Agenda - UK Ophthalmology Alliance | UK …...6 Swabs (for prep/drying fingers) 100x100mm 4ply non woven gauze swab 7 Tracer labels Bar coded self-adhesive tracer labels 8 Tape Duo
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Agenda
What is the UKOA andwhy things need to change
Melanie HingoraniConsultant Ophthalmologist, Moorfields,
Chair UKOA
UKOA quarterly meeting 13th March 2019
Why does ophthalmology matter?
• Joint busiest hospital OP specialty (with orthopaedics)
• Commonest operation and 6% of all surgery.
• 20-30% increase activity over last 10 years, expect the same again over next 10 years
and the next 10
• Demographic changes, new treatments, rapidly expanding and technologically
developing area, lots of unmet need in the population
Why does ophthalmology matter?
• Not just minor elective stuff - chronic diseases e.g. AMD, DR, glaucoma -
causes permanent visual loss which can be preventable but requires timely
repeated attendances and interventions e.g. injections
• Sight loss is devastating, reducing independence, affects driving, work,
depression, anxiety, falls, dementia and very costly
Why does ophthalmology matter?
• Not enough doctors
• ~80% units have unfilled or locum-filled consultant posts, >50% have unfilled
SAS posts
• 400 consultants needed to fill current and next 2 year requirements, but only 70
get CCT/CESR per year
• Currently huge capacity and demand mismatch with >200 patients per year
undergoing serious visual loss; 1/5 patients having treatments or clinics cancelled
There are solutions• Work harder, smarter, faster
• Use MDT and non–medical roles better
• Community optometry work preventing referrals or sharing care
• Virtual clinical (telemedicine), AI and automated processes
• Do need more doctors
• National programmes: GIRFT, NECT, Right Care, NCIP
But the “ophthalmic sector” are working in silos – professional,
organisational - we need to work together to find national solutions more
effectively and more rapidly to get where we need to.
We need consistent uptake of best and innovative practice.
UKOA: UK Ophthalmology Alliance
• Started in August 2017 from national vanguard programme
• 20 eye unit founder members
• Covers all UK, with >70 hospital ophthalmology unit members to date and still
growing• Stakeholder members include: RCOphth, RCN, BIOS, CoO, GIRFT, RNIB, IGA, Macular Society,
Vision UK
• Aim for UKOA to include all NHS providers
• Multidisciplinary – patients and charities, clinical all roles, managerial, everyone
• UKOA Board created Summer 2018 to develop strategy and provider leadership
• The UKOA is centrally funded until March 2020 – then may need to be self-funded
• Website: www.uk-oa.co.uk with a private members section where workstream
activity is available.
UKOA Board MembersMelanie Hingorani, Chair
Consultant Ophthalmologist, Moorfields Eye Hospital
Email: m.hingorani@nhs.net
Mary Freeman
Consultant Nurse, Sheffield
Email: mary.freeman@sth.nhs.uk
Penelope Stanford
Lead of RCN Ophthalmic Nursing Forum
Email: penelope.stanford@manchester.ac.uk
Allison Beal
Director of Special Projects, GIRFT
Email: Allisonbeal@nhs.net
Bill Newman
Medical Director Manchester Royal Eye Hospital
Email: William.newman2@mft.nhs.uk
John Ashcroft
CEO, Manchester Royal Eye Hospital
Email: john.ashcroft@mft.nhs.uk
Veronica Greenwood
Chair, British and Irish Orthoptic Society
Email: veronica.greenwood@orthoptics-bios.com
Keith Valentine
Director of Development – RNIB
Email: Keith.Valentine@rnib.org.uk
David Probert
CEO, Moorfields Eye Hospital
Email: d.probert@nhs.net
AimsA whole system alliance which can:
• Provide a forum for regular liaison and discussion on efficiency, quality and other mutual areas of interest between key stakeholders for ophthalmic services
• Join the expertise of clinical professionals with expertise from managers and trust leaders in commissioning, operational management and financial flows in ophthalmology
• Establish quality standards and best practice pathways agreed between all the key professional bodies and providers and patient bodies covering care provided by any ophthalmic professional in any setting
• Support NHS programmes of data and transformation programmes (e.g. GIRFT, Right Care, High Impact Intervention, Model Hospital, NCIP etc) to to be relevant and in use to benchmark and drive up standards
• Provide buddying and support to improve quality and efficiency between providers with good and less good performance in specific areas
• A group with a powerful voice who can negotiate locally and nationally for the benefit of ophthalmology commissioning and resourcing, and champion the specialty.
UKOA Meetings
Sharing Best Practice: Regional sessions• London
• Manchester
• Northwest region - at Blackpool Hospital– EPR/IT and networking
• Southwest region - at Bournemouth NHST
• West of Scotland – at Glasgow
• Others upcoming in Midlands and Yorkshire regions
Quarterly Meetings - national Friends House, London
• Wednesday 13th March
• Wednesday 5th June
• Wednesday 11th September
• Wednesday 4th December
UKOA Update: Stakeholder representationTrying to ensure all the right people can input or hear about crucial national and
regional work impacting ophthalmology:
• NECT/HII (High Impact Intervention) – Elective Care Community of Practice contact by
emailing England.electivecare@nhs.net.
• Right Care – data pack drafted, first stakeholder meeting held 22nd Nov, providers invited,
draft can be shared with UKOA for input
• Model Hospital – feedback on metrics
• NCIP – national clinical improvement programme – consultant level metrics
• HSIB - wrong IOL national investigation
• Industry Vision Group parliamentary round table
• GIRFT – report consultation, implementation support, procurement strategy
• Regional GIRFT meetings – working with regional teams to develop their knowledge of
UKOA and link into trusts to promote involvement
Our Work 3 key strands of work
Data and costs: Procurement• National data is inaccurate and poorly understood by national analysts
• Commercial confidentiality inhibits transparency and comparison
• More accurate data - better analysis of efficiency: costs, productivity
• More clinical input - better understanding quality, safety, ease of use, appropriateness
• UKOA working with the national procurement hub for ophthalmology/GIRFT/NHSI
• Put together:
• Advise providers how their costs and productivity benchmark against others
• Advise providers what are the most cost effective models and suppliers
• Make supplies more consistent for productivity, safety and costs
• Assess supplies vs outcomes
• Drive down costs via bulk purchase or discounts
• Ensure assessment and safety for new devices
Intravitreal injection packs
• Honed down from hundreds to two• Lean, consistent, high quality,
acceptable• Mini-competitive tender with small
number of trusts• Roll out nationally
PictureProduct number
1 Paper wrap Paper crepe wrap minimum 500x500mm
2 Tray
Rigid, solid plastic tray with 2 integrated separate gallipots; minimum
size190x130mm; all dividers are of the same height; depth minimum
30mm
3 SpeculumBarraquer speculum 6mm x18mm (0.8mm thick) polycarbonate solid
curved blades, wire 1mm diameter 30mm wide rounded (non angled) end
4 Calliper/marker
Double ended pointed calliper/scleral marker 3.5/4mm (2 × 0.55mm tips
with 3.5mm Spread/2 × 0.65mm Tips with 4.0mm Spread. Polycarbonate
(clear). 108mm Long or similar
5 Buds Double ended cotton Buds
6 Swabs (for prep/drying fingers) 100x100mm 4ply non woven gauze swab
7 Tracer labels Bar coded self-adhesive tracer labels
8 Tape Duo tape lid/lash tape for eye surgery, 1 strip for lower lid, 1 strip for
upper lid
Product description: IVT Pack Without Drape)
Proposed national intravitreal pack 1
Procurement: IOLs
• IOL quality criteria: expert working group identified and prioritised quality and use criteria for IOLs through evidence review, meetings and a survey
• UKOA examining the list of IOLs in NHS use and how they compare against these criteria
• Analysis of national IOL use and any rationalisation possible• Future work on procurement for quality criteria:
• Posterior capsular rupture• Rates of YAG laser capsulotomy for PCO• Refractive outcomes• Explantation (removal/replacement) rates• Spoilage/wastage during operation• Surgery times/efficiency• PROMs QoL measures• Other postop complications especially inflammatory & cystoid macular oedema.
• How to choose an IOL UKOA handbook• How to procure in ophthalmology
Procurement work – now
• Phaco and other pack and instrument set rationalisation and consistency• Have identified trusts and will work in detail on their spend, benchmarking and
support for improvement• GIRFT implementation – national ophthalmic procurement plan - UKOA is supplying
the clinical engagement, establishing formal group and framework with GIRFT, NHSI, NHS Supply Chain etc
• Safety• Outcomes• Cost• Innovation
Staff and services: Extended roles and advanced practice
• We need to work differently and use the MDT at the top of their skill set• Huge variety in terms of numbers and banding of staff for various roles from
intravitreal injection, minor ops, cataract clinics, consenting etc.• Units are working individually to generate competencies, training, policies,
protocols, audits etc. - duplication and re-inventing the wheel• Sharing of resources and knowledge – lots of documents on website• Developing generic UKOA resources editable for local use
• To fit with College /BIOS OCCCF establishing training nationally
What else can we do? What else should we work on? What are the barriers and how do we address these?
Quality: IOL guideline
Data & Costs: Coding
• National coding workshop held previously
• Working with NHS Digital National Casemix Office, National Clinical Classifications and Coding Support Unit
• Published and on website:• Coding guide for ophthalmology • Detailed coding guidance for cataract surgery
• Next steps:• ICD-11• Other subspecialty areas
UKOA Update: Glaucoma
Based on evidence, and combining successful Manchester, Moorfields
and IGA patient support programmes:
• Improve understanding, compliance and patient engagement and
experience
• Empower staff to support glaucoma patients better
• Demonstrate value and efficiency through research
• Develop glaucoma patient standards
UKOA Update: Glaucoma patient support
UKOA Update: Glaucoma
• Patient info on:
• Disease
• Drops and appliances
• Clinic and practicalities
• Glaucoma standard draft now with IGA for finalisation
• Develop metrics to assess benefit
• Implement in a volunteer unit - resources plus staff and patient training
• Roll out
UKOA Update: Patient Standards• Patient standard published with RNIB
• Good example of co-development with
professionals and patients working together
• Promoted widely and to use as standard for
patient care specific to eye clinics
• Please use as audit standard
• CEOs and clinical leads received, much
interest
• Survey
• Now updating ECLO framework with RNIB
Eyefficiency
• Eyefficiency is a global cataract surgery sustainability project: RCOphth Sustainability Working Group & research funding
• Aims to gather information from units across the world to work out the carbon footprint of cataract surgery around the world.
• NHSI funding to develop NHS version for training and risk/case-mix adjusted time and efficiency benchmarking tool
The next steps
1) Expansion of cataract surgery app
2) Development of an intra-vitreal app and dashboard
3) Development of an online dashboard for analysis and like for like benchmarking, with tips for improvement
• Allows upload from the app• User login to access your own time-and-motion studies• Ability to view i studies benchmarked against national averages and similar units• Ability to filter based on certain features, e.g. training list, lists with complex casemix, lists
with a complication. – compare with similar units.
UKOA
• Bringing everyone together – all disciplines, all sectors• Practical and solution based• Mutual support and learning• Input into national programmes and raise national issues effectively
• Please get involved:• Lead, participate in, and feedback on, the work
• Reply to emails, attend meetings, engage
• Provide key contacts for the key areas of work who will engage and reply
• Identify and put us in touch with staff who may have time to support the work more actively
• Disseminate our work and communications actively, promote and explain the UKOA in your unit
• Use our publications and standards
• Share your pathways, documents, good practice, resources
• Write up your good pathways as “how to” guides with our help
• Consider hosting a regional session
• Suggest or present on topics at our meetings or suggest possible areas of work
Extended role vs. Advanced practice& Indemnity
Connor BeddowClinical Leadership & Sustainability fellow
Moorfields Eye Hospital
John CooperAdvanced Nurse Practitioner
Manchester Royal Eye Hospital
Quarterly Meeting 13th March 2019
Current BIOS recognised extended role/Advanced practice areas:
• Falls
• Glaucoma & Retinal Disease
• Neuro Orthoptics/Neuro Ophthalmology
• Paediatric Ophthalmology
• Low Vision
• Special Educational Needs• Stroke and Neuro Rehab• Vision Screening• Visual Processing Difficulties
Extended roles Advanced/Extended service roles
Extended Roles
• An extended role relates to activities, roles and responsibilities which would usually be carried out by a doctor but which have been delegated to a non-medical health care professional. These roles require additional training and are outside the traditional scope of practice.
• BIOS published standards for extended roles• Sets out professional practice guidelines expected by BIOS
• Expected examination procedures/tests to be carried out
• Management standards
• Methods to monitor the service
• RCOphth- Published CCCF 2016 (currently being updated-release 2019):• Cataract
• Glaucoma
• Medical Retina
• A+E
Advanced Practice• Multi-professional framework for advanced practice in conjunction with HEE:
• Underpinning by masters or equivalent education
• Covers four main pIllars of knowledge/skills:• Clinical practice
• Leadership and management
• Education• Research
Advanced/Extended service roles; these involve enhancing existing knowledge and skills from the core curriculum and may be supplemented by formal qualifications or training. The role itself does not lie outside the traditional scope of core Orthoptic practice.
However definition has been formally laid out by HEE and ACP.
• The ACP framework over in detail the knowledge and skills required to truly work at Advanced clinical level. It does acknowledge that not all professionals with ‘Advanced’ in their title will be at the levels outlined and suggests they be supported to undergo adequate training and development to reach this level.
• The fundamental outcome of working at advanced level is to be able to work autonomously and accept the level of responsibility and risk associated with this.
Extended roles support• Clinical Advisory groups
• Networks which set the direction and support documentation for extended role areas
• Provide clinical guidance as well as:• Education events
• Professional network
• Resources for education and best practice
• Source of senior guidance and leadership in each extended role aea.
Advanced Nurse PracticeInternational Council Nurses (ICN) definition (2008)
“Registered nurse who has acquired the expert knowledge base, complex decision-making skills and clinical competencies for expanded practice, the characteristics of which are shaped by the context or country in which (she/he) is credentialed to practice”.
Key countries: UK, Australia, NZ and Canada
Advanced Nursing Practice• Promote health and well-being
• Implications of social and economic, political context
• Clinical judgement
• Extensive knowledge of diagnostic, therapeutics, pharmacology, biological and epidemiological nursing care
• Consultation and clinical decision-making
• Complex situations
• Manage own work-load
• Improve quality of care/service provision
• Empowerment, ambassador, forefront of practice, innovative care & research
DOH, 2010
Advanced Practice within nursing • Changeable term applied to a number of roles, term ‘advanced’ used in titles
• ANP take responsibility & practice within the Scope of Professional Practice (NMC, 2015)
• Masters Level
• Tasks do not define advanced practice e.g. cannulation
• Working within the four pillars
• Access to an ANP programme, but not necessarily tailored to ophthalmic nursing
• Grading inconsistency
• No requirement to register the qualification. RCN have commenced credentialing (£295), but not statutory ? Drive up and standardise role
• NMC yet to put something in place – accreditation
Advanced Nurse Practitioner• VR/Macular - Macular Injection
• Corneal – Lasix
• EEC/Primary care
• Uvietis – clinic
• Theatre – Assisting surgeon
• Oculoplastic - clinic, surgical role
• Temporal Artery Biopsy
Advanced Nurse Practitioner• Inconsistency across the UK with regard to practice
• Grading variation
• Access to training/courses
• Competency/consistency may vary from area to area
• Some individuals are concerned about advanced practice
• General public and patients also confused
• Research does indication significant impact from ANP practice especially in the acute sector
• Consistency (medical team always rotating)
Group Discussion- 15mins• For the next 10 minutes discuss in groups the following points:• What does extended role mean?
• What roles occur at your unit?
• What cases can be seen by non-medics? Independently? Alongside a consultant?
• We will then go around the room getting feedback from each of the groups. (5mins)
Case scenarios-1• Patient attends eye casualty with:
• erythematous, swollen lids
• General malaise
• High fever and headache
• Is this suitable for any extended/Advanced role practitioner to see?
• Why have you come to your conclusion?
Case scenarios-2• 3yo child attends with FHx of sticklers syndrome (sibling and one
parent)
• Parents feel child not seeing very well, sits v.close to T.V.
• Attend the paediatric Ophthalmology clinic for assessment
• VA on orthoptic exam <6/60 R+L.
• Is this suitable for any extended/Advanced role practitioner to see?• Do you think there is a particular staff group this would be best suited to?
• What models of service delivery might apply to this situation?
Case scenarios-3• 13yo female attends clinic with:
• Recurrent ‘lumps’ in lids-chloramphenicol, fuscidic acid been used multiple times ‘no use’
• Patient has achne and has only recently started getting this problem
• Which staff group would you traditionally assign this patient to?
• Why?
• Are there any limitations to certain staff groups?
Case scenarios-4• 8yo male attends with:
• recurrent headaches• Blurry vision • Nausea• Orthoptic report indicates reduced VA, CV and contrast sensitivity• Recent optometry appointment no refractive error identified.
• Is this suitable for any extended/Advanced role practitioner to see?
• Why/Why not?
• Is any one staff group more suited to this case?
Case scenarios-5 – Discussion points• Theatre scrub nurse requested by the surgeon to indent during
surgical procedure
• ANP to undertake more complex surgical procedures
• Expanding the role of the macular treatment injector
The UKOA Extended Roles SurveyMelanie Hingorani
Consultant Ophthalmologist, Moorfields, Chair UKOA
UKOA quarterly meeting 13th March 2019
Extended roles and advanced practice survey
• Try to get a feel of what is happening now as a baseline for development• Sent out to all hospital unit lead orthoptists by BIOS, follow up reminders by UKOA to members• Electronic survey completion, pdf to collect data first
• How many staff
• Working directly alongside consultant in same clinic (consultant led) or working without consultant rostered to the same
clinic (practitioner led).
• What banding – and only for the sessions (sessional banding) or for the whole week
• Training – local by consultants/local by NMCP ie cascade/CoO diploma or certificate/Univ MsC or similar/other if so what
• Protocol, guideline, policy etc
• Details of formal competency records
• Formal written JDs
• Indemnity – trust, BIOS, other
Extended roles and advanced practice survey
• 34 completed online (1 extra via email)
Consent
• Nurses: 60% yes
• Optoms: 37% yes
• Orthoptists: 37% yes
Cataract preop
Nurses OptomsOrthoptists
~45% units do thisSome have quite a few nursesMixed consultant and practitioner ledBand 5-8 majority band 6No sessional banding
~78% units do thisSome have quite a few optomsMixed consultant and practitioner led mainly consultantBand 6-8 maj band 7No sessional banding
~13% units do thisSmall numbersMixed consultant and practitioner led more consultantBand 6-7No sessional banding
Cataract postop
NursesOptoms
Orthoptists~60% units do thisSmall numbers per unitMajority practitioner ledVast majority B6, minimal B5
~45% units do thisLarger numbers per unitMixture cons & practitioner led more consultantB6-8 vast majority B7
~13% units do thisSmall numbersAll practitioner ledNearly all band 7
Glaucoma
NursesOptoms
Orthoptists~50% units do thisSmall numbers per unitMajority consultant ledB6 and 7
~75% units do thisLarger numbers per unitMixture although more consultant ledB6-8 vast maj B7
~57% units do thisMixed consultant and practitioner led mainly consultantB6-8 maj B7
AMD stable
NursesOptoms
Orthoptists~40% units do thisSome have more numbersMix practitioner & consultant ledB6-8A little sessional banding
~50% units do thisSome have large numbers doingMix practitioner & consultant led mainly consNearly all B7A little sessional banding
~27% units do thisSmall numbersMixed consultant and practitioner B6-8 majority B7No sessional banding
AMD active
NursesOptoms
Orthoptists~50% units do thisSome have bigger numbers per unitMajority consultant ledB6-8 mainly B7Small amount sessional banding
~55% units do thisSome have large numbers per unitMixture, majority consultant ledB6-8 majority B7Small amount sessional banding
~27% units do thisSmall numbersMixed mainly consultantBand 6-8 maj band 7No sessional banding
Uveitis
Nurses OptomsOrthoptists~20% units do this
Small numbers per unitMainly practitioner ledBand 5-8
~10% units do thisSmall numbersMixture cons & practitioner ledB8 only
1 unit do thisAll consultant ledB7-8 majority B7
Corneal
NursesOptoms
Orthoptists~20% units do thisSmall numbers per unitMajority consultant ledMainly B6-8
~25% units do thisMajority consultant ledB7-8
None
Adnexal
NursesOptoms
Orthoptists~30% units do thisSmall numbers per unitMix consultant and practitioner ledMainly B6-8Occ sesssional banding
~10% units do thisSmall numbers Mix consultant and practitioner led more consB6-8 mainly 7
2 units do thispractitioner led onlyB6-8
Postop adnexal
NursesOptoms
Orthoptists~30% units do thisSmall numbers per unitMajority consultant ledMainly B7-8
1 unitMix consultant and practitioner ledB7
1 unit do thisMixed consultant and practitioner ledBand 6No sessional banding
Paeds
NursesOptoms
Orthoptists2 units do thisVert small numbers per unitALL consultant ledB5
>50% units do thisLarger numbers per unitMix consultant and practitioner led more consB6-8, mainly B7-8
~60% units do thisSome have quite a few orthops e eg >10Mixed consultant and practitioner led more practitioner ledB5-8 maj B6-8
Urgent / A&E
NursesOptoms
Orthoptists~40% units do thisBigger numbers per unit e g >10Mixed ledMainly B6-7 range 5-8
~35% units do thisMix consultant and practitioner led more consNearly all B7-8
10% units do thisV small numbersMixed consultant and practitioner ledB6-8
IVI
Nurses OptomsOrthoptists
~68% units do thisBig numbers, some units had >21 nursesMajority practitioner led , still quite a few cons ledNearly all B6-8 mainly B6-7Just under half banded sessionally
~13% units do thisSmall numbers Mainly consultant ledAll B7 not sessional
~30% units do thisMixed consultant and practitioner led more practitionerB6-7 maj B7Min sessional banding
YAG caps
NursesOptoms
Orthoptists~13% units do thisSmall numbers per unitPractitioner ledMainly B7-8
~20% units do thisSmall numbers per unitAll practitioner ledB6-8, mainly 8 2 % units do this
practitioner led onlyB 6
YAG PI
Nurses OptomsOrthoptists
1 unitAll consultant ledB5
~13% units do thisSmall numbers All practitioner ledB7-8
none
Retinal laser
Nurses OptomsOrthoptists
none
1 unitconsultant ledB5
None
Minor ops
NursesOptoms Orthoptists
none~40% units do thisMajority practitioner ledB6-8Small amount sessional banding
none
Botox
NursesOptoms
Orthoptists~45% units do this spasmLarger numbers per unit3% motilityMajority practitioner led except motility consultantB5-8 mainly 6-830% sessional bandingB7-8 for motility
none 20% units for spasm2 units for motilityMixed consultant and practitioner led mainly practitionerMotility cons ledBand 6-8 maj band 7No sessional banding
CXL
Nurses Optoms Orthoptistsnone
~25% units do thisSmall numbers per unitMajority consultant ledB5-8 mainly 6-7
1 unit??
Extended roles and advanced practice survey
• Only 23% have orverarching trust policy• ~50% had documents eg SOP, guideline, policy for their extended practice – this probably means lots
may not• Big areas e.g. cataract, glucoma, IVI did• Areas that did not were less common things ie uveitis, adnexal, also A&E, MEC, lasers, minor ops,
even botox
Training
• Cataract: mainly local consultants or cascade, occ MSc or CoO cert/diploma• Glaucoma: many more MSC or CoO diplomas and certificates• Also AMD slightly less so and paeds slightly less so• Other usually local, some cascade including intravitreal• 73% had recorded competencies of some sort
Discuss!
Extended Role Optometry in Moorfields Glaucoma Service
Julia TheodossiadesLead Optometrist Glaucoma Service Moorfields Eye Hospital
Presentation
1. Overview of Moorfields Glaucoma service
2. Optometrist extended role training and duties
3. Optometrist-led glaucoma and laser clinics
4. Qualifications to support extended role
5. Additional benefits to utilising optometrists
Moorfields Glaucoma service
• 2nd largest service at MEH: fifth total clinical workload
• 110K outpx visits/yr: 50K City Road, 60K outreach
• 29 glaucoma consultants
• 70 glaucoma optometristsoWork 120 sessions /wk across the Trust
oOptometrists have been working in an extended role capacity in glaucoma service for 15+ years
Patient flow
Optometrist-led
Technician-delivered
Consultant-led
Current Optometrist commitment to glaucoma service
70 glaucoma optometrists
• 50 work in consultant-led
• 35 work in optometrist-led
• 2 work in laser clinics performing laser procedures (PI, SLT and YAG capsulotomies)
• 1 about to start virtual reviews
Presentation
1. Overview of Moorfields Glaucoma service
2. Optometrist extended role training and duties
3. Optometrist-led glaucoma and laser clinics
4. Qualifications to support extended role
5. Additional benefits to utilising optometrists
The skills of an optometrist
• On qualifying:• Core optometry skills – refraction, Contact lens practice, low vision assessment• Can perform a range of clinical techniques to detect ocular disease • Familiar with supplementary tests (eg: visual fields, retinal/macula/ONH imaging,
corneal topography)
• On-going experience • Community: Primary care - used to referring pxs HES• HES: Clinical trials, research, audits• HES: other extended role specialties – MR, cataract, EXD, A&E, Paediatrics
• Postgraduate qualifications: MSc, PhD
• Management qualifications
Preparing an Optometrist for Extended Role
Gaining experience: Assessing pxs in clinic with supervision from consultant in consultant-led and lead optometrist in optometrist-led clinics
Higher qualifications: Consolidating, reinforcing and extending specialist knowledge
• Diploma in Independent Prescribing • Higher qualifications in glaucoma leading to Diploma in glaucoma
Following hospital protocols: MEH consultant-led and optometrist-led glaucoma clinic protocols
Attending courses and glaucoma teaching
Optometrist Extended role (1)
Full clinical examination then…..
• Interpret the significance of results – understanding limitations of results including artifact and excluding differential diagnoses
• Differentiate long term fluctuation from a clinically significant change
• Determine working diagnosis
• Make clinical decisions - taking into consideration px hx, risk factors, social circumstances
• Discuss management options with pxs including pros and cons
• Support consent process - discuss procedures and provide info
Optometrist Extended role (2)
• Making partial bookings for surgery
• Safe and effective prescribing – understanding contraindications and side effects
• Decide on appropriate follow up intervals – safe and efficient
• Discharge appropriate pxs eg: low risk OHT and stable OAG suspect
• Evaluate post surgical cases and present to consultant
• Refractive planning for px wishing to have cataract sx
• Give advice and manage some comorbidities eg: OSD, KC
Optometrist Extended role (3)
• Refer to other specialist services
• Give emergency advice to px with AMD, RD hx, previous uveitis
• Communicate with GPs
• Discuss driving standards, CVI and sight registration
• Discuss options for visual improvement – CLs, refraction, low vision aids
Where protocols allow, optometrists often work autonomously, making management decisions independently . But they are also not afraid to ask for advice.
Presentation1. Overview of Moorfields Glaucoma service
2. Optometrist extended role training and duties
3. Optometrist-led glaucoma and laser clinics
4. Qualifications to support extended role
5. Additional benefits to utilising optometrists
Optometrist-led glaucoma service
• First optom-led clinic opened City Road Feb 16 (1 clinic, 2 optomsseeing 16 pxs/wk)
• Audit: ophthalmologists agreed with management (83%) and FU interval (82%) of appts.
• In Nov 17 Sig expansion of optometrist-led glaucoma service o capacity expanded ~12 fold (8 clinics, 32 optoms, up to 200 pxs/wk)
o3 evening ‘education’ clinics for external optoms requiring placements to undertake the extended role training and to train internal new-to glaucoma optometrists
Extended role optometrist-led glaucoma (1)
• No medical supervision in these clinics
• Lead optometrist works autonomously, closely supervising a team of four optometrists
• Optometrists perform the same extended role as in consultant clinic
• Must follow prescriptive hospital approved optometrist-led glaucoma clinic protocol re: when to refer back to cons clinic, when to seek emergency advice, when to discharge
• Support available from consultant clinic for infrequent emergencies
Extended role optometrist-led glaucoma (2)
• Lead optometrist must meet the following criteria:oDiploma in Independent Prescribing
oHigher cert. glaucoma qualification
oMoorfields surgical interventions (tubes and trabs) competency sign off
oWork in a consultant clinic
• Where possible new to-glaucoma optometrists are initially placed in these clinics to gain experience seeing less complex case mix
Extended role optometrist-led glaucoma (3)
Additional extended role duties in an optometrist-led clinic for lead:
• Management of clinic - operational issues and px numbers
• Supervision of junior and placement optometrists (evening clinics)
• Dealing with queries from technician-led clinics
• Dealing with clerical queries
• Dealing with complaints
• Audit
Extended role optometrist-led laser clinic
• 2 optoms – over 11 years laser experience
• 2 laser clinics (St Georges 2006, City Rd 2010)
• SH:1600 procedures over 13 years (Yag capsulotomies, PIs (pre-txArgon + Yag), SLT, iridoplasties, laser suture lysis)
• Training: extended role glaucoma experience, IP + higher glaucoma quals, consultant training, supervision and competency sign off
• Audit 2017: 154 procedures between 11/2012 -1/2016 comparing clinical outcomes of superior vs temporally placed Pis no diff
Presentation1. Overview of Moorfields Glaucoma service
2. Optometrist extended role training and duties
3. Optometrist-led glaucoma and laser clinics
4. Qualifications to support extended role
5. Additional benefits to utilising optometrists
Diploma in Independent prescribing • enables optometrists to clinically assess a patient, establish a
diagnosis, determine the clinical management required and prescribe where necessary
• 3 stage qualification process• Attend a course to learn theoretical component• Undertake a clinical placement• Sit the Therapeutics Common Final Assessment exam
• Usually takes 3 years, P/T study
• Third of content relates to glaucoma
College of Optometrists Higher qualifications in Glaucoma• enable optometrists to take on greater levels of responsibility in
glaucoma clinics
1. Prof Certificate in Glaucoma (Prof Cert Glauc)2. Prof Higher Certificate in Glaucoma (Higher Cert Glauc)3. Prof Diploma in Glaucoma (Dip Glauc)
• Usually 3 years in total, P/T, 10 hrs/wk• Assessed by assignments, case records, written exams, OSCE, vivas
Moorfields Glaucoma optometrists
70 glaucoma optometrists
• 55 have/working towards IP
• 59 prof cert glaucoma
• 39 higher cert. glaucoma
• 10 diploma glaucoma
Presentation1. Overview of Moorfields Glaucoma service
2. Optometrist extended role training and duties
3. Optometrist-led glaucoma and laser clinics
4. Qualifications to support extended role
5. Additional benefits to utilising optometrists
The Value Optometrists Bring • permanent members of clinical team, no rotation
• Understand consultant preferred management
• Familiar with pxs & clinical history –> better patient experience
• Relationships with other specialty clinics running simultaneously
• Don’t mind asking for help (not under same pressures as Drs)
• work in other Moorfields sub-specialties (MR, EXD, UCC +A&E, cataract)• Transferable skills
• Can manage/advise on current best practice for range of comorbidities
• Over 80% glaucoma optometrists work in at least one other specialty
My progress in Glaucoma
Connor BeddowClinical Leadership&Sustainability fellow
Moorfields Eye Hospital
Quarterly Meeting 13th March 2019
Aims
• My journey• Paediatric Ophthalmology• Adult Glaucoma• Paediatric Glaucoma
• Challenges• Training requirements• Current work• Different service delivery models
My Journey
Started 2014
Core Orthoptics/ vision screening
Paediatric Ophthalmology
Glaucoma extended role
Completed higher PGC Glaucoma
2016
Moved trust
1. ‘Stable’ glaucoma2. Paediatric Ophthalmology
3. JIA
Moved trust
Started work in Service
improvement
Paediatric Glaucoma
Paediatric Ophthalmology- First run
• Training and competencies consisted of:• Basic technique training for binocular indirect ophthalmoscopy.
• After hours lectures with consultant ophthalmologist and trainee ophthalmologist on rotation.
• Covered various topics and lasted approx. 1 hour
• Refraction competencies (10 signed off).• Prior training as part of updated undergraduate course
• Supervised practice (indirect) 3 months.
• Case log of 30 patients- Diagnosis+management cross checked and signed off.
• Overall sign off.
Challenges• Learning to think more broadly about patient including general
medical health and not just seeing this as exclusively part of the history.
• Time management• Would often have to switch between Paeds/ophth and Orthoptics within
clinical sessions depending on clinic pressures.
• Quite difficult as the mindset is slightly different for each way of working and enhanced knowledge makes it difficult to pigeon hole patients into different clinic appointments.
• Lack of JD to support work in this area.
Benefits• Added breadth and depth to knowledge.
• Increased critical thinking and improved decision making.
• More complete management of patient, esp. for relatively new Orthoptist.
• Improved Orthoptic knowledge.
• Reduced skill fade and loss of slit lamp/refractive skills.
• Mentally stimulating work.
Glaucoma-Training phase 1• Trained with two glaucoma Ophthalmologists.
• Useful to gain experience in different ways of working.
• Approx 1-2 months of observation (pre-PGC).
• Self directed study.
• Mix of new/FU and post-op patients.
• Clinic 1-2 sessions per week.
Challenges• Due to infrequency of clinic exposure, difficult to get to become
proficient with technical skills particularly in early stages.
• Lack of in-depth theory to support practice.
• Great deal of knowledge to process from varying sources/angles.
• More reliance on ‘new’ technical skills rather than theory, which takes time requires a proficient and consistent trainer, with set regime or schedule of training.
Benefits• Further expansion of knowledgebase and skill mix.• Development of new technical skills.• Development of knowledge of basic vitreoretinal pathology due to co-
morbidities.• Become more accustomed to thinking about systemic disease and the
relevance for ocular disease.• Become more proficient in communication skills due to nature of capacity
and demand as well as counselling patients on importance of treatment.• Continuity of care and building long term rapport with repeat attenders.• Develop more of clinical structure and RTT workload/capacity issues.• Development of good time management skills.
Paediatric Ophthalmology- 2nd run• Developed a Policy and training standards as well as competency
document and squint surgery proforma.
• More self directed/ interesting case record/learning.
• Smaller patient volume- dedicated time to Paeds Ophthalmology only during the entire session.
• Each clinical session started with a mini ‘ward round’, opportunity to discuss cases, tests o be carried out and key point of visit.
Challenges• Designing a paediatric ophthalmology policy and supporting
documents with no national template.
• Lack of known precedent for Orthoptists in paeds/ophth, despite anecdotal evidence of this practice taking place elsewhere in the peninsula area.
• No national clinical advisory group.
Glaucoma 2nd run• Much more intensive timetable- Allowed for rapid acquisition of
technical skills required.
• High case volume also gave greater exposure to theory in practice and allowed collation of knowledge.
• Started initially with 11 patients per day: all required VF, Ant seg, GAT, Post seg. and +/- imaging.
• After 1 month full timetable 13 +/- 1 phaser for half of day.
• Non-EPR site between 16-17 per day. (less broad exam,but higher turnover).
Challenges• Time management.
• Patient expectation.
• Patient wait times.
• Managing co-morbidities and triaging referrals onward to relevant service.
• Patient waitlist risk stratification.
Paediatric Glaucoma• Started January 2019.
• Working under closer supervision than previously (all cases discussed with consultant and 95% have at least F2F discussion with consultant).
• Very different exam to adult glaucoma:• Minimal reliance on VF
• More reliance on IOP
• IOP much more diagnostic in Paeds Glaucoma
• Due to experience with basic techniques and exposure to some diseases which cause paediatric glaucoma, no observation period and started in clinic on first day.
• In view of each exam being discussed and prior competencies for paeds ophthalmology and adult glaucoma no formal competencies as yet.
Paediatric Glaucoma- next steps• Start more structured self-directed study looking at decision trees for
surgical management of glaucoma.
Training and governance• Paeds Ophthalmology
• Covered by Paediatric Ophthalmology extended:• Policy
• Competency document
• Portfolio of common diseases
• Squint consent protocol
• Passed through patient safety board for approval. (18 month process).
• Cases discussed regularly with consultant and started each clinic with mini ‘ward round’ (useful opportunity to discuss cases in clinic and identify own knowledge).
Training and governance• Glaucoma
• Technique based structured training:• Competencies for:
• Anterior segment exam• GAT Intraocular pressure measurements• CCT assessment• Gonioscopy• Van Herick’s method of anterior chamber depth• Visual field interpretation• Disc assessment
• Direct supervision and sign off within set tolerance for examination. Lasted 1-2 months.
• Quality assurance through random audit of 3 patients on a monthly basis.
• Patient satisfaction audits.
• MDT on a 6 weekly basis.
Models of service delivery
Models of service delivery
Overall learning• Need time to train.
• Mix of top-down training and self-directed study.
• Where possible exposure to clinic should be regular and fairly intensive especially in the beginning.
• More than one way to tackle a clinic with an MDT team.
• Ensure governance carried out in several ways and don’t just rely on paper policies, MDT’s and training evenings/ 1 to 1’s invaluable for feeling valued and truly supported as well as fully developing an individuals/teams capabilities.
Take Home messages• Non-medics can do very varied roles.
• Requires robust governance and guidance.
• Rewarding and challenging for non-medics.
• Improved skill mix within department.
• Different ways of working.
Extended Role Optometry in External Disease
Shima ShahPrincipal Optometrist, Contact lens and EXD Lead
Moorfields Eye Hospital
The External Disease (EXD) Service
MEH City Road Campus:14 consultants22 clinics a week
Last year:Follow ups 36,195New patients 6,292Total 42,487
Consultants, junior doctors, nurses, technicians, administrative staff, optometrists
Optometry & EXD
• 149 optometrists • 37 WTE core optometry• 30 WTE in extended roles• 5.3 WTE in EXD service
• External disease extended role optometrists• Consultant led adult clinics (35 optoms in 26 clinics)• Optom led early keratoconus clinics (24 optoms in 8 clinics)• Consultant led paediatric clinics (2 optoms in 2 clinics)• Optom led adult clinics (2 optoms in 2 clinics)• Confocal
Optometry & EXD
Consultant Led External Disease (EXD) Clinics (1/2)
• History, ocular exam, supplementary tests, management plan, discuss with consultant, prescribe, generate GP letter
• Autonomous working - independently manage stable low risk patients pre-defined by a protocol agreed with the EXD service. This requires consultant sign off.
• Visual rehabilitation – advice on spectacles, medical contact lenses, complex prescriptions
• Refractive planning• Minor procedures – punctal plugs, suture removal, swabs, scrapes
Optometry & EXDConsultant Led External Disease (EXD) Clinics (2/2)
• Ocular imaging – performing and interpreting• Prescribing• Know when to refer comorbidity to other sub-specialties• Work in other sub-specialities –helps when managing complex
patients• Stable presence in clinic, do not rotate – know how your consultant
works, able to manage queries, good patient experience
• AUDIT• 93% follow the EXD protocol• 20% could be independently managed
Optometry & EXD
Optometrist Led External Disease (EXD) Clinics
• Work to protocol agreed with the EXD service• Stable, non-complex, follow up patients• Facility to arrange on the day urgent review or rebook into consultant
led if required• Currently 2 optometrist led clinics staffed by senior IP optometrists
with EXD, EKC, contact lens and multiple extended role experience
Optometry & EXDEarly Keratoconus Clinic (EKC)
• NHS CXL approved for use in 2013• All KC monitoring was absorbed by EXD service• Monitoring:
• 6-12 monthly topography scan• Interpretation by a clinician -> large burden on already busy clinics
• EKC is optometrist led service for monitoring• Present day:
• 95%+ of patients with KC now reviewed in EKC rather than EXD• 24 optoms, 5 sites• Virtual clinics….
• Marcello Leucci, Principal Optometrist EKC service
Optometry & EXD
Confocal Microscopy
• In vivo imaging of the microstructure of the cornea• Aids in diagnosis and treatment of microbial keratitis, particularly
fungal and AK
• Support EXD service by acquiring and interpreting scans for patients presenting with complex keratitis
• Requires skill and experience to do well
Optometry & EXDTraining and Supervision
• This sub-speciality covers a wide range of conditions• Is not as prescriptive as others – e.g. injection clinics
• Core optometry experience• Already work in contact lens and/or Early keratoconus (EKC) clinics• Other extended role sub-specialities• Consultant sign off after 12 sessions (or longer if required) • Ideally have Independent prescribing qualification, or are working
towards it
• Local training by EXD consultant, leading to autonomous clinical decision making
Optometry & EXD
Training and Supervision: Independent Prescribing
“Enables optometrists to clinically assess a patient, establish a diagnosis, determine the clinical management required and prescribe where necessary” -- College of Optometrists
• Five universities in UK – distance learning and face to face days• Clinical placement and logbook (24 sessions in UK HES)• Common Final Assessment in Independent Prescribing
Optometry & EXDTraining and Supervision: Independent Prescribing
• Why is this important?• Not just about writing a prescription in clinic!
• IP competency framework (GOC):• Clinical and pharmaceutical knowledge• Establishing options• Communicating with patients• Prescribing safely• Prescribing professionally• Improving prescribing practice• Information in context• The NHS in context• The team and individual context
The role of Optometrists in Urgent Care Clinics
Mr. Nathanael Anguige Principal Optometrist Urgent Care – Moorfields Eye Hospital
BSc (Hons) MCOptom | MSc | Dip TP(IP) | Higher Cert Glauc | PG Cert HCL (Open)
Sharing Best Practice – Scotland
Rationale for clinics
• Difficulty in consistently delivering the national 4 hour A&E target• Increased patient presentations• Increased number of breach days• Increased requirement for extra locum staff in A&E• Repeated audit showed that at least 30% of patients presenting to A&E could be assessed more
appropriately in planned urgent care clinics• Aim to reduce over-running clinics and capacity constraints in the A&E service whilst supporting the daily
achievement of the national standard for A&E attendances• Urgent Care Clinics at Cayton Street were a key initiative to address the highlighted issues
Urgent Care – Cayton Street
• Initial pilot clinic : Clinic 5 Wednesday evenings 2016 – 2017. Patients triaged over from A&E
• Demonstrated clinic safety in the management of patients in a planned and controlled way
• Expanded to daily clinics at Cayton Street – Monday to Friday, morning or afternoon
• 4 Optometrists per clinic – 20 sessions staffed by 18 optometrists
• 1 Consultant / Fellow
• 2 Healthcare Assistants (HCA’s)
• 32 patients per session – reduced profile for medic to answer clinical queries from optometrists
• 160 patients per week triaged out of A&E
• Patients presenting to A&E triaged by nurse / medic
• If deemed non immediate sight-threatening condition patients offered an urgent care appointment, same day if available, otherwise next convenient day within the week
Urgent Care Optometrists
• All optometrists graduate with an undergraduate degree in optometry – minimum 2:2
• Complete hospital or high-street pre-registration year – continual formal assessment by the College of Optometrists. Registered with the General Optical Council (GOC). Approximately 700 newly qualified optometrists annually.
• Once qualified all optometrists meet the standard required to conduct sight tests and fit contact lenses to meet GOC core competencies. This includes:
- Taking an appropriate history
- Detection of any ocular disease or abnormality using direct or indirect methods:
- direct ophthalmoscopy, retinoscopy, binocular indirect ophthalmoscopy (headset / VOLK),
auto-refraction
- Visual field interpretation, pupil abnormalities, binocular vision assessment
- Measurement of IOP using contact and non-contact methods
- OCT, Pentacam, endothelial cell count, and fundus digital imaging and interpretation
- Instillation of cycloplegics, mydriatics, anaesthetics, fluorescein as indicated in patients
Urgent Care Optometrists
• 18 optometrists
• All work in other extended roles at Moorfields
• Bring experience, skills and knowledge of these clinics to urgent care:
- A&E, external disease, glaucoma, medical retina, vitreo-retinal, uveitis, adnexal, contact lenses, adult and paediatric refraction and low vision, paediatric extended role
• Of 18 optometrists - 14 are independent prescribers (IP qualified) therefore able to prescribe any licensed medication for conditions affecting the eye within recognised area of expertise and competence. In addition also become skilled at knowing when not appropriate to prescribe, and what change it is about a condition that warrants a drop to be prescribed
• Optometrists able to perform additional skills such as gonioscopy, scleral indentation, confocal microscopy, naso-lacrimal duct syringing and suture removal. In addition, optometrists can measure as required systemic observations such as blood pressure and blood sugar to aid in diagnosis. Although not trained by urgent care, having skills from elsewhere reduces unnecessary referrals from urgent care on to other services
• Optometrists also familiar with pathways for appropriate referral onwards to other services and ability to traverse the hospital system, clinics, and other protocols
Urgent Care Optometrists
• Optometrists at the hospital are a stable workforce in clinic – no rotation every few months so optometrists
build up a good grounding and understanding of conditions for the clinics they’re employed in
• Optometrists maintain up to date skills and knowledge through continuing education and training (CET) – statutory
requirement of the GOC. Minimum number of points covering a variety of set requirements needed in order to
ensure continued professional registration. Cycle resets every 3 years
• Many optometrists working in the urgent care clinics, have or are studying for Masters degrees, or PhD’s. Also
involved in research and publication of peer-reviewed journals
• Independent prescribing for optometrists – qualification completed in 2- 2½ years
• IP course concentrates solely on the management and treatment of ocular disease, unlike other allied health
professional courses
• Optometrists with this qualification therefore ideally placed to take on extended roles and independent working
Urgent Care Clinics
• Patients are referred as a new patient in to the urgent care service at Cayton Street from A&E.
• Usually have already seen an optometrist outside the hospital – primary care pathway
• Following examination patients are either discharged from the hospital, or referred onwards as a new patient to the appropriate service for further investigation and management as a new patient
• Letter sent out to GP and if appropriate, referring optometrist. Drops prescribed / not prescribed as required
• Most common conditions seen:
- Dry eye (25%), Vitreous Syneresis / Floaters (9%), Cataract (4%)
• Least common conditions seen:
- Disc Pallor (1%), Optic Neuritis (1%), Papilloedema (1%)
• Inappropriate conditions seen:
- Phacomorphic glaucoma, active toxoplasmosis chorioretinitis, carotid cavernous fistula
Urgent Care Clinics
• Audit showed that 100% of conditions are being managed appropriately. 62% of conditions were managed independently by the optometrists, the remaining conditions were managed jointly with the medic in clinic
• 82% of conditions audited as appropriate for the clinic for optometrists to manage independently based on the current protocol
• Improved triaging system now in place
• 100% of optometrists would recommend working in urgent care clinics to their colleagues
• Average urgent care journey time is 75 minutes, rather than in A&E where the average journey time is 140 minutes
• Overall 90% of patients are seen and discharged in under 2 hours from urgent care. No patients have breached the 4 hour A&E national standard
Final thoughts
• UK Population 66 million – approximately 3000 UK ophthalmologists. 14,000 UK optometrists, additional 700 qualifying each year. Are optometrists an under utilised resource?
• Potential for optometrists to become involved in triaging conditions to urgent care?
• Increased number of optometrists working in A&E?
• Consultant optometrist led urgent care clinics?
• Scope for urgent care to accept direct referrals from GP’s or to become involved in local MECS schemes?
• Scope to expand the clinics to provide training for primary care pathway optometrists to reduce number of referrals, and increase management in the primary care pathway?
• Optometrists work to the A&E / General Ophthalmology / Urgent Care protocol – due to be reviewed September 2019. Scope for conditions optometrists can manage independently to be developed?
• QIPP project to improve pathway for flashing lights and floaters
Any questions?
Nathanael Anguige – Principal Optometrist
n.anguige@nhs.net
AMD patient pathway
Adam Mapani Nurse Consultant and Clinical Teaching Fellow
Moorfields Eye Hospital and UCL
Challenges of providing AMD services to improve patient outcomes
NICE = National Institute for Health and Care Excellence.
1. Age-related macular degeneration guidelines for management. Royal College of Ophthalmologists. 2013; 2. Maximising
capacity in AMD services. Royal College of Ophthalmologists, 2013; 3. TA 155 Ranibizumab and pegaptanib for the
treatment of age related macular degeneration. NICE, 2008; 4. Commissioning Contemporary AMD Services. Royal
College of Ophthalmologists. 2007; 5. de Jong PTVM. N Engl J Med. 2006;355:1474–1485.
Patient outcomes
Patient pathway1,2
• Prompt access
• Early diagnosis after
referral
• Assessment and
treatment
• Clinic efficiency
• Good communication
Therapy
• Safety
• Efficacy
• NICE guidelines
• Clinic burden
• Risk of
endophthalmitis3
Cost
• Yearly spend
• Demonstrating value
for money to
commissioning
groups4
Key patient outcomeIf untreated, permanent scarring can occur within months of symptom onset5
Audit and benchmarking
The AMD patient journey
144
Ophthalmoscopy
Visualacuity testing
Fluoresceinangiography (FA)
(as required)
Arrival at
clinic
IndocyanineGreen
Angiography (as required)
GP (via 2-week rapid referral)
Emergency eye department
Optician or optometrist
OCT
145
Traditional Standard ARMD patient pathway
Optometrist
suspects wAMD
– refers to MEH
A+E
A+E Visit:
VA, history, IOP,
Dilate, doctor
review +/- OCT
scan
Usually optom
correctly identifies
wet AMD therefore
A+E doctors refers
to MRE within 1
week.
Medical Retina
Emergency Visit:
VA, history, dilate,
OCT, FFA, Doctor
review, information
to patient +/- same
day injection
If not wAMD then
referred to General
MR ClinicGeneral
MR Clinic
Injection
clinic
One Stop
Model
Current referral to treatment = ~40 days
Nurse led in parallel with treatment clinics Emergency slots for patients presenting acutely
wet AMD in Eye Casualty HCA/Technician standardised assessment
pathway: VA, IOP and pupil dilation Consent, history taking, clinical exam & retinal
imaging analysis by Nurse Practitioner (NP) Decision to treat made by Consultant NP led consent & treatment – 1 stop model
Nurse-led Medical Ret Emergency: Wet ARMD
147
Early diagnosis and treatment of wet AMD may lead to better outcomes1
Error bars indicate confidence limits.
ETDRS = Early Treatment Diabetic Retinopathy Study.
1. Rasmussen A, et al. Acta Ophthalmol. 2015;93:616–620.
Median time to treatment and change in best-corrected visual acuity (BCVA)
score over 3 months of ranibizumab therapy during four separate time periods
Year
Me
an
ch
an
ge
in
BC
VA
(ET
DR
S l
ett
ers
)
Me
dia
n tim
e to
trea
tme
nt (d
ays
)
The application of information technology
• Digital Innovation and patient care pathways
Enhanced digital surveillance service
• Designed as high patient throughput
• Minimal clinician contact
• Maximising capacity
• Technological advances –ophthalmic imaging
150
New Pathway-Direct referral wet ARMD
OCT enhanced /
Assessment clinic:
History, VA, pupils dilated,
colour fundus photographs,
conventional and
angio-OCT scans performed,
explanation and information
provided to patient;
reviewed later by Consultant
nurse or senior
Ophthalmologist or trained
optometrist
Contacted within 2 days
with provisional diagnosis.
wAMD clinic:
History, VA,
pupils dilated,
FFA, doctor
review +/-
same day
injection
General MR
Clinic
Injection
clinic
Same day
treatment
Fast track wAMD
services contacts
patient to make
appointment
Optometrist
suspects wAMD –
electronically
refers to new
‘Fast track wAMD
service’
Proposed referral to treatment <14 days
FFA: Fundus Fluoroscein Angiography; MR: Medical Retina; OCT: Optical Coherence Tomography; VA: Visual Acuity; wAMD: Wet Age-related macular degeneration
151
Benefits
Efficient access to treatment for wet AMD
Better clinical outcomes
Electronic referrals – referral receipt confirmation and audit trail
Appointments – flexibility and convenience to patient
Reduced waiting times in clinics and A&E
Better communication and a stronger partnerships between Optoms, GPs, patients and carers
Pathway for Nurse/Optom-led stable AMD face-to-face clinic
No Injection required
Refer to AMD stable
clinic
Logmar, IOP, Dilation &
OCT
Clinical Exam & OCT Image
Reading
Stable 3/12 Active
retreat 2/52
Enhanced Digital Surveillance stable AMD
VA, IOP, Dilation & OCT
OCT Scans reviewed (2 days later)
Clinical Decision
Stable 3/12 Active retreat 2/52
Reviewing 40 patients per session
Thank you for your attention
Sheffield AMD service and virtual clinics
Mary Freeman – Consultant Nurse; Sheffield Teaching Hospitals NHS foundation Trust
UKOA Quarterly Meeting 13th March
Influencing change - external pressures
• Aging population– ( 65 years + increased from 13% in 1971 to 16% in 2002.and projected to rise to 23% by 2031)
• rising cost of healthcare- Need to provide VFM
• Recruitment challenges and EWTD
• Unmet demand – waiting times for assessment/ intravitreal injections. Overburdened clinics with insufficient capacity result in difficulty in following patients up at the appropriate time determined by their clinical need.
All above resulted in gaps in service provision
“The reality is that increasing demand for eye clinic
appointments comes from patients with chronic eye
diseases, such as macular degeneration, glaucoma and
diabetic eye disease. These patients are the most
vulnerable and at the greatest risk of irreversible loss
of vision. These conditions require long-term ‘return’
or ‘follow-up’ appointments for repeat monitoring and
regular treatment procedures”.
Professor Carrie MacEwen - 16th march 2016 also authored article for BBC’s Scrubbing up
• By 2035 - number of people aged 85 and over will be almost 2.5 times larger than in 2010, reaching 3.5 million and accounting for 5 per cent of the total UK population.
Traditionally health care professionals have individually provided care to patients which reflect their own specialist skills. Sheffield however is an example of how “blurring” professional boundaries has allowed us to deliver more flexible team working.
Underpinning our service: multi-disciplinary team
The team in Sheffield
3 medical consultants
• 1 Nurse consultant (6 session)
• 3 optometrist (p/time)
• 4 Nurse practitioners ( p/time)
• 1 AMD coordinator and 4 clerical officers
• Diabetic eye disease, AMD, VO, DESP
• Photographic team
• Clerical team
AMD Service
Population of approx. 550,000 with drift from surrounding areas such as Rotherham, Barnsley, Doncaster and North Derbyshire.
Standards underpinning the model:
• Rapid access
• 2 weeks from referral to assessment
• 1 week from assessment to treatment
• Expertise in diagnosis and treatment
• Equity of access (eye cas, tertiary referrals from DGHs)
Service Aspirations…
• Baseline stereoscopic fundus fluorescein angiography/ OCT -A
• Optical coherence tomography by trained staff
• Appropriate facilities for IVT injections
• Expertise in the management of AMD/DMO/VO
• Appropriate capacity for monitoring and re treatments
• Timely review and treatment for patients
wAMD Reviews
• 1 stop – Patients requiring regular anti-VEGF therapy: T & E regimen.
- Assessment and treatment on the same day.
• 2 stop – for the more stable patients who are no longer requiring regular Anti-VEGF therapy.
- VA/imaging performed during their visit and findings reported on at a different point in time (virtual reporting).
Injection lists
• 1 Dedicated weekly list for urgent intravitreal injections for AMD, VO and DMO (capacity ≈ 15 pts.)
• 9 Injection lists (up to 16/list ≈ 120 pts./wk.) Used for more stable pts. and for DMO and VO) [ 6 nurses and 1 locum]
• 3 x 1 stop AMD sessions yields ≈ 100 injections
Total injections/wk. ≈ 230/wk. (AMD, DMO, VO)
In summary for the AMD service…In a week;
NEW patients:
• 18 new AMD referrals yield ≈ 6 - 10pts. needing injections. (Added to a dedicated weekly list).
REVIEW patients:
• X 3 One stop sessions- assesses and treats ≈ 110 pts.
• X 4 Two stop clinics with virtual reporting sessions ≈ 60 pts.
• X 9 injection lists (≈ 120 pts.) [AMD, VO, DMO]
NMC position on role boundaries
• The NMC accepts that through meeting post registration education and practice (prep) standards, registered nurses and midwives will develop their knowledge, skills and competence beyond their initial registration throughout their careers.
• For this reason, The NMC does not place any boundaries on the roles of nurses or midwives in relation to the parts of the register and fields of practice.
Masterton suggests that….
• Very few health care tasks and procedures are restricted legally to any one professional group, for it is predominantly custom and practice that link it to any one profession.
• She states that once acquired “skills become commonplace, they become subsumed into nursing practice”... “What was once unthinkable, - nurses carrying out endoscopies, acting as specialists in diverse areas of care such as diabetes, or running their own clinics in acute and primary care is now becoming commonplace”.
Masterton, A. (2002). Cross-boundary working: a macro-political analysis of the impact on professional roles. Journal of Clinical Nursing 11 (3): 331-339
The NMC Code: Standards of conduct, performanceand ethics for nurses and midwives
• Nurses are expected to recognise and work within the limits of their competence
• Complete the necessary training before carrying out a new role
• Ask for help from a suitable qualified and experienced professional to carry out any action or procedure that is beyond the limits of their competence
For New Roles to Succeed…
They:
Needs to happen for the right reasons, not to meet personal aspirations.
• Practice needs to reflect patient needs.
• Not only requires a readiness to cross traditional boundaries in practice but in education too.
• Right environment with an inclusive attitude
Roles need to ….
• Be supported by appropriate level of education, clinical expertise, and support to exercise informed judgement in clinical decisions and prescribing
• Have clear training and development framework
• Have adequate mentorship support
• Be evaluated
Challenges (1)
• Training and education- Specific courses can be difficult to source or prohibitive in cost and in-house courses are often unaccredited. However maintaining and updating knowledge in the field of expertise is vital.
• Measuring effectiveness - notable interest in competence and clinical governance, place a legal obligation on employers to ensure that their employees are “fit for purpose” and competent to carry out the tasks or activities they are undertaking
• A supportive nurturing environment is important in order to ensure success of the post
Challenges (2)
• Collaborative working - new role should be planned and developed collaboratively, involving both nursing/optometry and medical professions and job descriptions need to accurately reflect the role.
• Clinical supervision - opportunities for clinical supervision should be available to debate and discuss practice.
Thank you for listening…
The UKOA Intravitreal PolicyMelanie Hingorani
Consultant Ophthalmologist, Moorfields, Chair UKOA
UKOA quarterly meeting 13th March 2019
Intravitreal injections
• Key area of extended role practice which has expanded enormously and proved highly beneficial – considered a success
• Has kept services going where otherwise would not have coped in many units• Many still exploring or early in the journey• Already many contributions and responses to consultation so near final draft
• Contains:• Policy
• Training details
• Competencies and work place based assessments (WpBA)
• Log book (case) proformas
• Overall sign off document
• Risk assessment
• Outcomes and monitoring
• Reflective practice template
• SOP
Scope of policy
• Relevant for all trusts who have and want to have advanced practitioners• Nurse• Orthoptist• Optometrist
• This document should be used in conjunction with trust’s • consent policy, • clinical governance/risk policy, • local safety standards for invasive procedures• sharps policy• medicines management policy
Who is eligible for training and practice?
To be eligible for undertaking the procedure staff must have a minimum time of 1? 3? years post registration experience and:
• Registered nurse at band 6 or above who must either hold an ophthalmic nursing qualification or have sufficient ophthalmic experience to be judged by their manager and lead retinal nurse/consultant ophthalmologist as competent to commence training can we define this?.
• Registered orthoptist at band 6 or above who has sufficient ophthalmic experience to be judged by their manager and lead retinal nurse/consultant ophthalmologist as competent to commence training
• Registered optometrist at band 6 or above who have sufficient ophthalmic experience to be judged by their manager and lead retinal nurse/consultant ophthalmologist as competent to commence training.
Suitable staff members from a nursing or orthoptic background at band 5 level may commence training for an extended role in botulinum clinics and progress to band 6 on completion of their training.
Responsibilities
• Practitioners responsibilities
• Consultant ophthalmologist’s responsibilities• Delegated trainers: HCP with >2 years’ independent intravitreal injection experience, or a
fellow or ST 6 and above ophthalmic trainee
• The consultant will arrange that they or a suitably other ophthalmologist is immediately available to support the HCP during an intravitreal injection clinic. The doctor should either be present in the clinical area or, if the HCP is competent to manage immediate emergencies (see below), by phone with a pathway in place to see a doctor urgently with the appropriate safe timescale if required, once the HCP has undertaken initial treatment.
• Managers responsibilities
• Employers responsibilities
Baseline competencies
• Slit lamp
• Tonometry
• Assessing patients with ophthalmic conditions
• Handling of medicines, delivering injections
• Basic knowledge of ophthalmic disease
• Consenting
Intravitreal advanced practice training
Combination of following
• Attendance at a recognised external intravitreal training day
• Locally delivered half to one day training course run by local medical retinal consultants and non-medical health care professionals.
• One to one sessions with medical retina consultant to informally cover key knowledge.
• Educational DVD or online video training
• E-learning for health RCOphth approved modules
• Access to wet lab to practice the technique on an artificial eye with saline
HCP will need to know
• Anatomy and physiology of the eye and the retina• Classification of macular disease• OCT images (relevant to macular disease)• Issues around infection control and intravitreal injections• Pharmacology update (to include all drugs administered during
injection visits• Risk and legal issues around extended role development• Latest clinical information on treatment and treatment delivery and
up to date evidence underpinning this practice• How to audit HCP injections• Consenting for intravitreal injections• Process of giving intravitreal injection, including the practicalities• Recognition of complications and what actions to take• Reflective practice
Practical Training details• Observing 20 cases full pathway
• Supervised 20 cases prep patient and room/drugs/equipment with 2 successful WpBA
• Supervised 30-50 cases injection admin with 2 successful WpBA
• Reflective practice
• 1st 3 lists have trainer nearby
• 6 months/100 case audit/review
• Maintain a portfolio for annual review
Outcome measures• Record of all cases to be kept by HCPs
• Regular audit of adherence to protocols and record keeping
• Endophthalmitis rates
• Number of cases presenting as emergencies post injection
• Regular reflective practice
• Any incidents/serious incidents/patient complaints with appropriate reflective practice
• Patient experience/satisfaction survey
• Regular updates of portfolio including outcomes, cases, condition summaries and evidence of reading and learning
Monitoring compliance with policyElement to be
Monitored
Staff conducting Tool for
Monitoring
Frequency Responsible Individual/Group/
Committee for review of
results/report
Responsible individual/ group/
committee for acting on
recommendations/action plan
Service delivery
and unit
outcomes
Lead Retinal
Consultant
Audit Every 12 months Ophthalmic clinical
governance/audit meetings
Ophthalmic or MR clinical lead
HCPs Lead Retinal
Consultant and
Lead Nurse
Audit and patient
satisfaction survey
For the first 100
patients then
annually
Lead Consultant and Lead Nurse Retinal Team
Complications or
adverse events to
be recorded
All staff Incident reporting ongoing Lead consultants
Risk team
Ophthalmology CG
Complaints Complaints team Complaints
process
ongoing Lead consultant Ophthalmology
manager
PALS
Ophthalmology CG
Discuss in groups• Eligibility and banding
• Training
• Other aspects to debate
• Changes you would like to see
• Concerns you have
• Someone keep notes!
Use of advanced and enhanced practice orthoptistsand optometrists in community eye services
Deborah Podmore – Community Eye Service Coordinator Pennine Foundation Trust
Defining community services:
• They are stand alone clinical services delivered in the community
• They are the conduit between primary and secondary care/tertiary care
• They are not primary care
• They are not hospital outreach
StructureService Manager
8a
0.60 wte
Complex children
Orthoptist and deputy
for HMR
Band 7
Lead Specialist
Glaucoma
7
Clinical and
Professional Lead for
orthoptics
8a
0.40wte
Lead specialist
LVA/ALD
7
Deputy and Lead in
SLD/special schools
Bury
Specialist
Optometrist
6
Glaucoma
Assistant 4
Orthoptic Support
Worker 3
Stroke specialist
Orthoptist
6
Paediatric specialist
orthoptist
6
Orthoptic Support
Worker 3
Specialist Orthoptist
LVA
6
Orthoptist Band 5
Consultant
Ophthalmologist
0.10wte
Bury
Specialist
optometrist
7
Orthoptist Band 5
Value for money• That team of only 9.60 wte makes about community 19500 contacts
each year plus providing orthoptic services to the local hospital
• On a combined budget of less than £500,000.
• There are pressures and waiting times are longer than I would like so further investment is needed but nowhere near the expense of the same patients attending the hospital.
Community Glaucoma Service• Established in 2006 as a monitoring service then in 2013 the referral refinement pathway was
added
• Orthoptist/optometrist led and delivered and commissioned by Bury CCG
• Triage
• Referral refinement pathway
• Monitoring pathway
• Ophthalmological opinion accessed either from the community ophthalmologist or from the local hospital as appropriate
Month Total No of referrals Number referred for ↑IOP only Follow up Refer to Mr H Refer to FGH Disch non attendance
Jan-18 32 9 3 5 1
Feb-18 45 5 1 4
Mar-18 58 7 1 5 1
Apr-18 44 5 5
May-18 8 3 1 2
Jun-18 6 4 1 3
Jul-18 10 4 4
Aug-18 6 4 2 2
Sep-18 12 3 2 1
Oct-18 30 9 7 2
Nov-18 22 3 2 1
Dec-18 7 2 2
Totals 280 58 13 41 4
2017 Glaucoma referral outcomes
0
50
100
150
200
250
300
Number of new referrals Number of new referrals tofollow up
Number of new referralsdisharged
Number of new referrals DNA'd Number of new referralsunsuitable
Number of referrals we refer toOphthalmology
Cost efficiency• Staffed by 0.6 Band 7 and 0.7 band 4
• Delivered at two venues
• In 2018 700 patients (new and follow up) were seen in 965 contacts
• Currently 590 open cases
• Staff cost was £50,162
But it’s not all about money• We have had 2 patient complaints in 10 years
• Patient satisfaction is very high 98% of patients attending all of our services would be likely or highly likely to recommend our services to family and friends
• Glaucoma patients often compliment the service
• On telephone satisfaction surveys glaucoma always highly rated
The staff were lovely and put me at ease
straightaway
…was very patient and thoroughIt was so much
better than the (local private)
hospital
Everything was explained to
me…was very well informed as
well as kind
…much easier to get to than the
hospital
Community Low Vision service• Established in 2006
• Orthoptic led by Band 7 orthoptist
• Also delivered by Band 6 orthoptist
• Low vision aids loaned, if broken or lost within 2 years patients may be asked to pay for replacement
• Easy to access service
Working with the 3rd sector• All Certificates of Visual Impairment are registered by the blind
Society as the Local Authority did not have the capacity
• Very close relationship with Bury Blind society
• No ECLO in Bury but the Blind Society take on the role
• Patients are not offered follow up LVA appointments but are referred to Blind Society for guidance and support.
• Any changes in circumstance then the Blind Society will refer the patient back into our service
Quality of life
• Supports return to employment following sight loss
• Ensures patients access useful occupation following sight loss
• Reduces risk of mental health problems following sight loss
Cost effectiveness• Across Bury and HMR the total cost of the service including staff, aids
and overheads is around £80000
• Number of contacts is in the region of 500 per year across the 2 boroughs
• Delivered by 0.6 Band 7 and 0.2 Band 6 currently, in a larger service the band 7 to band 6 ratio could be much improved
Bury only data
Low Vision Aid Servicecurrent under blockBand 7 0.3 15,520Band 6 0.1 4,070Band 3 0.05 1,160Non Pay 7,000Subtotal 27,749Overheads as per current contract 15,304
Total 43,053
The glasses and magnifiers….are
a Godsend
..life is much easier
now
Life is a struggle with AMD many, many thanks for
your help
I followed your advice and was able to make
greetings cards to send at Christmas
The LVA clinic has been a very useful service, especially hand-in-hand with the SNT-V (specialist teachers) who has then provided follow up training for the prescribed equipment.
….she spent a long time finding the best thing for
me and explaining everything
What next?• Develop cross borough services
• Further integration with acute services
• GM pathways ….possible GM services
What would be the benefits• Access to professional leadership for all staff
• Economy of scale
• Safer governance
• Improved cross cover and succession
• Equitable access to safe evidence based care
• Opportunity for career development
Thank you for listeningdeborah.podmore@nhs.net
The Challenges and Success in adult Orthoptic Extended roles in a
DGHSonia MacDiarmid Head Orthoptist
Warrington and Halton NHS Foundation Trust
UKOA Quarterly Meeting 13th March
Background• 2 Boroughs – Warrington and
Halton
• Population over 350,000
• 6 Consultants
• 4 Associate Specialists
• 12.85 wte Orthoptists
• 4.56 wte Optometrists
• 19 Qualified nurses
Local challenges
• Workforce issues:
Recruitment of medical staff –vacancies
Reduced number of training posts
Retention of trained non medical practitioners
High number of medical staff close to retirement
• Financial pressures
• Limited investment
• CQC - Requires improvement
• Increasing population ( >65y 22% increase in 10 years)
• Old age dependency ratio rapidly
Facing the challenges• Whole team approach – MDT
• Strategic plan - developing Orthoptic extended roles
• Developing innovative ways of utilising staff
• Approval of business cases
• Utilised funding – external training course
• Development of local competencies and training with Consultants
• Advice and guidance from BIOS
Clinical Advisory Groups
Extended roles
Glaucoma virtual review
IVT injectionBT injection
BlephrospasmNeuro-
ophthalmology
Glaucoma virtual review
Success
• Successful internal training
• Masters module
• Multidisciplinary team approach
• +560 reviews per month
• Regular MDT and training
Process
• Orthoptic assistants/HCA’s diagnostic testing
• Risk stratification tool used by sister in charge to determine:
White fields – virtual completed by non medical staff (orthop and optom)
Moderate fields – experienced orthop/optom
Black fields - Consultant or Principal optom
Glaucoma virtual review
• Challenges
• High expectation for number of reviews per session
• Ensuring good governance
• Meeting the demand
• Timely virtual review
• Dual system EPR and medical records
Intravitreal injections • Internal training
• Development of internal wet lab training courses
• Nursing and orthoptist injectors
• MDT approach
• Av 300 injections per month
• Cost saving
• Increased productivity and efficiency
Intravitreal injections
• Retention of trained staff
• Time taken to be competent
• Banding levels
• Rising demand levels – stress to staff/safety concern
• Lack of capacity
Neuro – ophthalmology
• Different model of care
• Stable neuro- ophthalmology patients (IIH, pituitary tumours)
• Internal and external training
• Continual learning
• Work shadow – Neurologists, neurosurgeons
• Robust patient pathways
• Pathway for escalation
• Excellent feedback
Neuro – ophthalmology
• Assessment of visual function • Ocular motility• Interpretation of visual fields and
disc OCT• BMI measured• Weight loss information provided• Referral pathways to:Local healthy living programmesCBTDieteticsDetailed report
Botulinum toxin injections – Blephrospasm
• Local training and competency
• LocSipp
• Alter dose and site if required
• Consultant consents for “longterm course” of BT
• Releases valuable Consultant time
• BIOS Indemnity insurance
Locssips
Intravitreal Injection LOCSIPP- Ophthalmology
SIGN IN
Initiated by Clinician/Practitioner undertaking the procedure TIME OUT
Initiated by Clinician/Practitioner undertaking the procedure
SIGN OUT
Initiated by Clinician/Practitioner undertaking the procedure Prior to incision/ checked by nurse on admission After prepping & draping, prior to incision Prior to Clinician undertaking the procedure leaving the location
VERIFICATION STEPS SPOKEN OUT LOUD FOR ALL TEAM MEMBERS TO REVIEW: Document Yes /No/NA
TEAM MEMBERS PRESENT VERIFY 1. Patient identification
(to include the patient as per SOP)
(minimum 2 identifiers: Name & date of birth, +/- Hospital number)
2. Procedure site/side checked:
(to include the patient as per the SOP)
with consent form, marking verification form and site marked
3. Known allergies - example Latex/Iodine
4. Significant co morbidities or any changes to recent health
ALL TEAM MEMBERS 1. Introduce themselves by name and role if
not already done so at list briefing
2. Patients’ name, DOB and hospital number with ID band ( to include the patient as per the SOP)
CLINCIAN/PRACTITIONER UNDERTAKING THE PROCEDURE VERIFIES
3. Known allergies - example Latex/Iodine/egg
4. Procedure/Site/Side & Position confirmed 5. Site marking visible (IVT to include A, L, E) 6. Anticipated risks/Duration 7. Sufficient clinic information is available to
proceed with procedure 8. Consent matches planned procedure site 9. Sterility confirmed 10. Check phakic or pseudophakic eye
STOP! Any questions from the team?
CLINICIAN/PRACTITIONER VERIFIES 1. Name of procedure to be recorded in notes and
Medisoft, as appropriate
ASSISTING CLINICIAN/SCRUB PRACTITIONER VERIFIES
2. Final counts (safe disposal of sharps) 3. Any equipment problems to be addressed
END OF PROCEDURE DEBRIEF WITH ALL MEMBERS 4. Any concerns throughout duration of procedure
(As per SOP) 5. Issue of post-operative drops with instructions
for use issued
Signed
Signed
Signed
Name/Designation/Date
Name/Designation/Date
Name/Designation/Date
Comments:
Name of procedure: Comments:
Comments:
(Apply addressograph label or write)
First Name
Surname
Date of Birth
Hospital Number
NHS Number
Advanced Orthoptic Roles
• Variety of advanced clinical roles
• Experts in the clinical areas
• Roles that have not previously been done by an Ophthalmologist
• Prevents referral to Consultants
• Timely assessment and treatment
• Care closer to home
• Stoke
• Special Educational needs
• Visual processing
Clinical governance
Safe Effective Caring Responsive Well led
0 - never events0 - Direct complaints
Clinical audit MECC –Signposting patients to appropriate services
Redesigningclinical role to meet the demand of services
Training for staff
Culture to report incidents
Patientfeedback
Continuity of care Breaking down traditional barriers
Policies/SOP’s
LocSSIPs Service user feedback
LD/Dementia alert system
PGD’s Local competency
BIOS Indemnity insurance
Fit for purpose Job descriptions
Pathways for escalation of clinical concerns
Risks effectively monitored
Areas for future Orthoptic extended roles at Warrington
• Conduct a training needs analysis
• Delegated consent for Orthoptists for BT
• 1st post op strabismus
• 1st assistant in theatre – impact on trainees
• New adult ocular motility - virtual review
• Orthoptic led glaucoma patient information groups/clinic
• Glaucoma assessment
• Paediatrics
JIA
CVI Clinics
Lumps and bumps
Real benefits of extended roles in DGH• Orthoptists - highly skilled workforce
• Releasing Consultant time
• Delivering productivity
• True multidisciplinary working
• Added value of Orthoptists – high quality, safe care
• Meeting rising demand
• Bridging the gap of a reducing medical workforce/reduced no. trainees
• Improving efficiency
• Research and clinical audit
Summary
• Pressure facing the smaller hospitals
• Utilising staff innovatively to break down barriers
• Added value
• Maintaining high quality, safe care
• Thank you
• Sonia.macdiarmid@nhs.net
Paediatric Ophthalmology Policy
Connor BeddowClinical Leadership& Sustainability Fellow
Quarterly meeting 13th March 2019
Aims
• Outline of policy and reason for policy
• Structure and framework of policy
• Areas currently covered
• Areas to be covered
• Discussion and review of policy
• Feedback
Outline• Policy developed to provide a framework for non-medical Ophthalmic
professionals working in extended or advanced practice roles in paediatric Ophthalmology
• Designed to be applicable across non-medical workforce boundaries, regardless of background.
• Competencies and training framework designed to produce a bespoke portfolio style of knowledge and skills and can be extensive or specific depending on service requirements.
• Consists of:• Main policy document• Competency document• WpBA templates
Main Polcy• Outlines
• Scope, entry requirements, training and monitoring etc
• Policy covers two categories of disease profiles/patients:• High risk- Must be discussed and or seen by consultant
• Low risk- May be discussed or seen independently
• Training requirements• Core competency (baseline levels)
• Additional competence• Self directed study- portfolio
• Observational training
• Log book
• Completion of 2 WpBA’s
Main Policy• High risk are those patients deemed to have a potentially life or sight
threatening disease or who may have rapid deterioration in their disease without careful monitoring.
• Decided to give clear sub-division to caseload to reduce ambiguity for non-medical staff on what they need to discuss and clarify some of the governance around different cases.
• Help ‘new starters’ differentiate high and low risk and aid them in management decisions.
• To make training more structured and targeted.
• Allows individuals to tailor training depending on what level of involvement they want within the paedsophth service.
Training regime• Consists of 5 parts:
• Core upskilling competence work
• Observational practice
• Theory portfolio- Low risk disease profiles
• Case-log
• Successful completion of 2 WpBA’s
Core competence/Observational practice• Core:
• Due to varying skills and knowledgebase of differing non-medicals decided there should be guidance on baseline competence.
• Intended to create equity in skillset before commencement of extended/advanced skills and theory
• If classed as core competence as part of undergraduate or post graduate (ophthalmic nurse certificate) no need to revisit this.
• Observational:• Intended to give ‘new starters’ idea of clinic structure/flow and become familiar with way of
working as well as taster to see if it is for them.
• For experienced clinicians transferring useful to understand structure of clinic and understand the admin associated with clinic.
Theory Portfolio• Basic 1 page A4 covering
• Signs/Sympt
• Management
• Red flags
• To be produced for low risk diseases to provide quality assurance of knowledgebase and also to frame discussion with senior clinicians/trainers on areas for improvement.
• Reduces amount of time spent in observational stage and provides clear evidence for own CPD/portfolio.
WpBAs• HCP to nominate patient cases prior to commencement of of
assessment can be done as:• Disease specific
• Generic WpBA
• Level of detail depends on level of involvement in clinic and level of autonomy to be afforded to non-medic.
• HCP must successfully complete (pass) 2 WpBA’s in order to be passed off as competent in a given area.
Training regime WpBAs
Task• 10mins
• Read over Policy and in sub-groups discuss the policy and record views on the following:
• Positive aspects of policy
• Areas for development
• Any comments or feedback generally on the policy• Would it work in your area
• Would you like to see any additional content
• 5mins-Feedback from each sub-group on main points to share with the whole group
Crossing boundariesPrimary and secondary care providers in the
cataract pathway
Rachel Thomas, Lead Optometrist, Moorfields at Bedford
UKOA Quarterly Meeting 13th March
• Working with primary eye care providers to run safe and efficient cataract schemes
• The lessons we have learnt.
Why work with Community Optometrists?
• Out-number consultant ophthalmologists 10:1
• Readily accessible to patients in community setting at convenient times
• Often have a good relationship with the patient already
• Have the core skills required to manage basic eye disease
Why work with Community Optometrists?
• Out-number consultant ophthalmologists 10:1
• Readily accessible to patients in community setting at convenient times
• Often have a good relationship with the patient already
• Have the core skills required to manage basic eye disease
Majority of our referrals come from Optometrists
We need to work together to make them better
• Using the right skill set
And
• Developing a level of trust
To relieve our capacity problems in the HES
To do this we need to
• Communicate / review / feedback
Why the cataract pathway?
• MECS / Repeat measures …. / others….
• Cataract patients – straightforward referral pathway
• Straightforward to risk stratify once we have the correct information
• ALL Optometrists have the core skills needed to assess patient signs and symptoms
First things first
Improving relationships and communication with community optometry
• Clinical feedback
• Referral guidelines
• Referral helpline
• General support and feedback on quality of referrals
• Offer regular training sessions and invited to clinics
• Enabled an understanding of the capacity and demand problems we are experiencing
• Understanding when and how to refer
• What sub-specialties are available and how to access them• Pathway into the acute clinic
• Pathway into intravitreal service
• Etc etc
The cataract pilot scheme• Training and accreditation
• Two sessions in clinic and theatre
• Routine post-op patients
Then
• Low risk pre-op patients
Pre-op data collection
• Pre-op forms
• Forced choice to ensure appropriate risk factors are documented
The pre-op form…..
Scrutiny of each referral = individual feedback provided as required.
Now• All Bedfordshire optometrist practices have at least one accredited
optometrist (>80 Optometrists participating in the pathway)
• Annual reaccreditation event • Accept attendance at Addenbrookes or Potters Bar events• CET evening which includes feedback for any complications etc
• Invite new optometrists to come in for a session in an optometrist led cataract clinic – more if they would like and include a talk on identifying risk factors
• Audit Data (2018)
• 2103 Cataract Procedures
• Refractive data for 85+% of our cataract patients
• Intraoperative complication• PCR 1%
• Postoperative complications• CMO 1.9%• Raised IOP 1.7%• Corneal oedema 2.14%• Post op uveitis 0.95%
Exclusion criteria?
• Why?
• Would we do it differently?
Extended role optometry team• Communication, communication, communication
• Liaison between primary care provider and surgeons
• Training to enable a deeper understanding of the risk factors and implications of identified risk factors to ensure correct information is passed onto patient during consenting
• Guarded prognosis - the importance of knowing what else is going on• Risk of intra / post operative complications and how this changes related to the risk factors• Protocols and guidelines in place
• All extended role optoms have undertaken in-house consent training
• Run low risk optometry-led cataract clinics
Any questions?
Cataract extended role UKOA policy
Tina Khanam, Fellow/ST7, Moorfields
Scope of policy
• Relevant for all trusts who have and want to have advanced practitioners• Nurse• Orthoptist• Optometrist
• This document should be used in conjunction with trust’s • consent policy, • clinical governance/risk policy, • local safety standards for invasive procedures, • preoperative assessment policy
Responsibilities
• Practitioners responsibilities
• Consultant ophthalmologist’s responsibilities
• Managers responsibilities
• Employers responsibilities
Who is eligible for training?
To be eligible for delivering this care staff must have a minimum of 1 years post registration hospital ophthalmic experience and be:
• Registered nurse (RN) at band 6 or above who must either hold an ophthalmic nursing qualification or have sufficient ophthalmic experience to be judged by their manager as competent to commence training.
• Registered orthoptist at band 6 or above who has sufficient ophthalmic experience to be judged by their manager as competent to commence training
• Registered optometrist at band 6 or above who have sufficient ophthalmic experience to be judged by their manager as competent to commence training.
Suitable staff members from a nursing or orthoptic background at band 5 level may commence training for an extended role in paediatric ophthalmology and progress to band 6 on completion of their training.
Training
• Baseline competencies for training
• Cataract advanced practice training
• Frequency of practice
• Outcome measures
Baseline competencies
• Slit lamp
• Tonometry
• Slit lamp fundoscopy with fundus lens
• Understanding refractive errors and refractive correction
• Basic knowledge of cataract and ophthalmic disease
• Consenting
Cataract advanced practice training
Combination of following
• Local, regional and national courses
• Informal in house training or sessions with consultant or other trainer
• Additional reading around subject area in books or journals
• Reading of local and national cataract care guidelines
• E-learning modules
Training details• Observing and when ready to progress -
• Supervised 20 cases
• Reflective practice
• 2 Work place based assessments for preop and for postop each
• Attend 2 surgical sessions
• Low risk versus high risk cases
• Maintain a portfolio
HCP will need to knowAnatomy and physiology of the eye Causes and classification of cataract
Assessment of cataract and other ocular and systemic disease
Knowledge of refraction, refractive errors and refractive targets in cataract surgery
Biometry, choosing an IOL, avoiding wrong IOLs Imaging (A scan, B scan, OCT) relevant to cataract related conditions and comorbidities
Principles of cataract surgery Ocular and systemic and personal risk factors for surgery and how to risk stratify cataract surgery
Latest clinical information on cataract surgery and treatment delivery
Anaesthetic types, risk and benefits, anaesthetic choices for cataract surgery
Process of cataract surgery, including the practicalities, the pathway, the on the day journey
Infection control for cataract surgery
Any CCG thresholds for surgery Pharmacology to include relevant drugs to assess, during and following cataract surgery, drugs that affect cataract surgery
Recognition of intraoperative and postoperative complications and what actions to take
Is aware of any possible red flags and how to escalate concerns
Risk and legal issues around extended role development
How to audit NMP practice
Outcome measures• Record of all cases to be kept by HCPs
• Regular audit of adherence to protocols
• Regular reflective practice
• Any incidents/serious incidents/patient complaints with appropriate reflective practice
• Patient experience/satisfaction survey
• Regular updates of portfolio including outcomes, cases, condition summaries and evidence of reading and learning
Monitoring compliance with policy
• Service delivery and unit outcomes via audits
• HCP appraisal/performance review
• Complications via incident report
• Complaints
• Further details in clinical policy
Acknowledgements
• Special thanks to Melanie Hingorani
• Moorfields cataract extended role policy document (particular thanks to Aneel Suri)
• Various other trust cataract extended role policy documents (e.g. Northwest Anglia, Bedford)
ROLE OF THE NAMED NURSE IN THE CATARACT PATHWAY
Sinead Metcalfe Staff Nurse CTC
Dianne Hurcombe Dept Manager CTC
Tina Morrell Directorate Manager
Cataract Pathway• One stop Clinic:
-Registered Nurse will assess medical/ophthalmic history.
-Visual acuity.
-IOP measurement, Biometry.
-Basic Observations.
-Assess for topical/injection/sedation.
-Dilate.
Advantages of one-stop clinic• Single pre-op visit.
• Patient preferences addressed when booking surgery appointment.
• Patient leaves department with Surgery date and Post-Operative appointment in Plan of Care Booklet.
• Reduction in FTA rate.
• Cost saving as it reduces number of OP appointments.
Benefits of Registered Nurse• Awareness of RTT – 18 week pathway
• Knowledge & understanding of Biometry, eg: atypical measurements, special lens requirements.
• Ability to liaise with surgeon to address any issues/concerns.
• Autonomy to book directly onto suitable list
-topical/injection/sedation/anaesthetic
Operation Day Patient Pathway
• Patients arrive at staggered times
• Wrist band printed on admission
• Primary nurse interprets plan of care based on patient’s pre-assessment.
• Primary nurse rechecks scan and chosen IOL
• Primary nurse calls for patient and reassures family
• Plan of Care booklet retrieved from patient
Operation dayPatient Pathway continued
• In theatre admission room, WHO Checklist commences.
• Consent confirmed, form signed.
• Wristband and patient label attached
• Allergies addressed
• Property locked away safely.
• Patient concerns addressed.
Theatre Flow
Prep Area Recovery
Anaesthetic Room Theatre
Recovery Prep
Theatre Anaesthetic Room
Prep Area• Primary nurse
-Escorts to theatre chair safely
-Commences anaesthetic/dilating drops
-Cannulation if required
-BM if necessary
-Reassurance/explanation given
-Patient meets surgeon, checks performed, eye marked
-Issues/concerns addressed
-Patient transferred on operating chair to anaesthetic room.
Anaesthetic Room• Observations recorded, BP, Pulse, O2• Anaesthetic/dilating drops continue• Scrub nurse - ID correct patient, WHO checklist, Consent &
Biometry/correct lens• Ensure correct eye is marked• Anaesthetist – sedation/injection if required.• Honan’s bulb applied.• Further observations recorded.• Ongoing reassurance/explanations.• Prepare eye/skin cleaning.• Patient transferred on operation chair into theatre area.
Theatre Room• Chair positioned, patient made comfortable
• Observations recorded throughout
• Scrub nurse applies drape and speculum
• Reassurance throughout, hand held
• Operative notes completed.
• Post surgery eye cleaned.
• Patient sat up gently
Recovery Area• General assessment of patient
• Cannula removed and lid taped if necessary (injection).
• No shield required.
• Identification label/wristband removed.
• Beverage prepared.
• Surgeon completes post operative plan of care
• Patient escorted to Discharge room
Discharge Room• Reunited with family
• Property returned
• Plan of care discussed with patient and relative and documented in Booklet
• Post operative prescription given
• Post operative appointment reinforced
• Possible side effects and emergency contact numbers provided
Surgery Pathway Advantages• Staggered appointments – reduces length of stay
• 1:1
• Reduction in repetition/handovers
• Reduced risks of errors
• Improves Safety
• Reduced turnaround time in theatre <5 mins
• Individualised care
Post-operative visit• 3-4 week review post op.
• Nurse-led clinic.
• Patient’s comments recorded re: outcome
• VA, Auto-Refraction, IOP, Dilate
• Post-op Nurse examines
• OCT performed if required
• Speciality referral, discharge or list for 2nd eye – appropriate consent obtained and risks and benefits discussed.
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