patient referral pathways [.ppt
Post on 09-Feb-2017
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Patient Referral Pathways
Michael Austin Consultant Ophthalmologist, ABMU Health BoardRachel WhitehallAssistant Director of Planned Care, NHS Wales
Overview
• Diabetic retinopathy• Glaucoma• Unscheduled eye care• ‘wet’ AMD• Cataract• (Children) • (Everything else…)
• Clinical prioritisation & ‘routine new referrals’• Electronic referrals…
http://howis.wales.nhs.uk/deliveryandsupportunit
Sobering thought 1…New patient demand…
is double new patient ‘Dr.’ slots
w/c 30th December 2013
Audit of new patient referrals: Observations
• A pattern emerges…• Not much from GPs (and mainly low priority)• Cataracts & glaucoma largest groups• Many general-type cases• But… other routes of entry for…
– Children/ diabetic retinopathy/ surgical retina– ‘wet’ AMD
Diabetic retinopathy
• DRSSW• 2003 WG initiative• 2006 fully operational and…
– 1.2 million eyes– 29,000 screen positive and referred to HES
• No longer No. 1 cause of sight loss – in working age group– Liew G et al http://bmjopen.bmj.com/content/4/2/e004015.full
Glaucoma
• WECS-EHEW– Fuller clinical data set
• Optic disc stereo biomicroscopy (dilated)• Threshold perimetry • Applanation tonometry (GAT, PAT)
– Better clinical decision making
All Wales Glaucoma Care PathwayGetting referrals right
Patient
Focus On Ophthalmology: Glaucoma – DRAFT 3.3Diagnostics
Referral Form to reflect Guidelines –
NICE
Optometrist
GP
Public Awareness:RNI B Campaign/s e.g.
Glaucoma Week
NICE links
Consultant led MDT
(inc virtual clinic)
Long term monitoring
No abnormality detected
SOS route
Goldmann ApplanationVisual fields as appropriateCorneal thickness disc: slit lamp +/ - dilation
Goldmann Applanation+/ - Visual fields (Humphrey)Corneal thickness disc: slit lamp +/- dilationHRT & digital disc image
Monitor
Referral with refinement / investigations
Community Eye Care Assessment and Treatment
CentreODTC
DU glaucoma audits 2014
• 100% of referrals are direct from optometrists– Except for 2 units (30%, 89%)
• WECS forms largely incomplete (63% average)– But in one HB only 21% were incomplete…
• 6 ODTCs up and running (variable extent)– One HB has 10,000 ODTC appointments per year
• ALL new & approaching half of follow-ups– Poor accommodation– Only 4 virtual clinics
Virtual clinics: Patient satisfaction
• 135 VC patients sent questionnaire• 63% response rate• Mean satisfaction score 4.5 / 5
– Across whole of QUOTE PREM tool• 95% correctly identified glaucoma diagnosis• 96% found the information useful• No inferiority compared with ‘Dr’ clinic
ABMUHB audit data on file
New referrals – VC diagnosisMay – July 2013 Neath Port Talbot N = 56
Glaucoma 6 (‘Dr’ clinic next visit)
NOT Glaucoma 10 (& discharged back to optometrist)
G Suspect – disc 24 (& NICE reviews)
OHT 16 (& NICE reviews +/- treatment)
PDS 1
Narrow angle 6 (‘Dr’ clinic +/- iridotomy)
(Treatment via VC 5)
So how is it going now in my practice?
Not much Dr input required
Unscheduled Eye Care Pathway
Unscheduled eye care
• Many routes into pathway• WECS optometrist = a good place to start
– (rather than GP)– 80% retained
• BUT… red flags = RACE via local triage system– Significant trauma– Sudden visual loss– Sudden onset diplopia
“Red Flags”“Red Flags”
Need to be seen “now”
But not many of them
Other unscheduled eye care
• Won’t die / go blind today…– Significant morbidity possible– And pain
• So… not “Eye Casualty” … but…• R.A.C.E.
– Rapid Access Clinic for Eyes– See patients according to clinical need– Within 1 - 7 daysDU Audits: By and large, patients in RACE needed to be there…
Unscheduled Eye Care Pathway
TRIAGE !
‘wet’ AMD
‘wet’ AMD
• DU audits confirm…• Appropriate referrals• Increasing uptake of standard referral form• MDT working evolving• Issues
– Accommodation, staffing, nurse injectors• Other indications for intravitreal therapy
– Diabetic retinopathy– Retinal vein occlusion
Wales Cataract Pathway
Wales Cataract Pathway:Ophthalmologist input
Swansea Cataract referrals January 2013
• N = 70• VA between 6/12 and 6/60 41• Comorbity = “No” 47• Both of above…
– …& ‘no special refractive issues’, so…• “Direct Access” suitable 32 (46%)
Swansea Cataract referrals January 2013
• “Cataracts Direct” unsuitable 38 (54%)
• Additional reason for referral 4• VA > 6/12
23*• VA < 6/60 5• Fellow eye no cataract & ametropia > 3DS 6• Comorbity = “Yes” 8• Incomplete data 13• THESE NEED SOME OPHTHALMOLOGIST ‘CHAIR TIME’ PRIOR TO CONSENT
(* … more likely to decline offer of surgery following discussion of risk vs benefit)
Direct access patients survey
• Patients having cataract surgery in 2012• Postop • Direct access route• 50 patients’ details from DSU records• Less duplicates• N = 47• Replies = 40 (85%)
Q8. Are you pleased with the result of your cataract operation(s) ?
• YES 38• NO 0 (no response = 2)
Q9. Knowing what you know now… would you go through the experience of a cataract operation with us again?
• YES 38• NO 0 (no response = 2)
47 questionnaires to Direct Access patients, 40 replies (85%)
Q10. Thinking about the visit to the Singleton Hospital Day Surgery Unit preassessment clinic BEFORE the operation (the one where you
were seen by a nurse to discuss the operation and sign the yellow consent form) ...
SA A NSO D SD
A I felt put at ease by the nurse I saw 29 6 1 0 0B I was able to express any concerns 23 9 4 0 0C I felt comfortable to ask questions 27 8 1 0 0D I was given explanations that were helpful 25 10 1 0 0E I was treated with respect and my opinion
was regarded as important 26 8 2 0 0F I had a good enough understanding to go
ahead with the operation 27 8 1 0 0G Overall my experience at the preop cataract
clinic was positive 29 7 0 0 0
Clinical prioritisation & ‘routine new referrals’
Wales Eye Care Plan:• Revise targets for ophthalmology to
incorporate measures for all patients (new and follow-up) that are based on clinical need and risk of irreversible sight loss.
• ‘New Measures” project• BCU & ABMU
• Condition codes• Priority codes P1, P2, P3
– (see next slides)• Patient-specific time to appointment
– New and follow-up patients– Evidence based & audited– Reporting “slippage” as % of intended interval– Instruction in event of CNA/ DNA/ ‘HCNA’
Priority 1
• Patients who may suffer serious irreversible harm from delayed appointments – e.g. wet AMD, diabetic retinopathy – progressing glaucoma– tumour surveillance patients – post-operative patients
Priority 2
• Patients who may suffer reversible harm from delayed appointments– e.g. cataract
Priority 3• Patients who may be inconvenienced or suffer
mild reversible consequences from delayed appointments – e.g. dry eyes, blepharitis, adnexal cysts
Electronic referrals
• OpenEyes EPR• An Eye Care Plan required action• Key trail- blazers installed by April 2015• Health care technology fund grant• Connectivity for community optometry
– NOT a license to swamp consultants’ email– Ground rules required…
Sobering thought 2…90% of FUNB is P1
• N= 156 survey in Singleton adult clinics– Glaucoma pathway patients 68– Diabetic retinopathy 39– Tumours 7– Neuro-ophthalmology 9– 'other miscellaneous P1' 15
• P2 = 11• P3 = 6
"If I had a magic wand"
• EPR to support virtual clinic / shared care• Independent prescribing • Peer support in community optometry• ODTC access for patients throughout Wales• Applanation tonometry & corneal pachymetry
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