With the current global pandemic of COVID-19 we have all had to redesign and reorganise our normal working practices. Non-urgent hospital work has been postponed to allow redistribution of resources, redeployment of hospital staff and to reduce the risk of transmission of the virus to outpatients.
However, patients will still develop sight-threatening eye problems and will need to be seen in the acute eye clinic. Below we outline the approach we have taken to minimise risk to patients but still maintain a safe acute eye service.
Now more than ever appropriate triaging is required. Patients will continue to phone the eye triage nurses and visit their GPs with issues and concerns about their eyes. True eye emergencies of course need to be seen and treated but we are trying to reduce bringing patients, who are often in the vulnerable category, into the hospital when their condition could be managed at home with over-the-counter medication. We have created a secure email address where GPs, opticians and patients can send images to help appropriate triaging. We are also encouraging patients to be seen by opticians in the community who are part of the Acute Community Eye Service (ACES) who can perform full eye exams and initiate treatment when required. Consultants are also involved in triaging acute referrals to reduce unnecessary attendances.
Figure 1: Flow chart for streaming from the emergency department to ophthalmology.
Patients attending the emergency department
Whereas in the past, our colleagues in accident and emergency would initially see and treat patients with eye problems, with their focus on seeing suspected COVID-19 patients, this system has changed also. Figure 1 shows that first COVID-19 symptoms must be excluded even in patients presenting with eye symptoms. Following this, the triage nurses liaise directly with the ophthalmic triage nurse and an outcome generated. Again, if appropriate, patients are directed to the ACES team in the community to reduce potential exposure.
As previously reported, some units are using a telemedicine approach in their clinics. This reduces the duration of time spent in close proximity to patients and hopefully is safer for both parties. The set-up we are employing is similar. The patient is booked in by the receptionists, the clinic structure is explained to them and they are directed to the examination room.
The casualty doctor, who is in an adjacent room, phones the patient and takes a relevant history. The doctor, wearing the personal protective equipment (PPE) advised by the Royal College of Ophthalmologists (scrubs, apron, gloves, surgical mask and eye protection), enters the examination room, carries out a slit-lamp examination and then leaves. From the adjacent room the doctor then phones the patient and explains their findings and the management plan. Once the patient has left, the room is then cleaned by the nurse / healthcare assistant. An informal satisfaction survey collected from patients shows they are happy with this service.
One recurring theme is that the patient feels safer with this method and feel less likely to contract the virus. Despite the reduced face to face time they still feel able to give their history, express their concerns and are appropriately managed.
Patients seen in clinic
As expected, the number of patients seen in clinic is currently greatly reduced. During a two-week period in November 2019, there were 136 referrals into the acute eye clinic and 147 patients seen in the clinic including follow-up patients. During a two-week period in March / April 2020, there were only 67 referrals into the clinic and 80 patients seen in clinic. Another difference is an effort to reduce unnecessary review appointments, with 46% of these patients being discharged, compared to 24% in November 2019. If required, patients are followed-up with telephone consultations or at their optician. As with the November group, the largest subgroup of patients presented with an anterior segment problem, followed by a vitreoretinal problem.
During this time, we have had to change our working practices to reduce the risk of spreading COVID-19 whilst maintaining a safe service. Patients will still develop sight-threatening conditions and need to be reviewed and treated, but hopefully using this approach we can protect both patients and staff.