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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


• 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


• 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.

http://www.uk-oa.co.uk/

UKOA Board MembersMelanie Hingorani, Chair

Consultant Ophthalmologist, Moorfields Eye Hospital

Email: [email protected]

Mary Freeman

Consultant Nurse, Sheffield


Penelope Stanford

Lead of RCN Ophthalmic Nursing Forum


Allison Beal

Director of Special Projects, GIRFT


Bill Newman

Medical Director Manchester Royal Eye Hospital


John Ashcroft

CEO, Manchester Royal Eye Hospital


Veronica Greenwood

Chair, British and Irish Orthoptic Society


Keith Valentine

Director of Development – RNIB


David Probert

CEO, Moorfields Eye Hospital


mailto:[email protected]









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 [email protected].

• 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


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


• 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


~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


1 unitAll consultant ledB5

~13% units do thisSmall numbers All practitioner ledB7-8

none

Retinal laser


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??


• 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





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


• 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


• 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





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


• 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


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

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

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

Thank you for your attention

[email protected]


My progress in Glaucoma

Connor BeddowClinical Leadership&Sustainability fellow


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

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


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

Optometry & EXD

Thank you!

Shima Shah [email protected]


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


• 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


• 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

[email protected]

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


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 [email protected]

The Challenges and Success in adult Orthoptic Extended roles in a

DGHSonia MacDiarmid Head Orthoptist

Warrington and Halton NHS Foundation Trust


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


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


• 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



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

• [email protected]

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


• Working with primary eye care providers to run safe and efficient cataract schemes

• The lessons we have learnt.

https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=2ahUKEwjaxoC3nPLgAhXr6OAKHS3cDWAQjRx6BAgBEAU&url=https://www.teamworkandleadership.com/2014/10/3-funny-communication-videos-share-at-your-next-staff-meeting.html&psig=AOvVaw0P4pq2XhWc7nsHOnjdbzW8&ust=1552123412294221

https://www.google.co.uk/url?sa=i&rct=j&q=&esrc=s&source=imgres&cd=&cad=rja&uact=8&ved=2ahUKEwjaxoC3nPLgAhXr6OAKHS3cDWAQjRx6BAgBEAU&url=https://www.teamworkandleadership.com/2014/10/3-funny-communication-videos-share-at-your-next-staff-meeting.html&psig=AOvVaw0P4pq2XhWc7nsHOnjdbzW8&ust=1552123412294221

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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