Reorganisation of the ophthalmic casualty in a district teaching hospital

Transcription

1 Anju Kadyan MS, FRCS (Ed), DMI, Soupramanien Sandramouli MD, FRCS (Ed), FRCOphth, Peter Caruana FRCS, FRCOphth ABSTRACT Background: The implementation of the European Working Time Directive has impacted upon junior doctor hours leading to greater scrutiny of out-of-hours ophthalmic emergency cover and alternate ways of providing a safe and reliable ophthalmology care. Furthermore, previous research has identified that patients attend A&E ophthalmic services when it might have been more appropriate for them to attend primary care services. Method: A prospective survey of patients attending an ophthalmic casualty was carried out to review the current utilisation of the service and reorganise it based on the findings. Results: Data collection was complete for 81 per cent (1295/1597) of new patients attending the eye casualty over a four-week period. There were 85 per cent (1099/1295) self referrals, 88 per cent of patients (1138/1295) had symptoms of up to one week and only 15 per cent (199/1295) presented out of hours. The number of patients presenting out of hours over the weekend (Saturdays: 23/1295, 1.8 per cent and Sundays: 2/1295, 0.2 per cent) was even lower compared with the weekdays out-of-hours attendance (174/1295, 13.4 per cent). The majority (57 per cent, 738/1295) were minor emergencies and discharged at first attendance by the nurse practitioners alone. Conclusion: In conclusion, out-of-hours ophthalmic casualty service seems to have a limited role and modification of the triage criteria was done to allow an appropriate use of ophthalmic casualty. Key words: Ophthalmic emergencies, triage, nurse practitioner, service reorganisation Journal of ESONT 2007; 1(3): ESONT

2 duration of symptoms, diagnoses and management plan. Out of hours was defined as after 5pm until 9pm. Duration of symptoms on presentation to the eye casualty were classified into six categories: 1- symptoms up to six hours, 2- more than six hours and up to 12 hours, 3- more than 12 hours and up to one day, 4- more than 24 hours and up to 48 hours, 5- more than 48 hours and up to one week, 6- more than one week. Classification into broad diagnostic groups was done based on final diagnosis. These included: trauma, infection, inflammation, ocular surface disease, vascular/ neurology, vitreoretinal, miscellaneous which included cataract, glaucoma, no ocular pathology and others not included in previous groups. Data was analysed using the Microsoft Excel programme. Average number of patients (with standard deviation) presenting to the casualty at different times and in the different diagnostic groups were analysed. RESULTS There were 2546 patient contacts in the study period, 1597 patients were new and 949 patients had review appointments including those arising from prior to the study period. The 1597 new patients were therefore included in the study. Data collection forms were complete for 1295 (81 per cent) patients, making up the study sample. Demographic data The mean age was 45 years (range one month to 93 years, median 45 years) and the male: female ratio was 1.7: 1. The relative proportions of each ethnic group were 85 per cent Caucasians, 13 per cent Asians and two per cent Afro Caribbeans respectively. Some 85 per cent (1099/1295) of patients were self referrals. Other sources of referral were general practitioners (10 per cent), optometrists (2.5 per cent) or other casualty departments (2.5 per cent). Time of presentation The daily new patient attendance rate (+/- SD) in the eye casualty was 50 +/- 14 during this period. There were more patients during the weekdays (daily average: 51 +/- 13) than on the weekend days (Saturday average: 39 +/- 7, Sunday average: 29 +/- 5). The time of presentation of the patients during the casualty opening hours are shown in Figure 1. Some 1096 new patients (85 per cent) presented during the regular hours of 9am to 5pm. Some 199 (15 per cent) patients presented out of hours during the study period. The number of patients presenting out of hours over the weekend was even lower (Saturdays: 23, 1.8 per cent; Sundays: 2/1295, 0.2 per cent), as compared to the average weekdays out-of-hours attendance (174, 13.4 per cent) Duration of symptoms and diagnosis Some 1138 (88 per cent) patients had symptoms for up to a week with 637 (49 per cent) having onset of symptoms for over 24 hours and 1022 (79 per cent) for over 12 hours. Over the weekend, 90 per cent (292/324) of the patients had symptoms for up to a week and those with symptom duration of longer than 24 and 12 hours were 143/324 (44 per cent) and 246/324 (76 per cent) respectively (Table 2). The 10 commonest specific diagnoses, which accounted for 76.6 per cent of the total, were superficial foreign body, conjunctivitis, corneal abrasion, dry eye syndrome, iritis, lid cysts, corneal ulcer/infiltrate, allergic eye disease, chemical injury and blunt trauma. The commonest diagnostic groups were trauma (37.5 per cent), infection (19 per cent), inflammation (17.5 per cent) and ocular surface disorders (14 per cent). Table 3 shows the distribution of the diagnostic groups in all the patients compared to the out-of-hours subgroup. Patients with trauma presented the earliest (76 per cent in <24 hrs), whereas most patients with ocular surface disorders, infection and inflammation had symptoms for longer than 48 hours (58 per cent, 48 per cent and 39 per cent respectively). Management and outcome Some 1027 patients (79 per cent) were managed by nurse practitioners, 81 patients (six per cent) were treated by doctors while 184 patients (14 per cent) were co-managed by nurse practitioners and doctors. Some three patients did not wait for examination after the initial triage, 738 patients (57 per cent) were minor emergencies and discharged at first attendance, 479 patients (37 per cent) had further review appointments in casualty and 11 patients (one per cent) were admitted for immediate management. The remaining 67 patients (five per cent) were redirected for management in outpatient, laser, minor procedures or posterior vitreous detachment clinics. Out of hours There was a higher ratio of males presenting out of hours (male: female ratio 2:1) and the average age was slightly lower at 39 years (range eight months to 81 years, median 41 years). The commonest diagnostic groups in this subset of patients were trauma (55 per cent), infection (18 per cent), inflammation (11 per cent) and ocular surface disorders (7.5 per cent). The distribution of the diagnostic groups is shown in Table 3. Amongst the 199 patients (15 per cent) presenting after 5pm, 190 patients (95.5 per cent) had symptoms for up to one week, while 68 (34.2 per cent) and 116 (58.3 per cent) 10 Journal of ESONT Volume 1 Issue ESONT

3 had complaints for over 24 and 12 hours respectively (Table 2). The duration for presenting symptoms for the patients that present during hours (9am to 5pm) and those presenting out of hours (after 5pm to 9pm) are compared in Figure 2. Some 60 per cent of these patients were discharged while the rest were given review appointments for the casualty, outpatients or special clinics. Some three patients needed admission and urgent treatment on presentation after regular hours. DISCUSSION The demographic profile and spectrum of eye disease in the A&E seen in our study are similar to the other studies (Vernon 1983; Chiapella and Rosenthal 1985; Jones et al 1986; Edwards 1987; Bhopal et al 1993; Fenton et al 2001). Males are more likely to attend than women and the greatest sex difference was found in the trauma group (77 per cent males). Similarly, the highest consultation rates were seen in the middle age group. The disease profile is also similar with trauma being the largest diagnostic group followed by inflammation and minor infection. The demand for out-of-hours emergency care was examined and the number of new patients that registered out of hours was much lower than during the regular hours. Furthermore, over half of these patients were found to have had symptoms for longer than 12 hours with only three patients needing admission and urgent treatment. In conclusion, a dedicated out-of-hours ophthalmic casualty seems to have a limited role and existing service can be modified to provide a casualty service from the main hospital for this period. The other service areas for which recommendations were made following our study included the self referrals, casualty review appointments and the triage guidelines The number of self referrals in our patient group was high as in previous studies (85 per cent versus per cent; Bhopal et al 1993; Fenton et al 2001). This reflects the historic availability of an open access casualty at WEI and to a lesser extent, the unavailability of direct access dedicated eye casualty after hours in surrounding ophthalmic departments. Also a general practitioner referral is mandatory for outpatient clinics, but to attend an emergency department, a referral is recommended but not strictly required and hence self referrals may seek advantage of same day consultation with specialist opinion, bypassing the general practitioner and outpatient clinic waits (Kula- Glasgow et al 1998; Fenton et al 2001). Review appointments seen by nurse and junior doctors are in excess of previously reported studies (37 per cent versus 5-23 per cent), (Edwards 1987; Fenton et al 2001). This may be due to the varied range of experience in acute ophthalmology amongst the junior doctors in casualty (including foundation year two and locum doctors, during the study period) and the lack of supporting care pathways for patient discharge. An effective training and referral chain needs to be developed with appropriate protocols and pathways of care to reduce these overwhelming review appointments in casualty. The management team is already working on this aspect based on our findings. Although our local triage criteria were effective, further revisions of the triage criteria may reduce the unnecessary use of the service without compromising the clinical safety. We revised the triage criteria using the symptom duration and disease severity at first patient contact, with the revised criteria having shortened symptom durations (Table 1A). However, limited literature exists on ophthalmic casualty triage including triage scales, facilities for triage, qualifications and experience of triage personnel, triage standards and guidelines (Sen et al 1999; Goransson et al 2005); and further research in this field is recommended. Based on our findings, the ophthalmic casualty opening hours have now been reduced from 9am to 5pm all days of the week with after-hours cover provided by the on-call doctors following review at the acute hospital A&E. Closure over the weekends is also being considered since our findings indicate suboptimal use of available resources. But this will be done following establishment of an ophthalmic nurse triage infrastructure within the acute hospital A&E during the weekend. A reorganisation of out-of-hours primary care has been shown to influence the utilisation of emergency care and increased utilisation of primary care (van Uden et al 2003). The authors are aware that limiting the eye casualty hours may influence the utilisation of emergency care services by patients with non-urgent health problems after hours. As more information becomes available to the public about how and when to use the services, we expect a shift towards primary care service utilisation for non-urgent care. Future research will be needed to investigate the cost; quality of care and patients' as well as care providers' satisfaction with the reorganised services. Conclusion Reorganisation of the eye casualty needs a critical review of the balance between patient needs and patterns of care to maintain high standards of care in the casualty with limited existing resources and staff. While our findings helped us to reorganise our service as mentioned above, we recommend such a reorganisation to other units only after the respective units have similarly examined the demand for eye care in their casualty as part of the reorganisation process ESONT Journal of ESONT Volume 1 Issue 3 11

4 The role of emergency ophthalmic nurse practitioners in reorganisation of casualty services is significant and should be supported by further development of triage scales with clear standards and guidelines. ACKNOWLEDGEMENTS The article is based on a poster presented at the Royal College of Ophthalmologists Annual Congress 2006, Manchester, UK. It has also been accepted in part for publication in Eye, Scientific Journal of Royal College of Ophthalmologists. Sincere thanks to the Wolverhampton Eye Infirmary A&E staff for their co-operation in the study. REFERENCES: Banerjee S, Beatty S, Tyagi A, Kirkby GR, The role of ophthalmic triage and the nurse practitioner in an eye-dedicated casualty department, Eye; 12: Bhatt R, Sandramouli S, Evidence-based practice in acute ophthalmology, Eye; Apr 28 (Epub ahead of print) Bhopal RS, Parkin DW, Gillie RF, Han KH, Pattern of ophthalmological accidents and emergencies presenting to hospitals, Journal of Epidemiology and Community Health; 47: Sen J, Rao P, Ilango B, The role of ophthalmic triage and the nurse practitioner in an eye-dedicated casualty department, Eye; 13: 812. van Uden CJT, Winkens RAG, Wesseling GJ, Crebolder HFJM, van Schayck CP, Use of out of hours services: a comparison between two organisations, Emergency Medical Journal; 20: Vernon SA, Analysis of all new cases seen in a busy regional centre ophthalmic casualty department during 24-week period, Journal of Royal Society of Medicine; 76: Windle J, Mackway- Jones K, Don't throw triage out with the bathwater, Emergency Medicine Journal; 20: Address for Correspondence: Soupramanien Sandramouli Consultant Ophthalmologist, Wolverhampton and Midland Counties Eye Infirmary, Compton Road, Wolverhampton, West Midlands, WV3 9QR, UK Telephone: Fax: samouli@aol.com Chiapella AP, Rosenthal AR, One year in an eye casualty clinic, British Journal of Ophthalmology; 69: Edwards RS, Ophthalmic emergencies in a district general hospital casualty department, British Journal of Ophthalmology; 71: Ezra DG, Mellington F, Cugnoni H, Westcott M, Reliability of ophthalmic accident and emergency referrals: a new role for the emergency nurse practitioner? Emergency Medicine Journal; 22: Fenton S, Jackson E, Fenton M, An audit of the ophthalmic division of the accident and emergency department of the Royal Victoria Eye and Ear Hospital, Dublin, Irish Medical Journal; 94: Goransson KE, Ehrenberg A, Ehfors M, Triage in emergency departments: national survey, Journal of Clinical Nursing; 14: Jones NP, Hayward JM, Khaw PT, Claoue CM, Elkington AR, Function of an ophthalmic accident and emergency department: results of a six month survey, British Medical Journal; 292: Kirkwood BJ, Pesudovs K, Loh RS, Coster DJ, Implementation and evaluation of an ophthalmic nurse practitioner emergency eye clinic, Clinical and Experimental Ophthalmology; 33: Kulu-Glasgow I, Delnoij D, de Bakker D,1998. Self referral in a gate keeping system: patient's reasons for skipping the general-practitioner, Health Policy; 45: Journal of ESONT Volume 1 Issue ESONT

5 Table 1a: Ophthalmic casualty triage guidelines original and revisions (in parenthesis) 2007 ESONT Journal of ESONT Volume 1 Issue 3 13

6 Table 1b: Vitreoretinal (VR) triage Table 2: Duration of presenting symptoms in relation to the presentation time in eye casualty Table 3: Distribution (percentage) of diagnostic groups in all the patients compared to the out-of-hours subgroup 14 Journal of ESONT Volume 1 Issue ESONT

7 Figure 1: Eye casualty presentation pattern Figure 2: Duration of presenting symptoms in the eye casualty. Symptoms duration categories: 1- up to six hours, 2- >six hours up to 12 hours, 3- >12 hours to one day, 4- >one day and up to two days, 5- > two days to one week, 6- > one week ESONT Journal of ESONT Volume 1 Issue 3 15