensure it is appropriate to turn off the main lights. Examine the eyes for contact lenses and remove. Do not apply fluorescein without checking as it can permanently stain contact lenses. 4.2 Two drops of fluorescein should be applied to the medial aspect of each eye in turn using the single-dose ocular applicator. Excess fluorescein can be flushed using a couple of drops of sterile saline. The upper eyelid should then be closed and massaged from medial to lateral with minimal pressure to spread the dye over the corneal surface. 4.3 The eye should be examined in a darkened room using an ophthalmoscope with a blue light. Look for yellow-green abrasions on the corneal surface. Evert the eyelid to check for blepharoconjunctival foreign bodies. When a full examination has been completed, flush the eyes with sterile saline. 4.4 Document the location of any abrasions clearly, using diagrams if necessary. If there are any concerns, an urgent referral should be made to the ophthalmologists. 8

9 Appendix 3 Prevention of conjunctival adhesions 1. Purpose 1.1 Large or multiple areas of denuded conjunctiva will form adhesions between themselves, including between the eyelids and the ocular surface. This results in significant morbidity. 1.2 This Appendix describes the use of a glass rod to divide conjunctival adhesions. 2. Palpebral synechiae and symblepharon 2.1 A palpebral synechia is an adhesion between the upper and lower eyelids, whereas symblepharon is the partial or complete adhesion of the palpebral conjunctiva of the eyelid to the bulbar conjunctiva of the eyeball. Both can occur following chemical or thermal burn injuries that result in significant corneal abrasions. They are seen in more than half of severe medical skin loss conditions, such as Stevens-Johnson Syndrome or Toxic Epidermal Necrolysis Syndrome (TENS). 2.2 The prognosis is often satisfactory for thermal burns. However, chemical burns and severe medical skin loss conditions result in abnormal conjunctival keratinisation and corneal scarring with significant visual morbidity, including blindness. The prevention of conjunctival adhesions is an essential part of eye care. 3. Equipment 3.1 Minimum equipment includes a sterile glass rod, 20ml sterile saline drops, topical ophthalmic anaesthetic solution, and sterile gauze. 4. Technique 4.1 Check equipment and ensure that there is adequate lighting. Apply two drops of ophthalmic anaesthetic solution (check pharmacy guidelines) to the medial aspect of the eyes. The upper eyelid should be closed and massaged from medial to lateral with minimal pressure to spread the anaesthetic over the corneal surface. 4.2 Evert the upper eyelid and fully expose the conjunctival surfaces. Examine all areas and consider taking a microbiology swab. 4.3 Apply simple eye ointment and use a glass rod to wipe the exposed surfaces and divide any adhesions between them. Ensure that the rod passes along the full length of the conjunctival folds and that all fibrinous debris is removed. Wipe the rod on sterile gauze between passes to prevent contamination of uninvolved areas. 4.4 Irrigate the eye with sterile saline and re-apply simple eye ointment or antimicrobial eye ointment(s) based on the current prescription. Return the glass rod to the ophthalmology department for sterilisation. 4.5 Document the findings in the medical notes. If there are any concerns, discuss with a burns team consultant and consider an urgent referral to the ophthalmologists. 9

10 Appendix 4 Irrigation of the eye with Diphoterine solution 1. Purpose 1.1 Chemical injuries to the eye must be treated immediately. Most industrial facilities have eye wash stations mandated by Health and Safety risk assessments but many of these only use sterile water. Diphoterine solution may reduce the progression of ocular chemical injuries. 1.2 This Appendix describes the use Diphoterine solution. 2. Chemical eye injuries 2.1 Chemical injuries to the eye are one of the true ophthalmic emergencies. Almost any chemical can cause ocular irritation but strong acidic and basic (alkaline) compounds are especially serious. Bilateral involvement is a devastating injury and every effort must be made to prevent progression of the initial insult. 2.2 The prognosis is determined by the injurious chemical and the efficacy of first aid measures. Permanent visual morbidity is common. 2.3 Diphoterine solution is a Class II medical device specifically designed to reduce ocular injuries from chemical splashes. It should ideally be applied within a minute of the event. However, a second treatment on arrival to the Burns ICU Admissions Room may be appropriate. The solution is not hazardous itself and no special precautions must be taken. 3. Equipment 3.1 Minimum equipment includes 500ml Diphoterine solution and absorbent pads. 4. Technique 4.1 Check solution is in date. 4.2 Open the eyes fully and irrigate directly with 500ml Diphoterine solution. The solution is a washing agent designed for copious volume irrigation of the eyes. 4.3 Document the findings clearly and refer for an urgent ophthalmology review. 10