Transcript Bal Manoj Presentation 1

PRIMARY EYECARE
ASSESSMENT AND
REFERRAL SCHEME :
A SIX MONTH AUDIT
G Ramsamy, P Boparai, P Rockett, A Bhatnagar
18 th April 2015
PEARS
 Introduced in Wolverhampton in Aug / Sep 2014
 Based on Wales Optometry model
 manage appropriate patients in primary care
 Based on core optometry competencies
 Accreditation process (OSCE)
 In Wolverhampton the scheme is run by LOC Company which
holds the CCG conract
 Optometry practices are subcontractors
 22 (of 38) practices in Wolverhampton, 3 out of area and 5 more to
join soon
PEARS
(
P RI M A RY E Y E CARE A SSE SSMENT A N D R E F ERRAL S C H E M E )
GP referral
Patient self- refers
PEARS - accredited Optometrist
Triage and seen within “appropriate” timeframe by the
optometrist
Discharged /
treated in
primary care
Referred to ARC via
email (to be seen within
24 / 72 hrs)
Referred to C&B via
email (to be seen in
OPD)
PEARS
Assessment / management / referral of recent
onset eye conditions
Small list of basic topical medications
available through PEARS
Expecting to manage conditions like
blepharitis/dry eye/corneal abrasion/conjunctivitis
referring appropriately and
being aware of own limitations.
6 MONTHS OF PEARS
 721 patients seen (now 190 per month)
 82% managed within community
 18% referred to hospital eye service
 6% 24 hour ARC referrals
 5% 72 hour ARC referrals
 6% routine referrals to ophthalmology
 1% fast track wet AMD referrals
PEARS
 TRIAGE SYMPTOMS – flashes & floaters
130 cases, 16% referred to ARC
 TRIAGE SYMPTOMS – dr y/sore/painful/red eye
447 cases, 9% referred
including 1 2 corneal ulcer, 5 abrasions, 5 uveitis.
PEARS
(
P RI M A RY E Y E CARE A SSE SSMENT A N D R E F ERRAL S C H E M E )
GP referral
Patient self- refers
PEARS - accredited Optometrist
Triage and seen within “appropriate” timeframe by the
optometrist
Discharged /
treated in
primary care
Referred to ARC via
email (to be seen within
24 / 72 hrs)
Referred to C&B via
email (to be seen in
OPD)
LOCAL STANDARDS
Referrals from OO to ARC via email
90%
Patients seen in the requested time
frames – (24 / 72 hrs)
100%
Referrals follow the locally agreed
guidelines
100%
Diagnostic accuracy of referrals
80%
METHOD
Patients referred by PEARS (Sep’14-Feb’15)
oDetails collected retrospectively from WEBSTAR
database
Details cross-checked with emails received in
ARC
Data analysed and cross-checked with
information on web portal.
RESULTS
86 patients
9-92 years (mean 57 years)
Referred by Email
Referral received by other means:
53 patients (62%)
33 patients (38%)
7 turned up at A&E
1 referral faxed
1 no evidence of optom consultation
3 likely not sent as no appts
21 unknown source
RESULTS
86 patients
To be seen within 24 hrs
To be seen within 72 hrs
46 patients (53%)
40 patients (47%)
Actually seen in:
Actually seen in:
<24 hrs
In 2 days
In 3 days
In 4-7 days
<72 hrs
20 (50%)
>72 hrs
20 (50%)
28 (61%)
8
6
4
WHY THE DELAY IN SEEING THESE PTS
24 hr referrals
72 hr referrals
Not given
appointment
within 24 hours
1
6%
Seen in AMD clinic
2
10%
Patient attended
A&E
6
33%
Cancelled
appointment
5
28%
Seen in DR clinic
1
5%
Not given appointment
within 72 hours
7
35%
Likely referral processed
next day
5
25%
Likely referral
processed next
day
6
33%
No referral received
3
15%
Referral sent late
2
10%
REASONS FOR REFERRAL
Ant seg related
referrals
Post seg related
referrals
24 hrs
24
22
72 hrs
21
19
RESULTS
A N T ERIOR SE G M E NT RE LATE D RE F E RRALS
N=46
Diplopia
2
5%
Raised IOP
1
2%
Unknown
1
2%
AAU
4
9%
Suspected C ulcer
11
24%
Red/sore/painful
eye
26
58%
RESULTS
P OST E RI OR SE G M E NT RE LAT ED RE F E RRALS
N=40
Mac hole
1
3%
Melanoma
1
3%
Reduced VA
?cause
3
7%
Vitr Hge (PDR)
3
7%
RD/Suspected
retinal tear / PVD
19
46%
RVO/RAO/Mac
lesion/Optic N
14
34%
APPROPRIATENESS OF REFERRALS
( C O M PA R E D W I T H AG R E E D G U I D E L I N E S )
24-Hr Referrals to ARC
(n=46)
Inappropriate
6 patients
13%
72-Hr Referrals to ARC
(n=40)
Inappropriate
6 patients
15%
Appropriate
Appropriate
Inappropriate
Inappropriate
Appropriate
34 patients
85%
Appropriate
40 patients
87%






Mac hole
Large subconjunctival haemorrhage
Reduced VA 6/12 >2/52. ?Cause
CSR (2/12 history)
Macular lesion (reduced vision over 12/12)
Chalazion (?)




Diabetic maculopathy
Bacterial conjunctivitis
?Wet AMD x3
Corneal Ulcer
DIAGNOSTIC ACCURACY
( R E F E R R A L D I AG N O S I S V S A R C O U T C O M E )
24-Hr Referrals to ARC
(n=46)
Indeterminate
7 patients
15%
Match
21 patients
46%
Mismatch
18 patients
39%
72-Hr Referrals to ARC (n=40)
Indeterminate
12 patients
30%
Match
21 patients
52%
Mismatch
7 patients
18%
Referral Diagnosis
ARC Diagnosis
Referral Diagnosis
ARC Diagnosis
RD/ Retinal Tear
(8)
PVD, Retinoschisis
Retinal Tear
PVD
Corneal Ulcer
(4)
Marginal Keratitis
Wet AMD
(4)
Dry AMD, CSR
Corneal Abrasion
(2)
Healed C abrasion, AAU
Limbal stain
(2)
Marginal keratitis
(8)
Vitreous haze
Episcleritis
Blepharoconjunctivitis
IOFB
Macular lesion
Myopic degeneration
AAU
C. Abrasion
Healed
Melanoma
Naevus
CONCLUSIONS
Audit Criteria
Std
Us
Referrals from OO to ARC via email
90%
62%
Patients seen in the requested time frames – (24 100%
/ 72 hrs)
61% /
50%
Referrals follow the locally agreed guidelines
100%
86% *
Diagnostic accuracy of referrals
80%
50%
*75% - Wales Study (Sheen et al) BJO 2009
Recommendations Action Plan
Lead
Deadline
PEARS optometrist to refer
patients using ARC email ID
Re-enforce the message to all
participating optometrists
LOC Chair /
PEARS Lead
ASAP
E-mails to be sent /
actioned promptly.
•
LOC Chair /
PEARS Lead
ASAP
•
Re-enforce the message to all
participating optometrists
Cut-off time for receiving email
in ARC – 4.30pm
Inform / educate patients about
PEARS
Information leaflets / advertising.
PEARSLead /
CCG
ASAP
Continuing education for
optometrists (improve quality of
referrals)
•
•
Ongoing
Re-audit
Re-audit in 12/12
•
Feedback to referring
optometrists (copy of GP letters)
Regular teaching session
•
Secretaries’
team leader
ALL
CD, PEARS
Lead
April2016
THANK YOU FOR LISTENING
ANY QUESTIONS?
A&E Attendances (Ophthalmology)
2011-12
2012-13
2013-14
2014-15
Sept
1299
1217
1323
1359
Oct
1220
1341
1425
1421
Nov
1244
1306
1301
1271
Dec
1150
1093
1216
1141
Jan
1206
1228
1268
1229
Feb
1187
1219
1238
1175
Mar
1334
1310
1433
1343
1600
1400
1200
1000
Sep
Oct
Nov
800
Dec
Jan
Feb
600
Mar
400
200
0
2011-12
2012-13
2013-14
2014-15
A&E Attendances (Ophthalmology)
2011-12
2012-13
2013-14
2014-15
Sept
1299
1217
1323
1359
Oct
1220
1341
1425
1421
Nov
1244
1306
1301
1271
Dec
1150
1093
1216
1141
Jan
1206
1228
1268
1229
Feb
1187
1219
1238
1175
Mar
1334
1310
1433
1343