PRIMARY EYECARE ASSESSMENT AND REFERRAL SCHEME : A SIX MONTH AUDIT G Ramsamy, P Boparai, P Rockett, A Bhatnagar 18 th April 2015

 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

PEARS ( P RIMARY E YECARE A SSESSMENT AND R EFERRAL S CHEME) GP referralPatient self- refers PEARS - accredited Optometrist Triage and seen within “appropriate” timeframe by the optometrist Referred to ARC via (to be seen within 24 / 72 hrs) Discharged / treated in primary care Referred to C&B via (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.

 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 6 MONTHS OF PEARS

 TRIAGE SYMPTOMS – flashes & floaters 130 cases, 16% referred to ARC  TRIAGE SYMPTOMS – dry/sore/painful/red eye 447 cases, 9% referred including 12 corneal ulcer, 5 abrasions, 5 uveitis. PEARS

PEARS ( P RIMARY E YECARE A SSESSMENT AND R EFERRAL S CHEME) GP referralPatient self- refers PEARS - accredited Optometrist Triage and seen within “appropriate” timeframe by the optometrist Referred to ARC via (to be seen within 24 / 72 hrs) Discharged / treated in primary care Referred to C&B via (to be seen in OPD)

Referrals from OO to ARC via 90% Patients seen in the requested time frames – (24 / 72 hrs) 100% Referrals follow the locally agreed guidelines 100% Diagnostic accuracy of referrals80% LOCAL STANDARDS

METHOD  Patients referred by PEARS (Sep’14-Feb’15) o Details collected retrospectively from WEBSTAR database  Details cross-checked with s received in ARC  Data analysed and cross-checked with information on web portal.

RESULTS 86 patients 9-92 years (mean 57 years) Referred by 53 patients (62%) Referral received by other means: 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 46 patients (53%) To be seen within 72 hrs 40 patients (47%) Actually seen in: <24 hrs28 (61%) In 2 days8 In 3 days6 In 4-7 days4 Actually seen in: <72 hrs20 (50%) >72 hrs20 (50%)

WHY THE DELAY IN SEEING THESE PTS 24 hr referrals72 hr referrals

Ant seg related referrals Post seg related referrals 24 hrs hrs 2119 REASONS FOR REFERRAL

RESULTS ANTERIOR SEGMENT RELATED REFERRALS N=46

RESULTS POSTERIOR SEGMENT RELATED REFERRALS N=40

24-Hr Referrals to ARC (n=46) 72-Hr Referrals to ARC (n=40) APPROPRIATENESS OF REFERRALS (COMPARED WITH AGREED GUIDELINES)  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 (REFERRAL DIAGNOSIS VS ARC OUTCOME) 72-Hr Referrals to ARC (n=40) 24-Hr Referrals to ARC (n=46) Referral DiagnosisARC Diagnosis RD/ Retinal Tear (8)PVD, Retinoschisis Corneal Ulcer (4)Marginal Keratitis Corneal Abrasion (2)Healed C abrasion, AAU Vitreous haze IOFB AAU MelanomaNaevus Referral DiagnosisARC Diagnosis Retinal Tear (8)PVD Wet AMD (4)Dry AMD, CSR Limbal stain (2)Marginal keratitis EpiscleritisBlepharoconjunctivitis Macular lesionMyopic degeneration C. AbrasionHealed

CONCLUSIONS Audit CriteriaStdUs Referrals from OO to ARC via 90%62% Patients seen in the requested time frames – (24 / 72 hrs) 100%61% / 50% Referrals follow the locally agreed guidelines100%86% * Diagnostic accuracy of referrals80%50% * 75% - Wales Study (Sheen et al) BJO 2009

RecommendationsAction PlanLeadDeadline PEARS optometrist to refer patients using ARC ID Re-enforce the message to all participating optometrists LOC Chair / PEARS Lead ASAP s to be sent / actioned promptly. Re-enforce the message to all participating optometrists Cut-off time for receiving in ARC – 4.30pm LOC Chair / PEARS Lead ASAP Inform / educate patients about PEARS Information leaflets / advertising.PEARSLead / CCG ASAP Continuing education for optometrists (improve quality of referrals) Feedback to referring optometrists (copy of GP letters) Regular teaching session Secretaries’ team leader ALL Ongoing Re-auditRe-audit in 12/12CD, PEARS Lead April2016

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