Nurse-led Clinic for Children with Cysts & Watery Eyes A Quality Improvement Initiative Jane Kearney - Paediatric Ophthalmic Nurse Dr Marie O Neill – Associate Specialist Maura Macklin - Orthoptist Paediatric Ophthalmology September 2017 This presentation is a brief examination of a Nurse-led clinic for Children with Cysts & Watery Eyes as a Quality Improvement Initiative.

PLAN 2012 Substantial Waiting List for General Paediatric New Routine Surgery Lack of standardised approach Plan to set up a Nurse-led clinic for a defined population of children under protocol Specialty Triaging by Ms McLoone, Ms George & Dr ONeill In 2012 the waiting list for general Paediatric New Routine Surgery was substantial and children who required surgery for minor procedures were being boarded without a standardised approach. The plan was to set up a Nurse-led clinic for children of a defined population under a protocol. Paediatric Ophthalmology moved to Specialty Triaging which allowed us to move to this type of clinic.

DO Children booked to attend clinic in Beech Hall Health & Wellbeing Centre Defined group – All Children <16 with Cysts and Watery Eyes/Blocked Nasolacrimal Duct Agreed a proforma to capture correct information Agreed standardised advice and information The initiative began in 2014 Children were booked to attend a clinic in Beech Hall Health & Wellbeing centre. Our defined group of patients were all children under the age of 16 who were referred to Ophthalmology for Cysts and Watery Eyes or Blocked Nasolacrimal duct. In the interests of patient safety and accurate record keeping, we used an agreed proforma to record relevant information and agreed standardised advice and information.

CLINIC SET UP Clinic set up to address waiting times New patient appointments Specialty Doctor, Paediatric Ophthalmic Nurse, Orthoptist Examination, advice and reassurance or boarded for Sx if required Nurse dictates clinic letter to GP The Nurse-led clinic was set up to address waiting times and only new patient appointments are booked. In 2012 the waiting time for new appointments was approximately 9 months. The clinic was staffed by Dr Oneill, a paediatric Ophthalmic nurse and an Orthoptist. We began with 1 clinic per week and the nurse saw the patients with Dr Oneill. The Paediatric nurses received relevant training for the clinic. In 2014, the Paediatric nurses saw the patients in clinic with the Specialty Doctor. By 2015 we had moved to a Nurse-led clinic which ran adjacent to the Specialty Doctor clinic.

Advice leaflet - Cysts Sample of Cyst Advice leaflet Eyelid cysts are a common problem in small children. They are swollen oil glands. There are around 20 of these oil glands in the body of each of the eyelids. They secrete oil into the tear film to stabilise the tears and keep the eye bathed. They are very long and thin and their mouths open at the base of the eyelashes. When the lid margins become red and inflamed, the tiny mouths swell up and close. The gland expands and the lid swells. It can become infected and appear as a tense red swelling. The active immune system in a child reacts to wall off the cyst. As the infection settles, the cyst wall can take some time to disappear. The cyst can rupture through skin and appear as a yellow based granuloma. It can also rupture into the other side of the eyelid. It then appears as a pink protruding fleshy area under the lid. Cysts are not a serious health issue, but are very unsightly. They are easier to influence in the very acute stage. Sample of Cyst Advice leaflet A copy of this leaflet is available on the GP web site and can be downloaded.

Management of Cysts Daily cleaning of lid margin Warm compresses Eyelid massage Daily Omega 3 supplement American Academy of Ophthalmology 2012 The most difficult aspect to the clinic is alleviating parental anxiety about cysts. Parents are given standardised, consistent and evidence based advice on the management of Cysts in terms of prevention and alleviating the discomfort of an acute cyst. They are advised to carry out daily lid hygiene, to commence the child on a daily Omega 3 supplement and to use warm compress and eyelid massage. In terms of what we do board for surgery, it is usually A Cyst which is has a visual risk in a young child Granulation tissue A sebaceous Cyst which is not likely to go away

Advice leaflet-Watery eyes Sample of A Watery Eye Advice leaflet

Management of Watery Eyes Daily Lacrimal Sac Massage Keep the eye clean 90% resolve by 1 year Parents are advised that they can improve the flow of the tears and reduce the likelihood of infections by carrying out lacrimal massage daily. Often the tear drainage system opens spontaneously as the baby grows and the watering stops. Around 90% resolve by the age of 1 year.   If watering persists beyond 1 year, the drainage system is unlikely to open. Parents are advised that at stage they can request a referral to a hospital eye clinic to discuss a Probing and Tear Sac Washout under GA. Who gets boarded for Surgery can be age dependent, we will normally board children over 1 year of age, younger children with Dacrocystitis, or severe skin excoriation due to excessive watering and discharge.

Attendance rate 203 Total New Appointments Last year we audited the Nurse-led clinic Our findings showed that For 2015 we had a total of 203 New Appointments. The attendance rate shows that 72% of those given a new appointment attended.

Assessment Diagnosis of those patients who attended -

Outcomes 8 Of the 203 New Appointments 76% were discharged 20% were boarded for Surgery 4% were booked for review either with the Specialty Doctor back in Beech Hall or to the Community Orthoptist 8

Surgery 2015 Of the 40 children who were boarded for surgery in Nurse-led clinic 3 – Removal of Lid Cyst 37 – Probing & Tear Sac Washout 40 children were boarded for surgery in the Nurse-led clinic 3 for Removal of a Cyst 37 for Probing and Tear Sac washout At this point there was noticeable change in waiting times for surgery for other procedures we decided to compare figures

LID CYSTS 2012 vs 2015 2012: 50 Meibomian Cysts GA 2 Nurse-led clinic 5 General Paed Pool Of 3 Cyst patients listed from Nurse-led clinic 2 – GA 13 year old M Cyst 13 year old Sebaceous Cyst 1 –LA 15 year old M Cyst Looking only at those children who had a cyst removed under GA we compared the figures with 2012. In 2012, 50 Children had a GA for Removal of a Meibomian Cyst In 2015, 7 Children had a GA for Removal of a Meibomian Cyst 5 Children were boarded for GA from General Paediatric Pool The Nurse-led clinic boarded 2 children for removal of a cyst under GA 1 Meibomian Cyst 1 Sebaceous Cyst 1 Meibomian Cyst under LA

Conclusions Huge saving of resources GA theatre time Free up 203 New Patient Appointments for more specialist appointments at General Paediatric Clinic Standardised and Consistent Evidence Based Advice to parents beneficial Expansion of role of Paediatric Nurse We feel this initiative has made a huge saving in resources in terms of the cost of GA theatre time. 7 GA booked in 2015 compared to 50 in 2012. It has freed up 203 new patient appointments which would normally have been seen in the general paediatric clinic. This makes room for patients who require a more specialist Ophthalmology clinic appointment and has enabled us to reduce the waiting time in the General clinics for Routine appointments. The waiting time for a New Appointment at the Nurse-led clinic is 6/7 weeks. The advantage to parents is that they are given reassurance, and standardised consistent information and advice on the prevention and management of cysts and the management of watery eyes. From a nursing point of view, there is immense personal satisfaction with the development and expansion of our skills and role in clinic.

Future Actions CYSTS Continue to give reassurance and standardised, evidence based advice Only boarded for Surgery – mechanical problem Expand clinic capacity Role out similar model for the Hub & Spoke clinics Prospective Audit  Children with Cysts – At clinic, parents are reassured and given standardised advice in relation to prevention and treatment. Only surgery if…..mechanical problem eg Pyogenic Granuloma rupturing through conjunctiva We plan to expand the capacity of the clinics and indeed since Nov 2015 we have increased our capacity from 5 to 11 patients per week. There is an idea to role out a similar model for the Hub & Spoke clinics I have been working on a Prospective Audit which has captured data for 2016 and 2017