This document covers the learning accrued by RNIB from three eye hospital trusts on their experience of reducing unnecessary sight loss in glaucoma patients through decreasing the number of delayed follow up appointments for glaucoma patients and patients lost to follow up. This work is in relation to the NICE Guidance for Glaucoma: diagnosis and management of chronic open angle glaucoma and ocular hypertension.
This example was originally submitted to demonstrate implementation of NICE guideline CG85. It has been reviewed and the practice described remains consistent with the updated NICE guideline NG81.
Aims and objectives
To reduce unnecessary sight loss in glaucoma patients through decreasing the number of delayed follow up appointments for glaucoma patients and patients lost to follow up.
- Patients are less likely to have their follow up appointments delayed.
- High risk patients are prioritised.
- Capacity is increased though effective use of staff time.
- Did Not Attend (DNA) patients are followed up in the community.
RNIB collated best practice examples from each site into a series of bullet points to share with other ophthalmology departments to help improve their systems. The best practice examples are shown in this document.
This submission relates to the work of Manchester Royal Eye Hospital (Miss Cecilia Fenerty: Consultant Ophthalmologist: Cecilia.Fenerty@cmft.nhs.uk) Moorfields Eye Hospital (Mr John L Brookes: Consultant Ophthalmic Surgeon and Glaucoma Service Director: John.Brookes@moorfields.nhs.uk ) and Sheffield Teaching Hospital Foundation Trust (Mr Simon Longstaff: Consultant Ophthalmologist: Simon.Longstaff@sth.nhs.uk).
Reasons for implementing your project
Three hospital trusts have taken action to reduce unnecessary sight loss by trying to reduce delays to appointments and ensure that patients are not lost to follow up. This work follows an alert released by The National Patient Safety Agency (NPSA) in 2009 which came as figures revealed that 135 patients with glaucoma experienced cancellations or delays to their follow up appointments - 44 of these resulted in partial loss of eyesight, including 13 patients who went completely blind in one or both eyes. In some cases, patient appointments had been delayed by as much as 18 months. A further 91 incidents related to delayed, postponed or cancelled appointments, but the level of harm is not known.
RNIB regularly receives calls from glaucoma patients who are concerned about their appointment s having been delayed. A 2012 Freedom of Information Request revealed that:
- 57 per cent of trusts surveyed did not know how many appointments are delayed.
- 26 per cent of trusts surveyed knew or gave an estimate and have a significant proportion of appointments delayed.
- Seven per cent knew or gave an estimate and have less than 10 per cent of appointments delayed.
- 10 per cent told us that they intended to begin collecting the data or were beginning programmes to reduce delays. The results, coupled with anecdotal evidence, suggests that appointments are being significantly delayed. One hospital reported that 44 per cent of glaucoma follow-up appointments are currently delayed by over one month.
How did you implement the project
1) Delayed and DNA'd appointments monitored and clinic capacity regularly reviewed:
- Moorfields: clerks cannot close clinic until all patients assigned outcome: "discharged" "rebooked" or for DNAs "follow up with GP". All patients booked into appropriate clinic on departure from their previous appointment regardless of capacity. Clinic capacity then reviewed prior to clinic date and appointments re-scheduled if needed. Thus, clerks can track when patients should have been seen and re-book their appointment within an appropriate time frame (appropriate as predefined by ophthalmologists) Barrier: backlog of patient records must be cleared and assigned an outcome costing staff time.
- Manchester: clerks use partial booking system and maintain Review List database of patients awaiting appointments. Clinics booked 6 weeks in advance when clerks and clinical staff can be sure of staffing levels.
- Sheffield: the Patient Administration System has a review list of patients awaiting appointments with due date. All patients remain on review list until they are booked: if there are patients on the review list whose scheduled appointment month has passed, they are visibly overdue.
2) Appointments are prioritised according to clinical need
- Moorfields: glaucoma patients ranked as high/medium/low risk of disease progression. Barrier: Cost of clinical and clerical staff time to review existing patients.
- Manchester: glaucoma patients flagged on the patient record so can be easily identified. High risk patients seen in separate clinics from low risk patients. Barrier: relies on ophthalmologists identifying patients and clerks remembering to flag patients.
- Sheffield: patients routed into different clinics according to clinical need.
- All: glaucoma patients largely seen within glaucoma only clinics.
3). Stratifying service delivery and effective use of different staff
- Sheffield: patients at risk of progression seen by ophthalmologists while stable glaucoma or ocular hypertensives have their tests taken by technicians in Glaucoma Unit: test results are reviewed by a consultant.
- Manchester: glaucoma service tailored according to severity of glaucoma and risk of progression. Patients with high risk of advanced disease are seen within the consultant led clinics, lower risk patients are seen in the optometry-led glaucoma clinics or the Glaucoma Evaluation Clinic.
- Moorfields: some nurses take IOP tests
1). Avoidable sight loss is reduced through delayed and DNA'd appointments being recorded/ monitored
- Ensuring patients are given a follow up outcome (follow-up/DNA) means that patient lists are accurate and contain only active patients; patients cannot be accidentally lost to follow up, and DNAs are chased via their GP.
In Manchester the combined effect of the strategies has improved timeliness of outpatient reviews for glaucoma patients: in 2009 around 50% of patients had a outpatient appointment offered at the appropriate review interval, and by 2013 over 90% of patients were receiving their outpatient appointments at the appropriate review interval.
- Accurate monitoring of capacity ensures that clinics have useful information to share with commissioners and can plan services effectively and put on extra clinics if needed.
2). Appointments are prioritised according to clinical need
- If capacity is an issue then patients with a high risk of disease progression can be seen in a timely manner.
3). Stratifying services and using a range of staff
- Manchester: the different pathway streams have allowed Manchester to maximise capacity for seeing glaucoma patients and those at risk of glaucoma without compromising care. Optometrists are employed as part of the glaucoma team under a consultant to help to monitor stable patients.
- Sheffield: clinicians can review considerably more patient data per session and can see patients in a ratio of at least 4:1. Setting up the Glaucoma Monitoring Unit requires little supervision. Release of consultant time for traditional clinics increases capacity and contributes to the low Sheffield DNA rate of 2% (Quantitative).
- Moorfields: Through nurses taking intraocular pressure tests capacity is freed up.
4). Capacity increased by ensuring that patients are discharged appropriately in line with NICE Guidance
- Moorfields: to discharge appropriate patients from the current pool cost a one off of 50 hours' of Band 3 staff time = £650
Key learning points
1) Involve clerks in patient care and planning:
- Clinic clerks play a major role in ensuring that patients are seen without delay and that any problems that are highlighted by patients are dealt with promptly.
- Clerks involved in clinic scheduling must have a basic understanding of glaucoma. Patients have reported to RNIB that in some areas clerks can be unaware that there are not normally any visual symptoms of disease progression for glaucoma which can mean that patients can be encouraged not to pursue the matter if their appointment if severely delayed and they are not noticing any changes to vision.
2) Ensure that patients know when they should be seen and what to do if their appointment is cancelled or delayed or they notice changes to their eyes:
- Some patients can worry needlessly if an appointment is slightly delayed; while others will not take action if their appointment never materialises, believing that their doctor is aware that they haven't had an appointment.
- As well as showing patients how to use their eye drops, patients may benefit from being shown how to monitor their own intraocular pressure by touch so that they can try to monitor their eyes in-between appointments and take action if they notice a major change.
- Patients need to know when they should next be seen and what to do if their appointment is severely delayed, if they are worried about their eyesight or they notice any changes to vision or feel of their eye(s).