Ophthalmic Referral Good Practice Christian Dutton BSc(Hons.) - - PowerPoint PPT Presentation

Ophthalmic Referral Good Practice

Christian Dutton

BSc(Hons.) MScClinOpt FCOptom Prof. Cert. Glauc

Opticians Act (1989)

‘A written statement that he is referring the patient and the reason for the referral’

GOC Rules Relating to Injury or Disease of the Eye (1999)

• Reason(s) for referral
• Urgency of the referral

College of Optometrists - Guidance for Professional Practice (2014)

• Relevant details from the eye examination
• Reason for referral
• Urgency
• Patient copy of the referral letter

Guidelines

• Why

Tentative diagnosis

• What

Signs & symptoms

• Who

Ophthalmology sub-specialities

• When

Urgency

• How

Legibility & route

• Helpful Resources

Adapted from Clarke, A. (2008) Writing effective referrals, Optician 11-12-08

Overview

✓Open with a 1-line summary & tentative diagnosis

e.g. “Routine referral to glaucoma clinic for ?OHT”

✗ Hide the reason for referral in a wordy paragraph ✗ Leave someone else to infer a tentative diagnosis

e.g. “Referring for macular changes”

Why

(tentative diagnosis)

✗ Hide the reason for referral in a wordy paragraph

Guidelines Why

(tentative diagnosis)

✗ Leave someone else to infer a tentative diagnosis ✓Describe signs & symptoms ✓Specify urgency (&reason)

Why

(tentative diagnosis)

✓1-line summary & tentative diagnosis ✗ Wordy paragraphs

SUMMARY

Why

(tentative diagnosis)

✓ Describe the signs & symptoms (onset, duration)

• Concise
• Relevant to the referral reason

✓ Include supplementary data

• Abnormal field plots, photos, OCT scans etc.

✗ Confuse the reader with unrelated/unnecessary information

What

(Signs & Symptoms)

✗ Confuse the reader with unrelated or unnecessary information

What

(Signs & Symptoms)

✗ Confuse the reader with unrelated or unnecessary information

What

(Signs & Symptoms)

✓Describe signs & symptoms ✓Specify urgency (&reason)

What

(Signs & Symptoms)

✓ Describe signs & symptoms ✓ Include supplementary data ✗ Confusing/unrelated information

SUMMARY

What

(Signs & Symptoms)

✓ Specify the referral reason

• Reduce time to care

✓ Prioritise multiple referral reasons

e.g. “Routine referral for glaucoma investigation. Also noted mild entropion”

✗ Leave someone else to infer which clinic is required

e.g. “Referral to ophthalmology please”

Who

(Ophthalmology Sub-specialities)

Cataract Ensure your patient meets CCG criteria Laser (YAG capsulotomy) YAG capsulotomy (not YAG PI) Low Vision LVA’s and SI Registration Squint / Ocular Motility Known/suspected squint or motility defect Orthoptics All non-squint orthoptics Vitreoretinal RD/hole/tear, PVD, ERM, VMT, lattice Diabetic Medical Retina Diabetic retinopathy/maculopathy Wet AMD Likely wet AMD - often local fast-track policy Other Medical Retina Macula, medical retina, pigmented retinal lesions (non-diabetic & non-vitreoretinal) Oculoplastics/Orbits/Lacrimal Eyelid lumps, ptosis, en/ectropion, exophthalmos, epiphora External Eye Disease Anterior eye (e.g. sclera, conjunctiva, dry) including non-oculoplastic lid conditions Cornea Cornea-specific conditions (within external eye disease) Glaucoma Raised IOP, shallow A/C angles and other glaucomatous signs Neuro-Ophthalmology Pupils, disc pathology (non-glaucomatous), neurological field defects, ?nerve palsies Paediatric Under 16 Not Otherwise Specified General ophthalmology (the rest!)

Who

(Ophthalmology Sub-specialities)

? ?

Who

(Ophthalmology Sub-specialities)

✓ Specify the referral reason

? ?

✗ Highlighter / marker pens

Who

(Ophthalmology Sub-specialities)

✓Prioritise multiple referral reasons ✓ Clarify the primary reason

Who

(Ophthalmology Sub-specialities)

✗ Leave someone else to infer which clinic is required

Who

(Ophthalmology Sub-specialities)

✓ Specify primary referral reason ✗ Leave someone else to infer which clinic is required

SUMMARY

Who

(Ophthalmology Sub-specialities)

✓ Specify an appropriate urgency

• ‘Urgent’ or ‘Routine’

✓ Make it very clear if a letter is:

• ‘For information only, no action required’

✗ Leave the recipient to infer the urgency based on your findings ✗ Send emergency referrals to Evolutio (put patient at risk) ✗ Rely on a ‘soon’ referral being seen quicker than ‘routine’ ✗ Mark referrals ‘routine’ or ‘soon’ with a comment ‘to be seen within 4/5/6 weeks’ [or ‘urgent’ within 2-3 days]

When

(Urgency)

Be aware of local protocols and College Guidance (C205) Emergency

• Vision or life is in imminent danger
• Eye casualty / ophthalmic outpatient clinic / A&E
• Usually within 0-2 days

Urgent

• 2 (-4) weeks

Routine

• Up to 18 weeks

Soon

• Not in common use (routine vs urgent ophthalmology)
• A flagged ‘routine’ so could be up to 18 weeks

When

(Urgency)

• Acute glaucoma
• Acute dacrocystitis– if severe or in

children

• IOP ≥ 45mmHg (independent of

cause)

• Chemical injuries
• CRAO<12 hours old
• Hyphaema
• Hypopyon
• Orbital cellulitis
• Papilloedema
• Penetrating injuries
• Unexplained pre-retinal

haemorrhage

• Symptomatic retinal breaks and tears
• Retinal detachment unless this is

longstanding and asymptomatic

• Sight threatening keratitis
• Sudden severe ocular pain
• Suspected temporal arteritis
• Unexplained sudden loss of vision
• Uveitis
• Vitreous detachment symptoms with

pigment in the vitreous

When

(Urgency)

http://guidance.college-optometrists.org/guidance-contents/communication-partnership-and-teamwork-domain/working-with-colleagues/urgency-of-referrals

Emergencies - NOT handled by Evolutio:

✓ Specify an appropriate urgency

• Longstanding floaters
• Not increased in size/number
• No photopsiae
• No suspicious fundus findings

When

(Urgency)

✓ Specify an appropriate urgency

• IOP 26 / 31 “slightly

raised”

• Narrow A/C “V/H 1”

When

(Urgency)

✓ Propose your management plan ✓ Know your local protocols ✗ Leave the recipient to infer the urgency based

• n your findings

When

(Urgency)

✗ Send emergency referrals to Evolutio (puts patients at risk)

When

(Urgency)

✓ Appropriate & consistent urgency ✓ Provide referral reason

When

(Urgency)

✓Include pertinent clinical data ✓Urgent (2/52) ✓Routine (18/52) ✗ Mark referrals ‘routine’ or ‘soon’ with a comment ‘to be seen within 4/5/6 weeks’

When

(Urgency)

✓Include pertinent clinical data ✓Urgent (2/52) ✓Routine (18/52) ✗ Mark referrals ‘urgent’ with a comment ‘to be seen in 2-3 days’

When

(Urgency)

✓ Specify appropriate urgency ✓ Clarify if no action required ✗ Send emergency referrals to Evolutio ✗ ‘Soon’ usually = ‘routine’ ✗ Specify unrealistic timescales

SUMMARY

When

(Urgency)

✓ Typed ✗ Hand written unless very clear (up to 6x longer to read) ✓ If using bespoke layout ensure all information is included ✓ Electronic transmission is the gold standard (ERS) Fax if no alternative: ✓ Avoid rescan/copy (each copy/transmission degrades image) ✓ Keep the scanning glass clean ✓ Align the pages carefully ✓ Don’t write in any margins ✗ Sending referrals to the GP Delays patient’s time to care Post, secretary read/scan, GP read/action, sec. forward to us (up to 19 days)

How

(Legibility & Route)

Generic details (5% of all referrals rejected): Patient

Full name DOB Address Phone number

GP

Name Address

Clinician

Full name GOC/GMC number Practice name Address Signature Date

How

(Legibility & Route)

✗ Hand written unless very clear (up to 6x longer to read)

How

(Legibility & Route)

✓ Avoid re- scanning/copying (each copy/transmission degrades image)

How

(Legibility & Route)

✓ Align the pages carefully

How

(Legibility & Route)

✓ Don’t write in any margins

How

(Legibility & Route)

✓ Typed (eRefer/electronic) ✗ Send referrals via GP

SUMMARY

How

(Legibility & Route)

Why? Summary & tentative diagnosis What? Concise signs/symptoms & attachments Who? Clinic type When? Urgency How? Current & clear (eRefer)

Summary

Social media – Good referral of the month

Glaucoma Choroidal naevus Paediatric neuro-ophthalmology Keratoconus Low vision Oculoplastics

Evolutio Affiliate Academy eCare Academy

Helpful Resources

Journal publications

Helpful Resources

Ophthalmology referral guidance document

Helpful Resources

✓ eRefer

Optometry RM software NHS Digital Compliant Track patient journey Reduce TTC Clerical/clinical standards Free for referrers

How

(Legibility & Route)

eRefer