Mapping Greener HealthcareMapping Greener Healthcare

Project Description

Background: Direct ophthalmoscopy (DO) is a critical skill acquired in undergraduate medical education for the diagnosis of sight and life-threatening conditions. Learning this skill is difficult at an undergraduate and trainee level, possibly due to device access.

Approach: The project was to compare the implementation of the Arclight (portable) ophthalmoscope in one student group against a student group using the standard direct ophthalmoscope based on competency in DO examinations. Each respective groups’ self-reported competence in DO and assessed competency was recorded.

Intended Benefits

Patient outcomes: By improving the clinician’s DO skills, patient outcomes might improve due to early and better diagnosis of sight and life-threatening conditions.

Environmental, Financial, Social: The Arclight group self-reported improved competence in DO and there was a mean increase in ease of use compared to the control group. According to assessed competency, there was no statistical difference between the two groups. The environmental and financial impacts need to be further investigated.

Potential Barriers

Challenges to addressing this issue:

• Other educational materials and approaches need to be changed

Key Aspects of the Project

This project addresses the clinicians’ skills in diagnosing and providing care to patients by changing access to equipment used in skill acquisition.

Project Description

Background: For neovascular age-related macular degeneration (nAMD), the ideal treatment regimen has not been determined. To address patient outcomes and resource use, a “Treat and Extend regimen” was applied for anti-vascular endothelial growth factor (VEGF) in nAMD.

Approach: With a “Treat and Extend regimen,” the aim is to individualise and gradually increase treatment intervals without reducing visual outcomes (i.e. quarterly injections instead of monthly injections). The team tested two separate drug treatments with the regimen: Eylea and Lucentis.

Intended Benefits

Patient outcomes: Under the new regimen, patients have visual outcomes similar to the previous approach.

Environmental, Financial, Social: A modified “Treat and Extend” approach reduces treatment burden and decreases monitoring visits, which would decrease the time spent travelling and associated carbon emissions.

Potential Barriers

Challenges to implementing this system could be:

• More resource intensive at start (number of injections may be higher during the year 1 and 2)
• Training staff to implement new regimen
• Patient adjustment and agreement to new regimen

Key Aspects of the Project

This project focused on a change in treatment that could reduce resource usage and improve patient experience.

Project Description

Background: Prisoners constitute a population with unique health needs as they rely solely on the prisons to provide access to hospital care by arranging hospital attendance. The impact of this type of regulation on prisoner health has not been reported.

Approach: The team assessed the attendance of prisoners to hospital appointments and the impact on health. Based on 1104 appointments offered to 161 patients, the team found the failure to attend rate was 41.9%. Of patients intended to attend appointments for interventions, 12.7% failed to attend. For first post-operative appointments, 37.1% of patients failed to attend. Of prisoners who failed to attend an appointment, 9.7% were at risk of harm.

Intended Benefits

Patient outcomes: By understanding the health status and access to care of prisoners, staff are able to provide better care and improve patient outcomes. Most noteworthy is the subgroup of prisoners who are placed at risk of harm directly as a result of delayed appointments.

Environmental, Financial, Social: By resolving the delay in appointments for patients, it is assumed that the wasted time on delayed and missed appointments could be saved. There could be additional impacts such as transportation costs and relationship dynamics between prison administrators and prisoners if more information were known.

Key Aspects of the Project

This project specifically focused on a marginalised population in the healthcare system to assess their access to care and health needs.

Project Description

Background: Ophthalmology services are increasing in demand. Appropriate referrals reduce burdens on the service and ensure patients with serious conditions are seen. The local clinical commissioning group (CCG) of Manchester Royal Hospital commissions a service to triage general practitioner (GP) referrals to secondary care, so patients who can be seen in other services are seen in secondary care rather than further burdening the ophthalmology services.

Approach: This project sought to investigate the quality of referrals to primary care/comprehensive ophthalmology. The main reason for referral was a decrease in vision. About two-thirds of referrals came from optometrists via GPs. Of GP referrals, approximately half went through the triaging gateway. Issues with referral standards included referral of patients for dry eyes without appropriate trial of lubricating eye drops, potentially acute conditions referred routinely rather than within 24 hours, and referrals to ophthalmology which could have been seen within other services.

Intended Benefits

Patient outcomes: By improving the referral system, patient outcomes could improve as well since referrals are made appropriately and reducing the burden on ophthalmology services. A particular issue is the routine referral of potentially acute conditions.

Environmental, Financial, Social: The project found that there needs to be further education and guidance on referring patients to outpatient ophthalmology. The triaging service is underutilised and subjective, so referral guidance provided directly to referrers might be beneficial. Through higher quality referrals, the environmental and financial impacts could be reduced as patients can be provided care from the appropriate service avoiding waste of resources.

Key Aspects of the Project

This audit allowed the hospital to understand how patient entry into care can be enhanced, improving patient outcomes and efficacy.

Project Description

Background: The patient voice is considered to be essential to understanding ophthalmic disease and its impact on patients’ lives. The first Patient Voice in Ophthalmic Research Workshop assessed how the patient voice was viewed in research.

Approach: Delegates of the workshop voted the patient voice was very important in research; however, currently, the patient voice has little influence over guiding research priorities.

Intended Benefits

Patient outcomes: It is assumed that the outcomes of the workshop survey would guide the development of ophthalmic research to prioritise and better incorporate the patient voice. By doing so, patient outcomes would benefit.

Environmental, Financial, Social: By increasing the influence of the patient voice in research, the relationship between the patient, researchers, and clinicians could improve. Further monitoring could be done to assess environmental and financial impacts.

Potential Barriers

Challenges to actualising the goals of this project:

• Training for researchers to better incorporate the patient voice in research

Key Aspects of the Project

This project focuses on how the patient voice are treated in ophthalmic research and seeks to improve the reception and use of the patient voice.

Project Description

Background: Traditionally, in undergraduate medical education, patients assumed a more passive role during clinic-based teaching. Recently, the General Medical Council emphasised the requirement for more active involvement of patients as teachers in undergraduate medical education.

Approach: The Patient as Teacher Symposium provided a unique forum to integrate clinical teaching and patient’s real-life experiences to reinforce learning.

Intended Benefits

Patient outcomes: By encouraging a more active role of patients as teachers in medical education, this might improve patient outcomes further down the line.

Environmental, Financial, Social: The medical students in attendance felt the symposium was very important for their education, rating an average of 9.54 out of 10 for very important. Students found the experience clinically informative and emotionally rewarding. The session also allowed for an understanding of how medicine interacts closely with other allied healthcare professions. Further investigation on environmental and financial impacts of emphasising patients as teachers is needed.

Potential Barriers

Challenges to this project:

• Initial adjustment to changing teaching methods and curriculum for students

Key Aspects of the Project

The project focused on changing how medical students are taught and view patients, amplifying the patient’s role and importance.

Project Description

Background: There are targets for the time of referral to treatment (RTT) of new patients referred into the hospital eye service. At the moment with no set government targets for follow up of patients, there is little data available to monitor the situation. This type of information would be useful to plan and implement solutions for timely follow up of patients and minimise adverse clinical outcomes.

Approach: This project conducted an audit to ascertain the delays in ophthalmic follow up appointments. In the audit, 174 patients were included. It was found that delays from intended monitoring intervals were on average 1.2-1.3 months.

Intended Benefits

Patient outcomes: As patients with chronic eye diseases require regular monitoring, if there is a lack of clinical capacity and delayed follow up, they are at risk of significant ocular morbidity, even visual loss.

Environmental, Financial, Social: Delays in monitoring are assumed to have negative environmental, financial, and social impacts. If a patient experiences delays in follow up appointments, their condition could worsen, requiring more medical attention and incurring more costs. The patient experience will be negatively impacted as well.

Key Aspects of the Project

This project focused on establishing an understanding of the patient experience in monitoring and referral to treatment.

Project Description

Background: A large proportion of intravitreal injections in the UK are delivered by nurse practitioners.

Approach: At Great Western Hospital, the staff chose to train 5 nurses to perform intravitreal injections using InVitria, a transparent polycarbonate device that fits around the cornea with a central window allowing for patient fixation.

Intended Benefits

Patient outcomes: Further monitoring is needed to determine the effect of the intervention on patient outcomes. The use of InVitria has maintained patient safety with no significant complications.

Environmental, Financial, Social: The team viewed the training period as short, possibly increasing time for other training or activities. Nurses and patients have both express satisfaction at the use of the intervention. There has been a decrease in costs as well, reducing costs of injections. There is estimated to be a reduction in procurement emission and waste.

Potential Barriers

Challenges to this project:

• Training of nurse practitioners to new device
• Patient adjustment to change in treatment process

Key Aspects of the Project

This project focuses on the treatment part of the patient experience by incorporating a device.

Project Description

Background: In the UK, there is a higher demand for ophthalmic services than there is available capacity, possibly leading to irreversible blindness for some patients. A virtual clinic removes the face-to-face clinician consultation. It is replaced with either a synchronous model where the clinician and patient interact in real-time via a webcam, or an asynchronous model where a technician collects data for the clinician to review later and make decisions.

Approach: Following the Royal College of Ophthalmology “Way Forward” document, a virtual glaucoma clinic was designed to address the capacity shortfall and the first year results were audited.

Intended Benefits

Patient outcomes: The clinic allowed reviewers to streamline patients to the most appropriate glaucoma service, changing the patient’s access to care and pathway. Further monitoring to assess effects on patient outcomes is needed.

Environmental, Financial, Social: There is an assumed reduction in travel time for patients, carers, and staff, allowing for patients and carers to focus on usual activities and for staff to see more patients. This might also reduce the impact on the environment due to travel.

Potential Barriers

Challenges to implementing this system:

• Resources needed to set up the surveillance clinic
• Initial patient/carer and staff adjustment to virtual surveillance system
• Technology and training required to operate

Key Aspects of the Project

This project made adjustments to the patient pathway and experience, ideally making the journey more accessible and appropriate for the patient’s needs. In addition, a focus of the project was to alleviate the demand for ophthalmic services through a change in service provision.

Project Description

Background: Enhanced case finding is using health information and education about appropriate health-seeking behaviours when a patient experiences symptoms of a health condition (in this case, glaucoma). This can involve improving access to diagnostic services as well.

Approach: At NHS Grampian, the glaucoma laser clinic used enhanced case finding to streamline patient attendance at the hospital glaucoma service. Also, staff triaged patients with suspect primary angle closure directly for assessment, and where needed, laser iridotomy treatment. Ophthalmic specialist trainees were trained as part of this glaucoma referral refinement scheme.

Intended Benefits

Patient outcomes: By using enhanced case finding, more than 75% of patients referred by community optometrists with suspect narrow angles actually were at risk for angle closure. YAG peripheral iridotomies were carried out at the first appointment, which could reduce the discomfort and burden of patients.

Environmental, Financial, Social: An ophthalmic specialist trainee conducted the assessment, consent process, and procedure, which allows trainees to develop skills. Further research is needed to determine the exact environmental, financial, and social impact on improving detection and treatment of narrow angles; however, the system can be assumed to reduce financial costs of late diagnosis for patients.

Potential Barriers

Challenges to this project:

• Training to correctly triage patients for angle closure

Key Aspects of the Project

This project considers the patient’s entry into care and how to improve the process to be more sustainable.