The Role of the Consultant Nurse in Ophthalmology - PowerPoint PPT Presentation

1 / 60
About This Presentation
Title:

The Role of the Consultant Nurse in Ophthalmology

Description:

(RGN, OND, MBA, MA) Royal Hallamshire Hospital. Sheffield Teaching Hospitals NHS Foundation Trust. Historical perspective how and why the post came ... to HES) ... – PowerPoint PPT presentation

Number of Views:389
Avg rating:3.0/5.0
Slides: 61
Provided by: royal84
Category:

less

Transcript and Presenter's Notes

Title: The Role of the Consultant Nurse in Ophthalmology


1
The Role of the Consultant Nurse in Ophthalmology?
  • Mary Freeman
  • (RGN, OND, MBA, MA)
  • Royal Hallamshire Hospital
  • Sheffield Teaching Hospitals NHS Foundation Trust

2
Aim
  • Historical perspective how and why the post
    came about
  • What I do
  • Challenges in developing a new role

3
The Nurse Consultant Role
  • The concept was introduced by government in
    1998
  • The aim being to
  • Improve outcomes for patients
  • Provide professional leadership in nursing
  • Create a career structure in clinical practice

4
Elements of the Post
  • Four core functions (HSC/199/217)
  • An expert function
  • - The post holder should dedicate a minimum of
    50 of their time in the clinical setting
  • A professional leadership and consultancy
    function
  • - Setting standards
  • - Promoting best practice

5
Elements of the Post
  • An educational, training and development function
  • A practice and service development, research and
    evaluation function

6
The Role
  • Stemmed from service need
  • Aimed to fill gaps in service provision
  • Enhance patient care
  • Focussed on areas of heavy workload
  • Where it could have the greatest impact

7
My Role As a Nurse Consultant in Ophthalmology
  • In Post Nov. 02
  • Macular Degeneration Service PDT/ IVT Lucentis
    (26,000 new cases of wet AMD in UK eligible for
    treatment/yr)
  • Glaucoma (accounts for 20 of ref. to HES)
  • Diabetic Retinopathy Screening (NSF and NICE
    developed guidelines on retinopathy screening)
  • Research Lead

8
OK So What Do I Actually Do?
9
Macular Degeneration and the PDT / Intravitreal
Service
  • Clinical function
  • Review new referrals with possible AMD
  • Request FA, ICG, OCT where appropriate
  • Undertake PDT laser therapy
  • Involved in the reporting session
  • Diagnose other pathology (macular holes, BRVO,CSR
    etc) referring to other clinicians

10
Clinical Function
  • New and review clinics
  • Obtain detailed history
  • Slit lamp examination including a fundal
    examination through dilated pupils using a 78D
    Volk lens
  • Diagnose and explain condition
  • Advise on recommended treatment (verbal and
    written -IVT Lucentis/PDT)

11
Clinical Function
  • Discuss concerns / support and counsel patients
  • Review patients who have had PDT

12
Organisational Function
  • Streamlining referral pathways
  • Provide increased clinic capacity rapid access
    clinic to allow patients to gain prompt diagnosis
    and treatment

13
(No Transcript)
14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
(No Transcript)
19
(No Transcript)
20
Glaucoma
21
Drivers for Change
  • Accounts for approx 15 - 20 of referrals to eye
    departments
  • Main source of glaucoma referrals result from
    opportunistic detection by community
    optometrists
  • High percentage of false positive referrals
  • Because of its chronic nature, glaucoma causes a
    heavy workload. (Once diagnosed, patients require
    regular monitoring)

22
A Multi-disciplinary Management Scheme Within
Secondary Care
  • In Sheffield In house scheme includes a glaucoma
    unit to monitor stable glaucoma pts and involves
  • - Nurses (qualified and
    unqualified)
  • - Orthoptists
  • - Nurse Consultant
  • - Medical Consultants
  • Modified the service in order to refine the
    quality of referrals into the clinic

23
Why Refine Referrals?
  • An audit in 2004 of glaucoma referrals in
    Sheffield
  • 254 patients who were referred by optometrists
  • 40 with subsequently discharged
  • 15 positive diagnosis of glaucoma
  • 22 glaucoma suspects
  • 23 OHT

24
Referrals Are Refined Because
  • High false positive referrals
  • Pressure on already overburdened clinics
  • Increasing pressure on reducing waiting times for
    a clinic appointment
  • Inconvenience and anxiety results from
    unnecessary appointment
  • Low sensitivity of investigations performed in
    community

25
Glaucoma Service
  • New referrals
  • - Patients attend for their tests and leave
    the department without seeing a clinician
  • - Clinician (nurse consultant) determines if
    pt is discharged (false ) or needs to be seen in
    clinic with suspected glaucoma or followed up in
    the unit (if OHT)
  • - Thus refining the referrals made into the
    glaucoma clinic

26
Investigations Performed Within the Glaucoma Unit
  • Corrected visual acuity
  • Applanation tonometry
  • Visual field tests (Humphrey armaly and 24-2
    fields)
  • Optic nerve imaging (HRT)
  • Auto-refraction
  • Auto-focimetry
  • Pachymetry

27
New Referrals
  • General eye examination, forms part of their
    optometrists consultation therefore not repeated
  • The Trusts clinical governance team consulted on
    this aspect and approval given
  • Local optometric and medical councils were
    consulted on the new pathway

28
Patient Pathway Optometrist
(GOS18) (Fax/post referrals) Glaucoma
Unit 1. Visual fields 2. IOPs 3. SLO (HRT)
Unit Report to Nurse consultant (Database)

No features
Ocular hypertension Features suggestive
suggestive of glaucoma (IOP ? 30mmHg)
of glaucoma OR i.e. Normal IOPs,

IOP ? 30mmHg fields and
healthy disc
(Pt
notified/GP/optom
advised of findings) Reassure/discharge
Glaucoma unit
Clinic (24-2 fields) back to optician -letter
to Pt ReportGP /
Glaucoma diagnosed Glaucoma
suspect optometrist
Commence treatment, review 6/52
(phase/ 24-2)



29
New Referrals
  • A database developed - aggregates outcome for all
    glaucoma referrals
  • Can be used to provide feedback to optometrists
  • Optometrist and GP advised of findings (database
    generated report)
  • Allows for the appropriate patient letter to be
    selected and printed, advising pts of outcome of
    unit attendance and
  • If further appointment is necessary, either for
    review in the clinic or the unit

30
Nurse Consultant Role within the Glaucoma Clinic
  • Assess new referrals with suspected POAG/OHT
    after having relevant investigations
  • Make clinical decisions based on visual fields,
    fundoscopy, tonometry and SLO
  • Diagnose glaucoma and prescribe glaucoma therapy,
    referring to ophthalmologist for subsequent
    reviews
  • Refer to other consultant if other pathology is
    found

31
Assessment Includes
  • A detailed history including-
  • Demographic data age and gender
  • Past / present relevant pathology
  • Ocular history / Non- ocular history
    (e.g.DM,asthma etc)
  • Medication history (may indicate systemic disease
    not reported by pt on questioning)

32
Assessment Clinic
  • Family history
  • 24-2 Humphrey visual field
  • Undertake a slit lamp examination
  • Assessment of A/C depth
  • Applanation tonometry
  • Optic disc assessment using 90D Volk lens

33
Optic Disc Assessment
  • On evaluating the disc, assessment includes
  • Assessment of neuro-retinal rim
  • Vertical cup/disc ratio and symmetry
  • Vascular signs such as bayoneting, flyover
    vessels etc.
  • Splinter haemorrhages
  • Advice is sought if concerns regarding other
    posterior segment pathology

34
Service Evaluation
  • Aim
  • Outcome of initial screening
  • Effectiveness of this model compared to what
    historically happened (seen in clinic)
  • Outcome of those patients subsequently referred
    into clinic

35
Audit
  • From 1/4/2006 1/9/08, 1966 new glaucoma
    referrals were managed in this way
  • In 80 of cases, an optometrist instigated the
    referral
  • 17 - via GP
  • 3 - eye casualty/EEC

36
(No Transcript)
37
Effectiveness of the Referral Refinement
  • Comparing the new model with a traditional OPD
    attendance.
  • Between the period of November 07 and February
    08, 73 patients had their management pathway
    modified
  • Seen in G/unit and also seen by Consultant before
    they went home

38
  • Clinic documentation resulting from consultation
    was removed from notes
  • G/Unit findings reported on at a later date in
    isolation to the clinic consultation
  • Both outcomes compared

39
Results
  • 73 patients received an ophthalmic examination as
    well as their glaucoma unit attendance
  • Of the 73, there was agreement in 71 of cases.
    i.e. agreement in whether the patient should be
    discharged or, if he/she needed further review,
    where this should take place i.e. Glaucoma unit
    or clinic

40
In the 2 Remaining Patients
  • It was suggested that the patient be seen in the
    glaucoma unit in 6 months whilst the consultant,
    (following the patients examination) requested
    that he be seen again in clinic in 4 months (no
    treatment was instigated)
  • (Full fields in both eyes and IOP s of 21mmHg and
    22mmHg. Optic nerve imaging suggested his optic
    discs were borderline ).

41
  • In the second case, it was suggested that the
    patient be brought back to clinic whilst the
    consultant deemed patient appropriate for review
    in glaucoma unit. (Elevated IOP in one eye, all
    other findings being normal).
  • In both cases, no harm resulted. The cause of the
    disagreement related to where patients were to be
    monitored.
  • No one was discharged or given a review appt.
    inappropriately.

42
Analysis of Patients Referred Into Clinic
  • 121 notes were randomly selected over last 2
    years

43
Analysis of Patients Referred Into Clinic
  • 69 of the glaucoma clinic attendances were
    either confirmed to have glaucoma or were thought
    to be glaucoma suspects
  • 15 were diagnosed as having ocular hypertension
    (nearly half of which were started on treatment)
  • A further 12 were subsequently discharged, after
    being diagnosed as having physiological discs

44
Benefits (1)
  • A sig. no of false positive referrals are made
    (31). Screening such referrals from the onset
    provides extra capacity in clinic for those
    patients who do need to be seen
  • A further 20 are monitored in the glaucoma unit,
    relinquishing further capacity in the already
    overburdened clinics

45
Benefits (2)
  • Direct referrals by optometrists negate the need
    for a further appointment at a busy GP surgery
  • All investigations are performed to a high
    standard and using standardised equipment
  • Limited no of staff in the unit mean that quality
    can be maintained and audited

46
Benefits (3)
  • A database allows data to be easily audited and
    relevant feedback given to optometrists from a
    clinical governance/educational perspective.
  • Differential waiting times for a clinic appt. is
    no longer an issue.
  • Service evaluation suggested service was valued
    by pts.

47
Sheffield Diabetes Eye Screening Programme
48
National Drive for Change
  • NSF for diabetes 2001/02 Alan Milburn set out a
    10 year vision for standards of care. One of the
    targets was that by 2006, a min of 80 of people
    with diabetes were to be offered screening for
    retinopathy, rising to 100 by 2007
  • NICE also drew up guidelines on screening for
    diabetic retinopathy and recommended annual
    surveillance through the use of digital
    photography

49
Community Based Eye Screening Programme
  • Grade diabetic eye disease
  • Refer sight threatening retinopathy to the eye
    clinic
  • Undertake a weekly bio microscopy clinic for
    those patients on whom we were not able to grade
    adequately using digital photographs (cataracts,
    poor mydriasis etc)

50
In Summary
  • How and Why Has My Role Emerged?

51
The Drive Behind the Blurring of Professional
Boundaries
  • Emerged through external pressures
  • Recruitment challenges
  • Reduce junior doctor hours
  • Fill gaps in service provision
  • Aging population
  • Rising cost in health care
  • - Need to provide VFM

52
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

53
But
  • I needed to have
  • Appropriate level of education, clinical
    expertise, and support to exercise informed
    judgement in clinical decisions and prescribing
  • Clear training and development framework
  • Adequate mentorship support
  • Evaluate new role

54
Challenges (1)
  • Training and education- Specific courses can be
    difficult to source or prohibitive in cost and
    in-house courses are often unaccredited
  • 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 (1)

(1) Department of Health. (1998a). A First Class
Service Quality in the NHS. HMSO, Leeds
55
Challenges (2)
  • Professional support - professional and personal
    support is crucial. Due to the nature of
    innovative roles there is a risk of isolation
    Established posts need to be reviewed to ensure
    that continuing needs for support and supervision
    are met (2)

(2) Reed S., Doyal L., Vaughan B. et al. (2001).
Exploring New Roles in Practice Final Report
Department of health, London
56
Challenges (3)
  • Collaborative working - new role should be
    planned and developed collaboratively, involving
    both nursing 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

57
Challenges (4)
  • Advanced practice protocols - need to reflect the
    new role and clarify its boundary providing
    guidance to practice
  • New roles not only need to be clear to the
    individuals undertaking them but to others within
    the organisation. These should include the
    trusts clinical governance forum and other key
    individuals

58
Challenges (6)
  • A supportive nurturing environment is important
    in order to ensure success of the post
  • Maintaining and updating knowledge in the field
    of expertise is vital
  • Any expansion in practice in needs to be
    undertaken with due consideration to the NMCs
    scope of practice and code of professional
    conduct

59
Benefits?
  • - Job satisfaction
  • - Optimising cost effectiveness
  • - Improve the patients experience
  • - Maximising benefits to patients

60
Thank You for Listening
Write a Comment
User Comments (0)
About PowerShow.com