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The demand for eye casualty appointments has been steadily increasing in the UK, leading to pressures on the hospital emergency services. The incidence of presentations to eye casualty services has been estimated at 20-30 per 1000 per year [1].

Evidence from London shows that over a five year period up to 2011, demand at two major eye casualty units increased by 7% and 10% year on year [2]. There is a high rate of non-emergency referrals to the ophthalmic A&E leading to increased waiting times for consultation for patients with real urgent clinical need [3]. Various hospitals are developing strategies to cope with this ever increasing demand to be able to focus on more complex needs. This includes better ophthalmic training for GPs, either as part of the existing training scheme or as part of continued education programmes and introduction of a standard GP referral form with focused questions allowing better triage of these patients on arrival in the A&E department.

Expansion of the role of the casualty nurse specialist to alleviate pressure on this overburdened system has also been tried [3]. The Grampian Eye Health Network and the Welsh PEAR scheme are two good case studies of innovative urgent eye care systems. They both provide urgent triage and treatment for eye conditions in the community where patients and health care professionals are successfully encouraged to view those services as the normal first port of call [4,5].

The Royal College of Ophthalmologists and the College of Optometrists published clinical commissioning guidance on urgent eye care on 25 November 2013. Our study was conducted to appraise Stockport Minor Eye Conditions Service (MECS) run by accredited optometrists based in Stockport. It provides treatment for people with recently occurring minor eye conditions. The service is available to people registered with a Stockport GP. Patients can telephone an approved optometrist directly to make an appointment. On contacting the optometry practice, they are asked questions to assess how quickly they need to be seen by the service. This can range from within 24 hours up to five working days depending on patient symptoms. The aim of our study was to assess whether MECS can reduce the number of non-urgent referrals to the ‘hospital based’ ophthalmology casualty service, enabling effective use of hospital resources. A review of all the patients attending hospital based ophthalmic emergency service, over a five month period, was undertaken following introduction of MECS. All patients seen in the eye casualty during this period were divided into five categories:

Group 1: Sight-threatening eye conditions
Group 2: Painful conditions
Group 3: Conditions which were both painful andsight-threatening
Group 4: Neither of these
Group 5: Others.

It was expected that MECS would serve as a filter to non-urgent conditions presenting to the hospital (Group 4 and 5). Since this service was recent, patient numbers in non-urgent groups were expected to fall over the five month study period.

On evaluation the percentage of non-urgent patients seen in the casualty service stayed nearly the same during the course of the study. No falling trend was noted (Table 1).

 

 

The percentage of non-urgent referrals was 26.5% pre-MECS and 25.2% post introduction of MECS. This difference was not statistically significant (paired T-test, p>0.05).

MECS has over 25 participating optometrists. We do not have the exact figures on the number of patients seen and the number referred on to ophthalmologists by MECS in the assessment period. All the patients included in this study were seen by the ophthalmologist as the first point of care (rather than MECS) and were either referred by the GP, A&E or self-referred.

In summary, the optician led service did not reduce the number of patients attending the hospital eye casualty service at Stockport. This could be due to lack of awareness about the existence of MECS. Being a community based service with shorter waiting times; MECS can provide more patient friendly care. Educating the public and the referring clinicians might help to achieve a shift in urgent eye care from hospital to primary care in the United Kingdom. This will enable ‘hospital based’ eye casualty to remain a genuine emergency service where complex and sight-threatening eye problems can be treated.

 

References

1. Commissioning better eye care. Clinical commissioning guidance from the College of Optometrists and the Royal College of Ophthalmologists.
2. Smith HB, Daniel CS, Verma S. Eye Casualty Services in London. Eye 2013;27(3):320-8.
3. Fenton S, Jackson E, Fenton M. An audit of primary care referrals to the Ophthalmic Accident and Emergency Department of the Royal Victoria Eye and Ear Hospital, Dublin. Royal College of Surgeons in Ireland Student Medical Journal 2010;3:25-8.
4. NHS Scotland (2008) Delivering Better Health, Better Care through Continuous Improvement: Lessons from the National Programmes.
5. Sheen NJ, Fone D, Phillips CJ, Sparrow JM, Pointer JS, Wild JM. Novel optometrist led all Wales primary eye-care services: evaluation of a prospective case series. Br J Ophthalmol 2009;93(4):435-8.


Declaration of Competing Interests: None declared.

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Ritu Chaturvedi

FRCS (Glasg), Manchester Royal Eye Hospital, Oxford Road, Manchester, UK.

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Nikhil Cascone

MD, FEBO, St Thomas Hospital, Leeds, UK.

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Conrad Yuen

MECOphth, FRCSEd, Stepping Hill Hospital, Stockport, UK

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Richard Brown

BSc, DO, MBChb, Stepping Hill Hospital, Stockport, UK.

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