Best Ophthalmology Service Improvement
This honour is designed to recognise improvements in care that have been implemented in eye units to: improve service delivery; save money and minimise the effect of reduced budgets; improve patient experience; improve patients’ quality of life; improve patient outcomes; whilst maintaining or enhancing the quality of patient care provided. Judges looked for evidence or audit results that showed the need for service improvement, the originality of the initiative, the potential for wider application, the size of the benefit achieved, the numbers experiencing this benefit and the cost-savings generated by the initiative.
King’s College Hospital NHS Foundation Trust
MOVES – Multi-disciplinary pathway for Oculomotor and Visual Evaluation in Stroke patients
The acute stroke unit at Denmark Hill treats 1,400 patients every year but did not have a dedicated referral pathway for ophthalmic assessment of stroke patients. This resulted in inequalities of care, with most patients being seen by junior doctors or general ophthalmologists who may not have a particular interest in stroke. In many cases patients waited for several months before assessment, resulting in delays to treatment and rehabilitation.
The team wanted to implement a clear online referral pathway that could be used by any member of the clinical stroke team, with the aim of patients accessing ophthalmic care in the right place at the right time.
The service was developed by Ophthalmologist Jim McHugh and Orthoptist Claire Saha, working with the wider stroke team to gauge interest in the service and develop the clear referral template.
During development of the online referral template the team came up against two main challenges. The first was an IT issue where access to the referral template address was restricted to doctors, and Allied Health Professionals (AHPs) were forced to refer through another channel. This issue came to light when the enquiries-only email was receiving service referrals. The team worked with IT to lift the restrictions on the AHPs who worked with stroke patients, ensuring they could access the tool.
The second was the initial number of inappropriate referrals for clinic-based assessments. Patients who had cognitive or mobility issues were referred to clinic and were unable to complete a full assessment due to these. To address this, the online referral template was modified to include a ward-based assessment request. These patients are now seen by the ophthalmologist, on the ward, outside the clinic time.
The clinic has been running since March 2018 and since the implementation of the clear online referral pathway they have seen:
- Reduced delays in visual problems being recognised and treated – all referrals are seen within a few weeks
- Reduced delays in registration of sight impairment and access to local sensory support team
- The team has also addressed the inequality of care they had previously seen as they now offer the same service to all stroke patients. By providing this service they also increased the potential for rehabilitation by providing accessible information regarding visual status to all members of the stroke team. This process also minimises the need for return trips to the hospital eye clinic to see different members of the eye care team
As an added positive outcome, many patients have been diagnosed with non-stroke related eye problems, which have been referred on to other specialist clinics, preventing visual loss, and a number of patients were identified as not eligible to drive, thus preventing illegal driving and the potential for road traffic accidents.
The team also achieved their goal of treating eligible patients with internet-based eye movement therapy, which has been shown to offer substantial improvements in reading speed, finding objects and avoiding collisions. These therapies are recommended by NICE for stroke patients, but are not routinely offered by orthoptists or ophthalmologists.
Although the service is yet to undergo formal evaluation, informal feedback from their stroke colleagues has been very positive. They conduct regular meetings to re-evaluate the proforma and plan to audit the results of the internet-based therapy on relevant patients.
Why this was chosen
“A much-needed and replicable service improvement that targets a frequently neglected group and has the potential for massive impact, by increasing the detection of visual impairment post-stroke, maximising rehabilitation and minimising unnecessary reviews.”
- Patients benefit from integrated multi-disciplinary pathways to supplement the skills of their primary clinicians
- Allied Health Professionals (AHPs) may be best placed to complete referrals to other specialities
- Patients should be seen before discharge to reduce did not attends
- There is a large burden of visual problems that exist in this group of patients, unrelated to their stroke diagnosis, and timely referral to other specialist clinics can prevent vision loss
- It is important to allow enough time for assessment as this is more time consuming than we anticipated
- This model is applicable to other stroke centres and we plan to roll this out across other sites
South Warwickshire NHS Foundation Trust
Delivering glaucoma services to meet capacity needs using a new model of care
The ophthalmology services at South Warwickshire NHS Foundation Trust serve a population of 300,000. In July 2013 the service was experiencing a lack of capacity to see new glaucoma patients, as the number of new referrals had increased due to changes in NICE guidance, and the continuing use of locum staff had increased the frequency of follow-up requests. This led to the service being placed on the Trust clinical risk register.
The team proposed a triage and referral tier system to increase capacity where specialist consultants saw more complex patients whilst optometrists and ophthalmic technicians saw lower-risk patients.
A glaucoma lead consultant was tasked to review the existing service and develop a plan for improvements. The suggested new model of care included ophthalmic technician-delivered new patient assessment with virtual consultant review; optometry-delivered follow-up care; consultant clinics for new and follow-up complex cases, post-op and laser review; a nurse-led medication clinic and the availability of virtual review for all patients seen by non-medical clinicians as required. A structured competency programme was introduced for the ophthalmic technicians and optometrists involved in the model.
Although the clinical model used is not unique to this Trust, the success of the review, implementation programme and the engagement of all the involved stakeholders has been a significant achievement.
The change in model has achieved an increase in new patient capacity of 65% and increase in follow-up capacity of 55%. The service was removed from the Trust clinical risk registers in May 2018. In addition, the new technician-led referral diagnostic clinics allow false positive referrals to be cancelled. This makes more appropriate use of the medical and optometrist clinical skills in managing those with a confirmed diagnosis.
Why this was chosen
“Capacity is one of the biggest challenges in today’s NHS and the increase in capacity achieved by this service is outstanding. Time was set aside to systematically go through the pathway and set up the service, which isn’t obvious, and the service user involvement was commendable. A best practice worth replicating.”
- Involve all stakeholders at the earliest opportunity during the review and planning process as different perspectives will often identify unforeseen areas for consideration not identified in the original plan
- The implementation of a complete service delivery redesign needs to be phased with clear aims and objectives at each stage. Trying to change too much at any one time could result in disruptions and potentially errors
- Investment in learning and development is essential to embed a positive learning culture and to recruit and retain staff successfully
- Keeping everyone involved and the wider team informed at all stages of the service development is crucial
Moorfields Eye Hospital NHS Foundation Trust
Improving patient accessibility to emergency ophthalmic treatment: Emergency Endophthalmitis Boxes for rapid treatment of endophthalmitis
Performing over 15,000 cataract surgeries and 35,000 injections a year, Moorfields Eye Hospital NHS Foundation Trust requires an efficient system to diagnose and treat endophthalmitis, which may occur after penetrating ocular procedures. European guidelines recommend delivering treatment within one hour of presentation, but an audit found that the time wasted to locate equipment and prepare antibiotics resulted in delays of several hours.
The hub-and-spoke model of care provided by Moorfields, with over 30 satellite sites, meant that standardising an endophthalmitis care package was vital in ensuring all patients received immediate treatment.
The initiative began at the City Road campus where pre-packed endophthalmitis kits containing the equipment required to ‘tap & inject’ the eye were prepared. However, some issues were observed, including confusion around the location of the kits, poor reporting of treated cases and completion of post-procedural paperwork, missing equipment in satellite sites resulting in patients having to be transferred, frequent wastage of antibiotics and confusion around dilution instructions affecting the Trust antimicrobial consumption reporting.
As a result, the antimicrobial pharmacist and A&E fellow discussed with representatives from the different sites how to streamline the process, and came up with a drug inclusive tamper-proof endophthalmitis treatment pack – named the ‘Emergency Endophthalmitis Box (EEB)’. Along with the required equipment and pre-packed antibiotic kits with dilution instructions, the boxes contain supporting materials including detailed instructions on drug dilutions, a flow diagram of the ‘tap & inject’ process, stickers to improve clinical record keeping and prompts to fill in the report form. The reporting system was also updated, so that endophthalmitis cases are now reported electronically.
Audits carried out pre- and post-EEB implementation demonstrated a dramatic reduction in time taken to prepare the antibiotics, tap and inject the eye, from a maximum time recorded pre-EEB of 60 mins, to a minimum time recorded post-EEB of 21 mins.
Simulated scenarios demonstrated time to injection being 73 minutes. To fully evaluate the success of the initiative, the team plan to run similar role plays at various sites and re-audit ‘time taken to injection’ using the final version of the EEB.
Why this was chosen
“While some hospitals already have protocols in place, Emergency Endophthalmitis Boxes with all necessary equipment and medication ready for use are still not standard practice in the UK. An idea worth sharing as this might save patients from sight loss.”
- If planning to implement a significant change, on a large scale, involve all members of the multi-disciplinary team affected, across all satellite sites
- Keep all parties informed at each stage and encourage the expression of opinions and provision of feedback
- Aim to collect information and feedback in good time to prevent project delays