Aim

In the past, patients referred with possibility of glaucoma were placed on a general waiting list where they waited, despite being graded as urgent, possibly over a year to be seen by a consultant due to capacity issues in the ophthalmology clinic. They often had to wait several months after this for various diagnostic tests such as visual fields to be performed before starting on treatment.

It is accepted that approximately 1/3 of referred patients will require treatment, 1/3 be considered as suspect and 1/3 discharged as false referrals.

We wanted to create a system where the resources were targeted at the patients who required the treatment whilst the non urgent patients were processed efficiently and did not waste consultant clinic time.

Methodology

An orthoptist was trained to triage the initial referrals from the waiting list. Specific skills were taught (specific history taking, tonometry, anterior segment examination) at the start of the service in 2001.

This allowed the orthoptist to see patients from the waiting list in a short timeframe and decide which were in need of prompt consultant attention and who was not in danger of losing vision.

As the service progressed, further training was undertaken and now the orthoptists involved are competent in all aspects of glaucoma diagnostics.

This has allowed for the orthoptists to diagnose patients and develop triage pathways according to diagnosis including initiation of treatment at the first appointment when deemed necessary

Results

The service established in 2001 when waiting times for referral to treatment could be as much as 18 months. 0.6 WTE orthoptists were employed at the start. Within a 6 month training and validation period, all of which was accomplished in house therefore not accruing any external costs, the waiting times for first appointment went down to below 6 weeks.

Over the next few years, the service was deemed successful and currently employs 1.3 WTE orthoptists, who see 550 new referrals annually, keeping waiting times consistently below 6 weeks. Over 2000 follow up patients have also been accommodated into the service annually.

Evaluation

 Considerable savings have been made to the Trust as previously these patients would have been seen by middle grade medical staff.

Patients have benefited as they have fewer appointment episodes between referral and treatment. Patients also have continuity of care as only 2 orthoptists are involved in delivering this service. We believe that this aids the patient experience and is the reason why no complaints have been received over the 6 year period.

Orthoptic staff have also benefited as they have opportunity to expand their skills and this has been reflected in their A4C outcomes.

Reflection

The initial training period, only allowed triage on a limited amount of information. We feel it has taken about 5 years to train to a level where we feel confident in all the diagnostic assessments required.

Further action

We have plans for a full diagnostic study which will evaluate the orthoptists decisions against the consultant. Depending on the outcomes of this study, we hope to be able to streamline the system so that certain patients will only have contact with the consultant as part of an audit cycle.