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What is the challenge your project is going to address and how does it connect to your chosen theme?

What do we want to do?
Moorfields Eye Hospital sees a large number of patients with wet AMD.  The patients come from all across London including Islington, Hackney and Tower Hamlets.  We would like to continue providing this care but streamline the referral to treatment process so that Optometrists can send their patients directly to us easily and efficiently for both the patients and optometrist.
Education is a central aim for this new wet AMD network.  Alongside a streamlined referral process communication will be two-way.  Feedback and information can be relayed back seamlessly to the referring Optometrists and patients’ GPs.  Moorfields Consultant Ophthalmologists will carry out regular educational events tailored specifically for patients, local optometrists and GPs.  This will allow better communication between all parties, foster a more inclusive relationship and allow faster and more helpful information about local services and advancements.

What currently happens?
When our community Optometry colleagues see a patient that they suspect has wet AMD they often have no choice but to send the patient to our Emergency department.  This is currently the fastest way for the patient to access the hospital service.
The Emergency department visit typically involves seeing an Ophthalmologist.  However it is not feasible to perform all the necessary tests to confirm wet AMD during this visit.  Thus the patient is usually booked into a Medical Retina Emergency (MRE) clinic within 2 weeks to have the full battery of tests.
During the MRE visit if the diagnosis is confirmed then the patient is usually offered the opportunity to receive an Anti-VEGF treatment on the day itself.  This can be daunting for most patients as they may have had several tests and may not be prepared to receive an injection to their eye at the same appointment.
If they do accept having an injection it often means accommodating them into an already busy injection clinic on the day which can lead to long clinic waiting times for all patients in that clinic.  The treatment typically consist of 3 monthly injections.  Therefore an unbooked injection can often disrupt efficient scheduling of future injections.
If the diagnosis is found not to be wet AMD then they are either discharged or brought back to a separate general Medical Retina Clinic for further follow up.

What is the main problem with the current system?
Our community optometrists are knowledgeable and often correctly identify wet AMD.  Therefore the visit into the Emergency Department is largely redundant as a diagnosis still cannot be confirmed at this visit.  This adds a delay to treatment and is disappointing to patients who may have been expecting same-day treatment.  Getting an appointment into MRE can take up to 2 weeks therefore there is a potential for delay to sight-saving treatment.

What does your project aim to achieve?

What change do we propose?
We would like to introduce a referral system for Optometrists who have suspected a new presentation of wet ARMD.  This will allow them to directly book into a clinic  where a team who are specialised in assessing patients with ARMD will assess both eyes.
The patient will then go home and be contacted within 2 days with a provisional diagnosis.
If the diagnosis is not wet AMD then an appropriate follow-up in a general medical retina clinic will be made for them to attend for further investigations or discussions.
If the diagnosis is wet AMD then the patient will be invited to attend clinic to have a fundus fluorescein angiogram to confirm the diagnosis of wet ARMD. This is currently a requirement by the Royal College of Ophthalmologists.  At this appointment the patient can discuss the diagnosis with a doctor or specialist optometrist and be able to ask any questions.  If they choose they can either have an intravitreal injection at the same appointment or schedule an injection for within 5 days.
This will reduce the number of unnecessary invasive angiograms and improve the referral to treatment time for wet AMD patients.  Additionally this new pathway avoids unnecessary hospital visits and will make the clinic flow more efficiently and thus improves the patient experience.

How will the project be delivered?

How would this service work?
1.     A patient is identified by a community Optometrist as potentially having wet AMD.
2.     A dedicated Moorfields New Wet AMD webpage allows the Optometrist to quickly and easily input some basic patient details (such as name and contact number) and to electronically send a referral to our ‘Fast-Track New wet AMD service’.  An email acknowledging receipt of the referral will be sent back.
3.     A dedicated member of the team will then contact the patient within 24 hours to arrange a prompt but convenient time for the patient to attend the hospital with information about their upcoming visit.
4.      On the day of the hospital appointment the patient will be seen in the Assessment clinic outlined above.  As there is no need to wait to see a doctor the appointment is usually faster with less waiting (30 mins).  The patient can then go home with information on wet AMD to read and digest at their own pace.  They will be advised to note any questions they have which can be discussed at the next appointment.
5.     The patient’s results are then reviewed by AMD specialists including nurse consultants, optometrists and senior Ophthalmologists.  The patient will be contacted within 2 days with a provisional diagnosis.
As mentioned above (see ‘What change do we propose?’) if the diagnosis is not wet AMD then a general Medical Retina appointment will be made.
If a diagnosis of wet AMD is made then the patient will be invited to clinic for confirmatory testing and treatment.
A feedback mechanism will allow the diagnosis to be relayed back to the referring Optometrist for their own interest.

What is the benefit of this proposed service?
–       Optometrists can provide their patients fast and efficient access to obtain treatment for wet AMD
–       Once the referral is made by our Optometry colleagues then our Fast-Track service will book a rapid appointment. (Referring the patient does not require waiting on the phone as it can all be done electronically at a time that is suitable for the optometrist
–       Electronic referrals will mean the Optometrist can be sure that the referral has been received with an audit trail available
–       Appointments can be made at a more convenient time for the patient instead of having to rush to the Emergency department.  This will avoid an unnecessary wait to see the A&E doctor and also offloads a very busy A&E service
–       An appointment system will also allow information to be given to the patient before their visit which will improve the patient experience
–       As the majority of wet AMD patients are of an older population appointments can be made to accommodate transport issues, help from carers etc.
–       Waiting in clinic will be reduced as all investigations will be pre-booked
–       Feedback can be relayed to the referring Optometrist for their own learning and interest
–       Better communication and a stronger relationship between local optometrists, GPs, Patients and Moorfields Eye Hospital can be forged for future improvements to help patients

What and how is your project going to share learning throughout?

Successful implementation of this project can lead to maximum impact across Eye clinic Departments in the country. Learning will be shared with key stakeholders, high street optometrists, GPs, Ophthalmologists and patient societies such as the Macular Society. The Q community will have the opportunity to receive regular updates, challenges and barriers to implementation.

How you can contribute

  • Electronic Medical Records

Plan timeline

2 Sep 2020

Comments

  1. There has been alot of work in this area at Taunton & Somerset.  Ed Herbert is our clinical lead for ophthalmology so if - as I hope you do - you get funding then it may be worth picking up with him as I am sure that there is an opportunity for some shared learning.  Good luck!

  2. Dear Adam,

    my lovely grandma had AMD and so I know first hand what a huge impact this condition can have on someone’s life. A heartfelt thanks for wanting to make an improvement in this area.

    There is a lot to learn from some of the Health Foundation’s Innovating for Improvement and Scaling Up teams about how to overcome the challenges of setting up a niche national service. There’s great work in Airedale about stammering and in Southampton about cochlear I plants for example that have elements I think might be useful for you, like how to get patients involved in the design and promotion of the services, how to link regionally and how to promote the service.

    Good luck with it

    best wishes

    Anna

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