Published on February 18, 2014
Delivering Quality and Value Focus on: Cataracts
DH INFORMATION READER BOX Policy Estates HR/Workforce Commissioning Management IM & T Planning / Finance Clinical Social Care / Partnership Working Document Purpose Best Practice Guidance ROCR Ref: Gateway Ref: 9873 Title Focus on: Cataracts Author NHS Institute for Innovation and Improvement Publication Date 14 May 2008 Target Audience PCT CEs, NHS Trust CEs, SHA CEs, Foundation Trust CEs, Medical Directors, Directors of Nursing, PCT PEC Chairs, NHS Trust Board Chairs, GPs, Opthalmic clinicians Circulation List Description This document is one of a series of documents produced by the NHS Institute for Innovation and Improvement as part of our High Volume Care programme. Produced by the Delivering Quality and Value Team, the aim of the Focus on series is to help local health communities and organisations improve the quality and value of the care they deliver. Cross Ref High Volume Care: Update Superseded Docs n/a Action Required n/a Timing n/a Contact Details NHS Institute for Innovation and Improvement Coventry House University of Warwick Campus Coventry CV4 7AL www.institute.nhs.uk For Recipient’s Use
Contents: 1. Introduction 2. Our approach 3. The recommended pathway 4. The key characteristics of high quality cataract care 5. Measures for improvement 6. Benefits of following the pathway 7. Next steps 8. Further information and resources 9. Acknowledgements Appendices 01
1. Introduction ‘Cataract surgery is now the most common surgical procedure undertaken in England, with around 300,000 operations performed annually in the NHS.’ Cataract is a common condition which causes gradual loss of clarity in people’s vision. The World Health Organisation has estimated that over 18 million people are blind due to cataract1, representing 48 per cent of total world blindness. 02 Mainly affecting elderly people, cataract can have wider consequences for individuals and can affect people’s ability to go about their normal lives, often leading to social isolation. Cataract surgery is now the most common surgical procedure undertaken in England, with around 300,000 operations performed annually in the NHS. With increasing life expectancy and an expanding elderly population, the incidence of cataract and, therefore the demand for surgery continues to rise. modernisation. The Department of Health’s Action on Cataracts2 publication and the Royal College of Ophthalmologists’ Cataract Surgery Guidelines3 have greatly assisted ophthalmology units in improving quality and standards for cataract patients. Following publication of these resources, the day case rate for cataract surgery has increased from 88 per cent in 2000-01, to 96 per cent in 2006-07. However, from our recent observations, there is still a marked variation in the way cataract care is delivered across the country, with many units identifying potential areas for improvement in their existing pathway. In developing Focus on: Cataracts we have worked closely with NHS ophthalmology units to identify the key characteristics of high quality and efficient care for cataract patients. What is care like now? These key characteristics are based on our observations of best practice adopted by ophthalmology teams across England. It is intended to help anyone involved in the cataract pathway improve their service and reduce variation in practice. Cataract care in England has been an excellent arena for service We have also explored the extent to which existing guidance has 1 World Health Organisation, ‘Prevention of blindness and visual Impairment’ www.who.int/blindness/causes/priority/en/index1.html 2 Department of Health, ‘Action On Cataracts: Good practice guidance’ (2000) www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_4005637 3 Royal College of Ophthalmologists, ‘Cataract Surgery Guidelines’ (2004) www.rcophth.ac.uk/docs/publications/CataractSurgeryGuidelinesMarch2005Updated.pdf been applied in practice (including Action on Cataracts and the Cataract Surgery Guidelines) and sought to identify any issues or barriers that may be hampering the implementation of such improvements. In addition to this, we also looked for further opportunities for quality developments in the delivery of cataract care. There are great challenges and opportunities for all those involved in opthalmic care. To meet these challenges and take advantage of the opportunities will take focused and planned effort. It will mean: looking closely at your current cataract pathway and taking time to compare it not only with existing guidelines, but with the recommended pathway and key characteristics explored later in this document. ‘Due to the high volume of cataract activity, any improvements in quality and efficiency will have huge benefits to patients, ophthalmology units and acute trusts.’
Delivering quality and value in cataract care Payment by Results (the system of paying hospitals according to the number or complexity of cases treated) is now firmly embedded within the NHS and plays a major role in financial planning within NHS organisations. The Payment by Results system is based on a national tariff - a price list for activity. The national tariff is calculated using national average costs (reference costs) as reported annually by every NHS trust. Reference costs are collected on a full ‘absorption’ basis meaning that they include all costs associated with providing a treatment such as staff, materials and equipment. The national tariff is published annually in December and implemented from the following April. In this way NHS trusts and PCTs can use the tariff to inform their local financial and service planning. Each procedure or treatment has its own Healthcare Resource Group (HRG) code and a national tariff. There are three HRGs assigned to cataracts: B13, B14 and B15 with the majority being performed under B13. The table below shows the annual volume and the associated tariff for each HRG. Figure 1: Baseline tariff payments and activity for cataracts in NHS England HRG code Elective spell tariff (2007/08) HRG name 03 Annual volume (2006/07) B13 Phakoemulsification cataract extraction and insertion of lens £720 269,745 B14 Non-phakoemulsification cataract surgery £825 2,951 B15 Other lens surgery low complexity £665 16,848 Tariffs are also assigned to outpatient appointments as shown below: Outpatient speciality code 130 Outpatient specialty name Ophthalmology outpatients Adult first attendance tariff (2007/08) £103 Adult follow-up Annual adult attendance first attendance tariff volume (2007/08) (2006/07) £49 1,615,978 Adult follow-up attendance volume (2006/07) 4,621,097
The graph below (Figure 2) sets out NHS organisations’ reference costs against the national tariff for the main cataract procedure, B13. ‘This means that: 57 per cent of organisations have costs in excess of the national tariff of £720 for cataract procedure B13.’ These figures again highlight the potential for improvement that can be made by streamlining the cataract pathway. Figure 2: NHS organisations’ reference costs against the national tariff for cataract procedure B13 (elective) HRG B13 - Phakoemulsification Cataract Extraction and Insertion of Lens 04 NB data does not include excess bed days and has been adjusted to account for market force factors. Reference cost data is based on Finished Consultant Episodes (FCEs) and tariff data is based on spells and therefore not directly comparable. Questions to be answered within your Trust: • How do your costs compare with the tariff? • What reference costs were submitted by your trust for cataract surgery? (HRGs and outpatients) • Are staff aware and involved with cost improvements? • Do your local costs properly reflect resource usage across HRGs and services? About the Focus on series This document is one of a series published by the NHS Institute for Innovation and Improvement as part of our High Volume Care programme. Produced by the Delivering Quality and Value Team, the aim of the Focus on series is to help local health communities and organisations improve the quality and value of the care they deliver. The areas we are focusing on in the programme have been selected because: they are high volume (and therefore high consumers of NHS resources), they show variability in their use of resources and they represent a range of clinical areas. To find out more about the programme and the Focus on series see the Delivering Quality and Value pages at: www.institute.nhs.uk
2. Our Approach At the NHS Institute we are committed to co-producing our products with frontline NHS staff. We invite clinicians, managers and patients from inside the NHS to work with us as part of our project teams. We also work closely with a range of NHS staff and organisations to ensure that the people who we want to use our products are able to influence their design as much as possible. Site selection phase: During the course of this project we visited a number of organisations specifically to look at the cataract pathway. We worked with nine ophthalmology units across England each with different configurations and different performance profiles and including two private providers. As well as spending time at each unit observing the cataract pathway (following patients through their journey from referral to aftercare) we interviewed more than 100 staff and patients. The Acknowledgements section at the end of this document lists and thanks the organisations with which we worked. Visit phase: Visits to the sites were conducted over one or two days. Our activities included a mix of pathway observation and semistructured interviews. We also considered how organisations were using information to aid clinical and non-clinical decision making. Our discussions involved a range of professionals within the cataract pathway including ophthalmologists, optometrists, orthoptists, pre-assessment nurses, theatre staff, anaesthetists, day case managers, ophthalmology operational managers, booking and administrative staff as well as patients themselves. Post visit phase: Following our visits we consolidated and validated the knowledge we had gathered. Working with frontline staff at a co-production event, we were able to review and agree the recommended pathway for patients with cataracts and start to identify the fundamental principles and characteristics that units need to embrace in order to deliver this pathway successfully. In the course of this work we also consulted numerous professional bodies and voluntary organisations about our findings. Our aim: This document aims to help local health communities and organisations improve the quality and value of care for cataract patients. It contains the key characteristics for a high performing, quality cataract service along with case studies and measures for improvement. The aim is for these characteristics to be widely adopted across the NHS so that cataract patients have a high quality experience irrespective of where they receive their care. 05
3. The recommended pathway Undoubtedly the national day case rate for cataract surgery has improved significantly to an average of 96 per cent ranging from around 74 per cent in a few units to as high as 100 per cent in several others. As a result units are still combining aspects from the traditional model of cataract care and the recommended model, resulting in: • delays • duplication ‘the national day case rate for cataract surgery has improved significantly to an average of 96 per cent’ 06 However, during our recent observations we found significant variation in how cataract care is delivered between ophthalmology units. For instance some cataract patients spend only one-and-a-half hours at the ophthalmology unit on the day of surgery, compared with up to six hours in other units. • and waste within their existing pathways. Many units appear to focus their improvement efforts on only one aspect of the patient pathway (e.g. the pre-assessment stage), meaning there is still scope for further improvements across the entire pathway. However, as the highest volume surgical procedure for most acute trusts, any improvements made towards the recommended pathway would generate huge benefits in both time and cost savings, as well as providing a more patient-focused service. Our observations and discussions during site visits, together with extensive feedback from stakeholders during coproduction, have enabled us to identify the key characteristics of the recommended care pathway for cataract patients. The following tables compare the traditional and recommended pathways for the management of cataract patients across the whole care pathway. We do not expect that units will be following the traditional pathway in its entirety but that they will be able to identify one or more areas within this they could improve upon.
Referral: Traditional (up to 2 weeks) Recommended (immediate) Step 1: Patient visits optometrist (including high street opticians) Step 1: Patient visits optometrist (including high street opticians) and is referred directly to hospital eye service • No specific information as to whether the patient has lifestyle problems due to cataract or whether the patient understands the risks and benefits of surgery and wishes to consider it • Complete GOS18 generic referral form and send to GP • Discuss risks and benefits of surgery (provide patient information leaflet and consent information) • Discuss patient lifestyle • Ensure patient wishes to proceed with surgery • Offer choice of provider • Complete bespoke cataract referral form, including refraction, and send to hospital eye service with a copy to the patient, GP and PCT Step 2: Patient visits GP and refers patient to hospital eye service • Send GOS18 form and details of past medical history to hospital eye service or book appointment via Choose and Book Benefits • saves unnecessary visit to GP • saves administrative time of GP generating Choose and Book referral • direct referral leads to shorter waiting time for surgery (appointment can be sooner as non-value added steps are removed from the referral process) • accurate bespoke referrals from optometry eliminates wasted visits to hospital eye service for the patient and saves unnecessary worry – this may reduce cataract referrals by up to 40% • higher percentage of correct referrals saves unnecessary clinic visits freeing up space for other patients. 07
Booking: Traditional (up to one week) Recommended (immediate) Step 1: Booking team Step 1: Booking team • Referrals allocated • Direct booking into cataract clinic (no or limited vetting) Step 2: Consultants • Referrals vetted by consultants Step 3: Booking team • Booking into general clinic Benefits • saves unnecessary administrative time 08 • speeds up time taken to generate appointment • frees up clinicians’ time as no (or limited) vetting of referral letters is required • reduces the number of patients booked into a general clinic and then returning for pre-assessment on another date.
Pre-operative assessment: Traditional (3 hours) Recommended (1.5 hours) Step 1: Patient sees nurse 1 Step 1: Patient sees either nurse, optometrist or orthoptist • Measure visual acuity, pupil reactions and intraocular pressure & perform biometry and focimetry • Measure visual acuity, pupil reactions and intraocular pressure & perform biometry and focimetry • Discuss past medical history • Discuss current medications • Complete observations • Provide patient information leaflets (including consent information for patients to review before consent is signed) • Agree day case • Discuss anaesthetic options • Dilate pupils • Investigations only if indicated Step 2: Patient sees nurse 2 Step 2: Patient sees ophthalmologist • Discuss past medical history • Slit lamp examination (including fundus) • Complete observations • Decide appropriateness for surgery • Discuss current medications • Discuss desired post-operative refractive status with the patient (including current type of spectacle correction) to enable the choice of lens implant • Identify 2nd eye surgery where appropriate Step 3: Patient sees nurse 3 • Perform biometry and focimetry • Perform auto-refraction • Perform ECG and blood tests Step 3: The following should be performed by the ophthalmologist or a suitably trained nurse, optometrist or orthoptist as seen in Step 1 • Complete bespoke cataract consent form (patient reads consent information) • Complete pre- and post-operative drug prescriptions • Complete admission documentation • Arrange INR test for one week pre-operatively 09
Traditional (3 hours) Recommended (1.5 hours) Step 4: Patient sees ophthalmologist Step 4: Patient sees booking team • Slit lamp examination • Offer patient choice of dates for surgery and for post-operative follow-up appointment • Measure intraocular pressure and pupil reactions • Agree type of admission • Discuss anaesthetic options • Dilate pupils • Fundus examination • Decide appropriateness for surgery • Complete consent using standard trust consent form (time is spent writing common risks on form every time as there is no specific cataract consent form) • Discuss desired post-operative refraction Step 5: Patient sees nurse 4 / booking team 10 • Complete admission documentation • Fixed date for surgery • Provide patient information leaflet Benefits • only one pre-operative assessment visit provides better service for patients and frees up clinic time • reduces the number of steps and handovers a patient encounters during their pre-assessment visit and therefore the amount of time the patient spends in hospital • suitably trained professionals performing most tasks frees up ophthalmologist’s time • pre-assessment visit ensures that everything is ready for the day of surgery (e.g. consent, choice of lens, INR test, 2nd eye listing, post-op drugs and post-op appointment).
Day of surgery: Traditional (6 hours) Recommended (1.5 hours) Day unit Step 1: All patients arrive at the beginning of a list (nil by mouth following trust policy) Step 1: Patient arrives at staggered or semi block times and meets ‘primary nurse’ who follows the patient through the journey including theatres (patient eats and drinks normally) Step 2: Nurses dilate patient’s pupil in the day unit Step 2: Patients dilate their pupil at home or on arrival Step 3: Review admission documentation Step 3: Review admission documentation Step 4: Examination of the eye by operating ophthalmologist Step 4: Recording of observations (blood pressure, pulse) Step 5: Complete consent form with operating ophthalmologist Step 5: Ophthalmologist or appropriately trained nurse marks eye and confirms consent 11 Step 6: Operating ophthalmologist chooses lens implant Step 6: No undressing Step 7: Operating ophthalmologist marks eye Step 7: Patient walks to anaesthetic room Step 8: Recording of observations (blood pressure, pulse) Step 9: Ophthalmologist completes post-operative drug prescription and sends to pharmacy Step 10: Total or partial undressing Step 11: Trolley or wheelchair patient to anaesthetic room Ideally, the operating surgeon should be in the position to meet their patient at pre-operative assessment to discuss refractive expectations and to choose lens implants for the patient ahead of the day of surgery. This will minimise delays and reduce last minute patient cancellations on the day of surgery.
Anaesthetic room Step 1: Monitor patient with ECG, pulse oximetry and blood pressure Step 1: Patient gets onto operating chair / trolley and is positioned comfortably for surgery Step 2: Venous access Step 2: Monitor patient with pulse oximetry Step 3: Anaesthetic given Step 3: Anaesthetic given Step 4: Patient wheeled into theatre on trolley and transferred onto operating table (using up to four members of staff) Step 4: Patient wheeled into theatre accompanied by primary nurse Theatre Step 1: Position patient 12 Step 1: Monitor patient – pulse oximetry and with hand holder Step 2: Monitor patient – ECG, pulse oximetry, blood pressure Step 2: Perform operation Step 3: Perform operation Step 3: Patient walks from theatre to day unit (if fit enough) Step 4: Transfer patient using pat slide from table to trolley (using four members of staff and risks injury to staff) Step 5: Trolley or chair patient to recovery area for observations Step 6: Operating ophthalmologist writes prescription for post-operative medication Traditional (30 minutes) Recommended (0 minutes) Recovery Step 1: Wheel patient to recovery Step 2: Monitor patient with observations (blood pressure, pulse) Step 3: Transfer patient by trolley or chair to day unit No stop in recovery
Traditional (1 hour plus) Recommended (30 minutes) Day unit Step 1: Monitor patient with observations (pulse, blood pressure) Step 1: Monitor patient with observations (pulse, blood pressure) Step 2: Await drugs from pharmacy Step 2: Reviewed by nurse for discharge (post-operative patient information and postoperative appointment date already given at preassessment, and post-operative drops already dispensed from pharmacy) Step 3: Patient’s eye examined by ophthalmologist / nurse on slit lamp Step 4: Post-operative information given to patient by nurse Step 5: Post-operative appointment arranged via booking team 13 Benefits • less observations needed • no need for patients to go to general recovery – this can be unpleasant for patients and it reduces staffing costs • staff time freed up by omitting unnecessary moving and handling of patient • shorter stay in day unit reduces pressure on nursing staff and helps them care for patients better. After care Traditional Recommended Step 1: 24-hour follow-up with ophthalmologist Step 1: 2-4 week review by nurse, optometrist or ophthalmologist Step 2: 2-4 week review by ophthalmologist Step 2: 4-6 weeks patient attends local optometrist Step 3: 4-6 weeks patient attends local optometrist Benefits • avoids 24 hour post-operative visit for the ‘routine’ patient which is more convenient for the patient and saves clinic time.
4. The key characteristics of high quality cataract care Through our observations and work with NHS partners we have found the following characteristics to be the key features for delivering both quality and value care for patients undergoing cataract surgery. After the explanation of each characteristic there are case studies from frontline teams and suggested improvement measures. These key characteristics are grouped and presented in two main categories: • overarching characteristics which are common to the entire pathway • pathway specific characteristics relating to the main steps in the recommended pathway: • referral • booking • pre-operative assessment • day of surgery • after care. 14
Overarching characteristics of an ideal cataract care pathway Key characteristic 1: The pathway is ‘fit for purpose’ The best performing units have developed pathways which are specifically designed for high volume day case cataract surgery. Examples of this include: • developing bespoke cataract consent forms • developing protocols that are specific to cataract surgery (such as allowing patients to eat before surgery). ‘We don’t treat cataracts but treat people with visual disability caused by cataract – there’s an important difference’ Case study ‘We treat people, not cataracts’ Worcester Cataract Clinic is part of the Worcestershire Acute NHS Trust and operates out of the Worcester Royal Hospital and Kidderminster Treatment Centre. The centre won a Beacon Award in 2000 for its friendly and efficient cataract service. At that time more than 100 consultants and staff from the UK and Ireland visited the department for lectures and live surgery sessions. The clinic has run a four-visit bilateral sequential cataract surgery service for the past three years resulting in significant savings to the health economy in Worcestershire. For every 1000 patients with bilateral cataracts there is a potential saving of 1000 outpatient appointments over the most efficient conventional system. The clinic believes, for instance, that if a patient’s blood pressure is acceptable at the pre-op clinic 10 weeks before it does not need to be tested again. ‘We don’t treat cataracts but treat people with visual disability caused by cataract – there’s an important difference’ explains Paul Chell, Clinical Director ‘We regard patients as being well and we respect their involvement in their refractive outcome. For example, if a patient is accustomed to monovision in contact lenses then we feel that option should be offered as an outcome for their cataract surgery.’ The pathway also offers: The service is patient focused and based on a set of fundamental principles which includes the concept of treating people from the point of view of wellness not illness. • one-stop cataract assessment and diagnostic clinic • one pre-operative appointment for both eyes • the creation of a refractive plan for each patient • a length of stay of 90 minutes on the day of surgery • improved privacy – with no need for patients to undress • one follow-up appointment for both eyes • open access to clinic for patients post-operatively • one opticians visit and one pair of glasses for both eyes. Results: Audits show that the interoperative complication rate is less than six per thousand for the department as a whole. This reduces the number of outpatient clinic attendances as intra-operative complications not only increase the risk of a poor visual outcome but also doubles the number of patient visits. 15
Key characteristic 2: The service has a high degree of autonomy ‘Ophthalmology units benefit enormously from being able to devise and adopt policies and procedures that reflect the very different nature of this extremely high volume surgical specialty’ 16 Ophthalmology is a unique service and the best practice pathway for cataracts has many specific requirements which are different to other surgical pathways. As a result ophthalmology units benefit enormously from being able to devise and adopt policies and procedures that reflect the very different nature of this extremely high volume surgical specialty. For instance, many ophthalmology units use a trustwide generic patient consent form. But consent could be obtained more appropriately and more efficiently using the bespoke cataract patient consent form devised by the Royal College of Ophthalmologists (see Section 8 - Further information and resources). Cataract surgery is the largest volume surgical procedure in many acute trusts and, therefore, by giving ophthalmology units increased autonomy will enable them to implement improvements more easily and develop a pathway tailored specifically to the requirements of cataract patients. We have observed that those ophthalmology units with a high degree of autonomy within a trust find it easier to develop a cataract pathway which delivers high quality efficient care. Key characteristic 3: Data and information are used effectively to enhance decision making Greater financial authority and responsibility may enable eye departments to develop new and better services. Clinicians should be aware of Healthcare Resource Group (HRG) costs and tariffs including the costs of instruments and pre- and post-operative drops. All staff can help in identifying potential cost improvements. Thresholds on a variety of clinical areas are being applied nationally. For instance, during our visits we observed thresholds implemented by a PCT which led to a considerable reduction on the number of cataract procedures listed. As this has been a recent adjustment to the service it is too early to judge the merit of this new practice. However, although there are no nationally agreed guidelines, ophthalmology units need to understand the implications to their service if thresholds are imposed locally. Audits should also take place on a regular basis (e.g. rate of optometrist referrals for cataract that actually require surgery, reasons for unplanned admissions and cancellations).
Key characteristic 4: Multidisciplinary teamwork is key Ophthalmologists, optometrists, orthoptists, pre-assessment nurses, theatre staff, anaesthetists, day case managers, ophthalmology operational managers, booking and administration staff all work together to make improvements to the cataract pathway. The whole team should be aware of the entire patient journey (ideally having observed it firsthand) so that a consistent message is given to patients and carers. The ‘do it once, do it well’ principle is useful here. Each part of the pathway needs to be completed by someone who is appropriately trained. ‘Having confidence in individual members of the team opens up new possibilities for the expansion of roles’ Having confidence in individual members of the team opens up new possibilities for the expansion of roles. For instance, during our observations some surgeons expressed a lack of confidence in the pre-assessment stage and felt ocular examination necessary on the day of surgery. This can lead to delays in starting and finishing lists and can prevent the unit from staggering the arrival times for patients. This can be avoided by: • ensuring staff have the correct training and support • close working between preassessment staff and the operating surgeon which helps promote confidence in all steps of the pathway leading up to, and following surgery. 17
Case study Flexible theatre cover; reduced waste The problem caused by increased demand for cataract surgery but with no additional theatre time or staffing has led to the creation of a new and flexible role within the Ophthalmic Unit at Norfolk and Norwich University Hospital NHS Trust. 18 Working closely with secretaries, theatre managers, booking clerks and the outpatient manager the associate specialist plays an important role in helping the unit target areas of need and minimise wasted theatre time. Results: The role of associate specialist was created by re-grading the staff grade. The move has significantly increased cataract capacity and throughput in the unit and has achieved this entirely within the existing theatre sessions and without the need for extra staffing. The associate specialist prioritises their time by picking up theatre lists in Norwich and Cromer first and then booking in clinics for the sessions they are not required in theatre. • overall an average of 1500 more cataract operations per year are carried out A database is kept of all the annual leave booked by all the medical staff in the unit and a monthly timetable is produced. This allows the associate specialist to identify and pick up theatre lists and clinics which would otherwise be left vacant. The system is particularly useful during school holidays when many theatre lists would otherwise be unfilled due to consultant absence. The move has significantly increased cataract capacity and throughput in the unit and has achieved this entirely within the existing theatre sessions and without the need for extra staffing On theatre sessions there is no case selection or cherry picking of more straightforward cases, and there is normally still time for the associate specialist to carry out some teaching of junior doctors. In the first year after implementing the new role: • wasted theatre slots were reduced by 85 per cent and an extra 1000 cases were carried out • a specialist registrar would normally do over 100 outpatients sessions per year (roughly 1800 outpatient slots). The flexible associate specialist is able to do that number in addition to all the extra cataract work. When cataract numbers were reduced in 2006-2007 due to PCT restrictions on patient eligibility for surgery the number increased to 170 clinics (over 3000 outpatient slots).
Key characteristic 5: Patient flow is optimised and waste and duplication eliminated The number of patient handovers throughout the pathway needs to be reduced. For instance, some patients can see up to seven different individuals (including four different nurses) during their pre-assessment visit while others see only three professionals in total. To support high throughput lists, the ideal set-up of an ophthalmology unit would be as a discrete (or self contained) unit within the trust. A ‘cataract centre’ containing its own outpatient rooms, day unit and theatres is an ideal way to facilitate patient flow. Careful thought should be given to how patients flow through the system with any steps that don’t add value being eliminated altogether. For instance, the day unit should be close to theatres making it easier for patients to walk to and from surgery. Some units have to trolley patients long distances taking up time and resources and often creating delays. Ophthalmology units will undoubtedly have restrictions to major layout changes so the basic components would be a dedicated day unit and theatre close together. The one-stop preassessment team should also be located in one area within outpatients. Much can still be achieved without the need to have a completely self-contained department. Key characteristic 6: Patient information is consistent, timely and accessible Patient information should be relevant and consistent throughout the whole patient journey. This should begin at the start of referral and involve an informed discussion between the patient and optometrist of the risks and benefits of cataract surgery. This allows a reduction in the number of inappropriate referrals and makes for a more efficient pre-assessment clinic. But it does require close links between referring optometrists and providers. Information also needs to be provided in an accessible format, such as audio tapes that patients can listen to at home before surgery. See Section 8 - Further information and resources for the Royal National Institute for the Blind’s ‘See it Right’ Guidelines. 19
Referral: key characteristics Key characteristic Direct referral is used to save patient and clinic time Bespoke cataract referral forms can filter out patients who are untroubled by cataract or do not wish to proceed with surgery at that time. 20 The form should trigger a discussion with the patient about the risks and benefits of having surgery. It is through this discussion that agreement with the patient can be sought to proceed with referral to secondary care for treatment options. The referral form should cover: • refraction • visual acuity • intraocular pressure • significant symptoms (e.g. night driving) • co-morbidity of the eye • relevant medical history from opticians (e.g. mobility problems, requirement for a interpreter) in conjunction with past medical history from the GP if required. Copies of the form need to be given to the patient, GP, PCT and hospital eye service. An example of a bespoke cataract referral form can be found in Appendix 1 at the end of this document. Optometrists are the preferred profession to provide this information. Although a fee is often incurred for direct referrals there are potentially overall savings as patients do not need to see their GP and unnecessary referrals to the hospital eye clinic are reduced. However, many PCTs do not currently have the funding available for direct cataract referral schemes. Where it can be achieved the direct referral pathway should be implemented alongside an education programme to introduce optometrists to the ophthalmic department criteria for cataract surgery. In addition: Consistent information from all healthcare professionals helps to manage patient expectations right throughout the pathway beginning with their visit to the optometrists. A leaflet including information about the risks and benefits and the consent process should be given to patients at this first visit. The optometrist should also have information about all providers of cataract surgery giving the patient choice of provider for their operation. Regular audits of optometric referrals should take place, and feedback given to referring optometrist to improve the standard of the service.
Case study Direct referral from optometrist to cataract service Surrey PCT has developed a pathway that is allowing optometrists to refer patients directly to the cataract clinic. The scheme requires the optometrist to undertake an educational lecture with local ophthalmic surgeons. This involves explaining the criteria for cataract extraction and the risks of cataract surgery. The optometrist is then able to discuss in detail the option of cataract surgery with patients helping them decide whether or not to proceed with the hospital referral. If, on visiting the optometrist, cataract is found, referral is only considered if the patient is noticing an effect on their lifestyle. Then: • the patient is informed of the risks of loss of vision from cataract surgery • if the patient wishes to proceed the referral is made • an assessment of angle closure is made and documented (enabling clinic staff to dilate the patient’s pupils prior to seeing the ophthalmologist) • the patient is given an information leaflet about cataract and the operation • the optometrist also has information about the choice of local providers for cataract surgery – meaning the patient can choose their provider • the bespoke cataract form is filled in and five copies are made - one each for the optometrist, patient, GP, the hospital cataract clinic and the PCT for remuneration. The optometrist receives £25 from the PCT for each referral regardless of whether the patient progresses to surgery or not. In cases where more than 10 per cent of an optometrist’s referrals refuse surgery when seen at the hospital eye service the optometrist is required to reattend the training lecture. Initially there were several similar schemes across the health community. These have now been brought together in one consistent system where the documentation is all the same. Results: • audit information from one cataract clinic found that before the set up of the bespoke cataract referral scheme 50 per cent of cataracts referred did not have any indication to have surgery • after the introduction of the scheme the conversion rate to cataract surgery in the cataract clinic increased to 90 per cent. 21
Booking: key characteristics Key characteristic Direct booking is supported by bespoke referral systems 22 Alternatively, patients can be given a choice of dates and times for their outpatient appointment through the Choose & Book electronic referral system. Direct booking into a cataract clinic from the bespoke referral form offers the most streamlined solution. Using information from the bespoke form booking staff can book patients into the correct one-stop pre-assessment clinic without the need to involve other professionals. For optimal waiting list management a robust policy for DNAs (did not attends) needs to be in place and followed. This reduces the need for clinicians to ‘vet’ referrals. Limited vetting should only occur for cases with co-morbidities. ‘Direct booking into a cataract clinic from the bespoke referral form offers the most streamlined solution’
Pre-operative assessment: key characteristics Key characteristic Pre-assessment is streamlined, comprehensive and avoids handovers From our observations, the time a patient spends at pre-assessment varies from one and a half hours to three hours. The shortest time was achieved in a one-stop clinic (as outlined in Action On Cataracts) where the patient only has one visit prior to surgery. It was achieved by the professionals listed below undertaking the following: Nurse / optometrist / orthoptist The following steps should be performed by the same individual member of staff to avoid handovers: • measure visual acuity, pupil reactions and intraocular pressure & perform biometry and focimetry • observations • past medical history • discuss current medications • patient information leaflets (including consent information for patients to review before consent is signed) • investigations (if required) • agree day case - if patient deviates from the ‘normal day case’ pathway follow strict inpatient criteria • discuss anaesthetic options • pupil dilation. Note: auto refraction is unnecessary at this point as the information has already been provided by the optometrist. Undertaking this examination at this stage is a duplication. Although The Royal College of Ophthalmologists Cataract Surgery Guidelines clearly states that there is no benefit in performing ECGs or blood tests there are still a small number of units currently carrying out unnecessary ECGs. 23
Case study Biometry could be an extended role for Orthoptists Biometry is a natural extended role for orthoptists using many of the skills they already have. Recognising this the University Hospitals of Leicester NHS Trust is using orthoptists to carry out biometry at its cataract clinics saving time for both patients and clinicians. 24 Orthoptic undergraduate training already covers the anatomy and physiology of the eye in detail: ophthalmology investigative techniques, refractive error and, of course, binocular vision. These are the areas that need to be fully understood in order to carry out successful biometry and for satisfactory post-op outcomes to be achieved. In addition, orthoptists routinely take an ophthalmic and medical history from patients - other key skills needed in cataract clinics. According to the trust the only additional training orthoptists require is in the use of the equipment (the keratometer and A scan, and, more recently, the IOL Master). Biometry is a natural extended role for orthoptists, using many of the skills they already have At Leicester two senior orthoptists were initially trained by medical staff and cascaded the knowledge to the rest of the orthoptic team. Regular competency assessments are carried out to ensure standards are maintained. An added advantage of the extended role is when binocular vision problems are identified for the first time during biometry. With orthoptists carrying out the test these can obviously be addressed at the same appointment. The British and Irish Orthoptic Society has produced a document, Competency Standards and Professional Practice Guidelines for the Extended Role of the Orthoptist (2006). See Section 8 Further information and resources.
Ophthalmologist • slit lamp examination including fundus examination – or, alternatively, this can be carried out by a suitably trained professional (e.g. nurse, optometrist, orthoptist) • decide appropriateness of surgery • discussion with the patient of the desired post-operative refractive status - this avoids complex discussion and decision making immediately before surgery which can be distressing for the patient • identify second eye surgery where appropriate. Note: Ideally, the operating surgeon should examine the patient. This is best performed once at pre-assessment and not left until the day of surgery or duplicated. This is more practical now that the time between preassessment and surgery is shorter. member of staff (ideally the same member of staff as in Step 1) to avoid handovers: • consent should be obtained through a bespoke consent form specifically for cataract patients • the consent form should clearly state the risks and benefits associated with cataract surgery and should be pre-printed • pre-operative drug prescriptions should be completed during this visit on a pre-printed form – this helps minimise delays on the day of surgery and could be undertaken by the nurse acting under Patient Group Directives • standardised post-operative eye drops should be prescribed in the initial pre-assessment visit and patients educated on how to instil them • patients unable to self medicate should be identified and contingencies put in place to support them - this streamlines processes on the day of surgery Remember: Do it once, do it well • specific requirements (e.g. translation, transport) on the day of surgery are identified and arranged in advance Ophthalmologist or suitably trained nurse / optometrist / orthoptist • admission documentation for the day unit should be completed at this point in the process, in advance of the day of surgery and reviewed on arrival for surgery The following should be performed by the same individual • the INR test should be arranged in the community one week before surgery - this avoids waiting for results on the day of surgery and the possible risk of cancellation. Information required at assessment: During our observations there were many examples where trustwide policies produced large amounts of unnecessary work. These steps did not add value to the process. Patients in one trust, for example, had to undergo a DVT risk assessment, a nutritional level assessment as well as a bed sore risk assessment before cataract surgery. Far from adding quality to the process these constraints may well detract from it by reducing the time staff have to discuss relevant issues and concerns with the patient. Booking team Patients are offered a choice of dates and times for their operation and follow-up appointments. 25
Case study ‘Plan of care’ booklet supports the whole cataract pathway As well as dealing with a vast throughput of patients since it opened in 1993 the Cataract Treatment Centre at Sunderland Eye Care Infirmary has also taken positive steps to help patients understand each stage of their care journey. 26 The unit has introduced a simple and informative plan of care that patients can use when they return home following preassessment, surgery and after their post-operative appointment. Working together to devise the booklet patients and staff agreed that the information should describe care from preassessment right through to post operative clinics. Knowing what will happen to them in advance allows patients and carers to make arrangements, for instance with transport or organising help with drops. ‘Knowing what will happen to them in advance allows patients and carers to make arrangements, for instance with transport or organising help with drops’ The booklet also supports the pre-assessment process by: • giving patients and carers a take-away resource so they don’t have to retain all the information given to them on the day • enabling staff to signpost information in the booklet so they don’t have to repeat information and instructions. Dates for surgery and all other appointments are clearly identified on the front of the booklet thus giving patients a useful ‘at-a-glance’ record. The plan also gives contact numbers in case the patient experiences any problems or needs advice. Care has also been taken over the font size of the booklet, setting it at N18 – a size which most patients with visual impairment are able to read. The booklet’s yellow colour also contrasts with the print to give high definition and ensure easier reading. The booklet is professionally printed and reviewed yearly with patients. Results: As well as patients and carers being better informed the booklet has helped reduce cancellations and forgotten appointments leading to better utilisation of clinics and theatre lists. See appendix 2 for the Plan of Care booklet.
Case study Nurse led consent Newcastle Upon Tyne Hospitals NHS Foundation Trust introduced nurse led consent in 2002 following the Department of Health’s ‘Consent Policy’ earlier that year. The Trust already had a fully nurse led preassessment clinic – so expanding the role to include taking consent was seen as a natural move and a good way to support continuity of care for patients. With all nurses now leading the consent process the consent form is signed by the patient and the nurse and remains in the medical notes. This is then readily available on the day of surgery when the nurse obtains the second signature. Results: • it provides a better patient experience as the nursing and consent aspects of treatment and care can be discussed at the same time • patients are offered a choice of dates and times for their operation and follow up appointment. • the process frees up 10 minutes per patient of consultant time 27
Day of surgery: key characteristics There is wide variation across NHS organisations in the total length of time a patient is in hospital for their cataract operation. In some units this is done in an efficient and timely manner and takes no longer than one and a half hours. In others a patient can stay for up to six hours without any added value. 28 • dilation is done at home or directly on arrival For operating lists to be efficient it is important to have a member of staff who is responsible for the flow of patients through the list. This role is best undertaken by an anaesthetist or theatre sister who, assisted by the use of a TV monitor, can assess how the operation is progressing and prepare for the next patient accordingly. • warfarin levels are taken a week prior to the day of surgery Key characteristic Day of surgery processes are streamlined • the eye is marked by ophthalmologist or nurse (who will remain with patient in theatre) – this allows the list to flow with staggered arrival times without removing the surgeon from the theatre. (See Section 8 Further information and resources for the ‘Correct Site Surgery’ Guidelines) What this means in the day unit: • a primary nurse remains with the patient throughout the surgical pathway from admission to discharge thus improving continuity of care • arrival times are staggered patients prefer this and it helps minimise pre-operative waiting. However, semi-block arrival times will also facilitate theatre flow and reduce the number of patients the nurses are looking after at any one time • admission documentation already completed at preassessment is reviewed • observations are recorded (blood pressure, pulse) • consent is confirmed with ophthalmologist or nurse • undressing is not necessary as patients wear a cap and a theatre gown over their clothes and good draping techniques are used to avoid iodine on their clothes • the majority of patients are able and happy to walk to the anaesthetic room thereby avoiding the use of trolleys and chairs - this reduces patient handling and risk of back injury and helps free up staff normally involved in patient transport.
Case study Primary nurse stays with patient across whole journey In the Cataract Treatment Centre at Sunderland Eye Infirmary patients benefit from knowing that the nurse who does their pre-assessment will be the same individual who accompanies them right throughout the surgical pathway. During assessment the named nurse involves the patients in making decisions about their care, offering them choices of dates and helping them think about other issues such as home circumstances, transport arrangements and anaesthesia. The nurse then places the patient on the operating list and ensures that they will be present on the day of surgery to look after their patient. On the day of the operation the nurse positions the patient for surgery and holds the patient’s hand throughout. Being this close means the nurse can keep talking to the patient and quickly deal with any problems, whether this is just reassuring them or something more practical such as adjusting air flow so the patient does not get breathless or start to panic. This has several benefits: ‘The one-to-one care makes the patient feel they are the only one that matters – they are less anxious and often presume they are the only patient on the list’ • a trust builds up between the nurse and patient with the nurse becoming more sensitive to the patients needs and able to detect when the patient is anxious and needs increased reassurance • there is less repetition which makes the patient feel they are being listened to and not handed from one member of staff to the next. Results: • the patient knows who will be looking after them during surgery and they are confident that they will see a familiar face - this is very important to patients who are elderly as they are often anxious about how they will cope during the operation, whether they will be able to lie still during surgery and whether they will feel any pain • the one-to-one care makes the patient feel they are the only one that matters – they are less anxious and often presume they are the only patient on the list • there are no handovers thereby reducing the chances of mistakes • patients cope well with surgery and are quickly ready for discharge • nursing staff have increased job satisfaction - staff motivation is high with reduced sickness levels and reduced staff turnover in the unit. 29
What this means in the anaesthetic room / pre-operative area: The anaesthetic room is essential for the smooth running of a cataract list. This enables more time to be spent getting the patient comfortable and ready for theatre without wasting time during the theatre slot. Specifically: 30 • the patient is positioned comfortably on operating trolley / chair • saturation monitoring is the only monitoring required • anaesthetic is given: • with sharp needle anaesthetic techniques - an anaesthetist should be present at all times (refer to The Royal College of Ophthalmologists Cataract Surgery Guidelines) • with topical anaesthesia and blunt cannula techniques – an anaesthetist presence is not essential as long as at least one member of the theatre team is qualified in Advanced Life Support. Notes: • The Royal Colleges of Ophthalmologists and Anaesthetists do not recommend routine blood pressure checks or ECGs in theatre • venous access is not recommended by the Royal College of Anaesthetists in patients undergoing topical or sub-tenons anaesthesia.4 What this means in theatres: Dedicated cataract lists can lead to greater efficiency and throughput. A minimum of six or seven operations can be performed on a list including training lists. High volume lists are regularly achieving at least nine. High volume lists are regularly achieving up to nine or ten operations a list. It is important that the complexity and the length of surgery are taken into account when deciding on the number of cases on a list. However, standardisation of the entire pathway can help efficient running of lists. Other specific things to consider include: • saturation monitoring is all that is required during surgery • the ‘hand holder’ is an excellent way to monitor patient experience and wellbeing as well as helping reduce anxiety levels - in some units this role is undertaken by volunteers • standardisation in types of instruments surgeons use will help the scrub nurses know which instruments the surgeon will need and will make setting up between cases easier • some units find it efficient to train the scrub nurse to drape the patient and to fold or load the intra-ocular lens prior to insertion • peri-operative drugs and postoperative drops should be preprinted to save surgeon time during the theatre list - ideally these should be prescribed at pre-assessment to save patients waiting for drops to be dispensed on the day of surgery 4 The Royal College of Anaesthetists and The Royal College of Ophthalmologists, 2001. Local Anaesthesia for Intraocular Surgery. www.rcoa.ac.uk/docs/rcarcoguidelines.pdf
• units are moving towards the Electronic Patient Record (EPR) but in practice most units continue to use a combination of electronic and paper records - a rational approach to this may help reduce duplication. In units where the process is nearly all paperless there may be great benefits from making the final push and becoming completely paperless. • the level of nursing staff in theatres and the day unit varies - the most efficient model we observed was: • 3 staff in theatres s 2 scrub nurses and 1 runner • 3 staff in the day unit 3 primary nurses / unit staff rotating through theatres and day unit. s What this means in the day unit: After the operation, if the layout permits, the patient should walk to the day unit thus avoiding further unnecessary patient handling. If needed, consider using a wheelchair. A single set of post-operative observations (blood pressure, pulse) can also be performed, avoiding a stop in recovery. Other specific things to consider include: • standardise post-operative medication between surgeons ordered at pre-assessment - this enables pre-packed, postoperative drugs to be available immediately ready for discharge • providing two bottles of postoperative eye drops avoids an unnecessary visit to the GP for patients needing another bottle • some units are no longer using eye shields after surgery, or for patients at night, without an apparent increase in postoperative complications • in many eye units the patients are reviewed post-operatively by trained nurses for discharge • unless a patient had complicated surgery or is in pain a slit lamp examination is not required and adds little value - this enables patients to leave the day unit sooner by reducing unnecessary waiting and time spent in the hospital • ideally a patient should be discharged within 30 minutes post-operatively - the same nurse discharging the patient should ensure patient education is given including emergency 24-hour contact details • date and time of post-operative appointment (agreed at preassessment) should be confirmed. 31
After care: key characteristics It is usual to arrange a single post-operative visit at two to four weeks. This can be done in a number of ways. The majority of patients are reviewed in hospital clinics and in some units nurses or optometrists perform this role for routine cases. 32 However, some patients are still being routinely reviewed 24 hours post-operatively regardless of whether there has been complicated surgery. This is unnecessary and means another visit for the patient. Other alternatives to hospital review have successfully been set up using local optometry services. Important features of the postoperative review include: • visual acuity measurement • auto-refraction to screen for refractive surprise • eye examination • discussion of post-operative results • management of post-operative refractive error • collection of outcome data • listing of second eye • refraction by optometrist - this should occur four to six weeks after surgery when the patient has stopped using their eye drops and has been discharged from the eye clinic. In cases of second eye operation refraction follows the second operation. Note: Most surgeons and patients prefer to ensure that the first eye has fully recovered before advising for second eye surgery. In line with the 18-weeks policy the clock officially starts when a patient is fit and ready for the second of a bilateral procedure. To keep up to date with 18-week requirements visit: www.18weeks.nhs.uk The second eye pre-assessment can be performed over the telephone by a nurse (and a choice of date offered for surgery) for uncomplicated cases. Some units proceed to second eye surgery without a post-operative visit for the first eye.
Case study 2nd eye telephone pre-assessment Newcastle Upon Tyne Hospitals NHS Foundation Trust has introduced telephone preassessments for second eye patients. As well as placing a burden on staff time and resources this was an unnecessary step for the patient and inconvenient if they had to travel long distances. Originally every patient would have to come back for another pre-assessment appointment at the hospital before their second eye operation even if it was only a few months since their first eye surgery. Now patients book their second eye operation date at their postoperative visit and nurses phone patients to check their details have not changed since their last operation. Results: • considerable time and resource savings for the department • an improved experience for patients. 33
5. Measures for improvement Through our observations we identified a need and desire in frontline staff and managerial teams to understand current performance in their cataract services and compare this performance to local and national benchmarks. Data to help identify potential improvement opportunities in cataract pathways was also highlighted as a key need. Wellperforming organisations that we visited had a good understanding of their own performance and routinely used data to drive quality and safety in their local 34 services as well as to assess the impact of any changes they made. They should also be used in conjunction with 18-weeks measures. The measures offered here are not in any way prescriptive. The aim of using these metrics is to: Local services will want to prioritise the use of these measures to reflect their own local circumstances. Agreement will also need to be reached on how frequently this information is collected and what level of detail is sought. • improve the quality and effectiveness of care and the patient experience • decrease the variation in cataract pathways • stimulate thinking and help local organisations consider their own position in terms of specific cataract processes.
Pathway Step Measure Aim Referral percentage of optometrist referrals for cataract that actually require surgery > 90% Booking percentage of referrals directly booked into cataract clinic without being vetted > 80% Pre-assessment percentage of patients not preassessed on day of initial consultation < 10% Pre-assessment length of time at pre-assessment visit target 1 1/2 hours 35 Day of surgery length of stay from admission to discharge target 1 1/2 hours Day of surgery utilisation figures for cataract theatres > 90% Day of surgery number of cases per week 70 per theatre (if 10 operating lists per week) After care patient satisfaction surveys quarterly After care percentage of patients using 24hour helpline vs patients attending eye casualty locally agreed
6. Benefits of following the pathway There are fewer visits to hospital and pre-operative and day of surgery visits are shorter: • patient flow is improved • variability in the process is reduced. This results in: • increased activity • better use of capacity (resources for inpatient operations and emergency care are freed up) • patients being treated faster • shorter waiting times. 36 Patient expectations are managed and satisfaction is improved: • consistent information is provided about the medical condition, the options for management and what to expect from treatment • patients have choice and certainty over dates for hospital appointments and over the operation date • patients are not referred unnecessarily to the pathway • access to well designed facilities improves the patient experience • well trained staff provide consistency of care • patients are able to return to their own homes sooner • risks of hospitalisation, e.g. through hospital-acquired infection, are reduced • effective pre-assessment and booking processes reduce cancellations. There are significant financial benefits: • reductions in the length of stay and standardisation of procedures and equipment all reduce costs • productivity is increased through reducing variations in the process • waste is reduced and resources are freed up e.g. fewer last minute cancellations. Surgical reputation is enhanced through improvements in quality: • opportunities for marketing are created in the new, competitive NHS environment • staff and patient satisfaction increase. Team working and the working environment improves: • the multidisciplinary care pathway achieves a shared vision and purpose • a high quality mindset is developed in staff.
7. Next steps The advice and ideas offered in this report are based on our observations of practice within ophthalmology units. Although these practices are delivering high quality care and value for money it should be recognised that they may not be the only way of achieving these. However, we believe they will offer useful guidance and direction to anyone seeking this goal. To improve services we advise organisations to use this guidance and take the following steps: • map your current pathway against the recommended pathway for cataracts and existing guidelines • identify areas of delays, waste, duplication and savings in your current pathway • generate a local plan for improvement. While this document offers suggestions to care providers and commissioners
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David Allen, Abhay Vasavada: Cataract and surgery for cataract. In: BMJ. 2006 Jul 15;333(7559), S. 128–132. Review, PMID 16840470;
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