Title: The Role of the Consultant Nurse in Ophthalmology
1The Role of the Consultant Nurse in Ophthalmology?
- Mary Freeman
- (RGN, OND, MBA, MA)
- Royal Hallamshire Hospital
- Sheffield Teaching Hospitals NHS Foundation Trust
2Aim
- Historical perspective how and why the post
came about - What I do
- Challenges in developing a new role
3The 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
4Elements 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
5Elements of the Post
- An educational, training and development function
- A practice and service development, research and
evaluation function
6The 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
7My 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
8OK So What Do I Actually Do?
9Macular 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
10Clinical 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)
11Clinical Function
- Discuss concerns / support and counsel patients
- Review patients who have had PDT
12Organisational Function
- Streamlining referral pathways
- Provide increased clinic capacity rapid access
clinic to allow patients to gain prompt diagnosis
and treatment
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20Glaucoma
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)
22A 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
23Why 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
24Referrals 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
25Glaucoma 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
26Investigations 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
27New 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
28Patient 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)
29New 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
30Nurse 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
31Assessment 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)
32Assessment 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
33Optic 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
34Service 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
35Audit
- 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
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37Effectiveness 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
39Results
- 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
40In 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.
42Analysis of Patients Referred Into Clinic
- 121 notes were randomly selected over last 2
years
43Analysis 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
44Benefits (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
45Benefits (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
46Benefits (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.
47Sheffield Diabetes Eye Screening Programme
48National 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
49Community 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)
50In Summary
- How and Why Has My Role Emerged?
51The 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
52For 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
53But
- 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
54Challenges (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
55Challenges (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
56Challenges (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
57Challenges (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
58Challenges (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
59Benefits?
- - Job satisfaction
- - Optimising cost effectiveness
- - Improve the patients experience
- - Maximising benefits to patients
60Thank You for Listening