Providing better service at AES

The Acute Eye Service (AES) is the busiest sub-speciality department within one of the busiest outpatients departments in New Zealand, the Eye Department at Auckland’s Greenlane Clinical Centre.

The AES provides urgent and emergency ophthalmic care for close to 1.6 million people across the Auckland, Waitemata and Counties Manukau District Health Boards. Over the last 12 months, there were 15,561 patient attendances at the Acute Eye Service, about a 30% increase compared with the same period the previous year.

It is plainly obvious, the demand for acute eye care is increasing yet the resources to provide this within the AES is not increasing proportionately.

We all know first impressions count. For many patients the AES is often their first encounter with the Eye Department and our staff. A relationship that may last only a few hours or perhaps a lifetime.

Unsurprisingly, just like the Eye Department as a whole, the AES suffers from overwhelming patient demand coupled with a lack of resources as evidenced across our public health system. In particular, the clinics have traditionally suffered from a lack of senior doctor “shop floor” cover as well as space and general staffing.

Reducing waiting times

To streamline the AES clinics, consultant ophthalmologists, Drs Kathleeya Stang-Veldhouse and Brian Sloan, have overhauled the service with remarkable results in both patient flow and management. The new service changes have now been running for eight months resulting in a substantial reduction in wait times for patients; now just two hours on average compared with six hours previously.

Today the AES consists of a single clinic. There is no ‘walk-in’ service and all patients must be referred by their GP, optometrist, emergency/accident or other medical clinic unless otherwise advised by ophthalmology department staff. Other key service changes include:

The introduction of the AES phone line for community physicians and optometrists to provide advice about potential treatment in the community or direct triage. The phone line is staffed by either a senior medical officer, a clinical nurse practitioner with more than 10 years’ ophthalmology experience, a senior clinical fellow or a senior registrar (see box)

More robust primary triage. Patients who are not deemed to have an acute eye problem following initial nurse assessment can be booked into the AES or outpatient clinic at a later date or discharged without assessment by a clinician depending on their condition’s urgency

Patients are seen in order of clinical necessity and not by time of presentation. If a patient has to wait six hours, it is likely their condition was not considered urgent

A senior ophthalmologist, either a consultant or senior clinical fellow, is now always present in the AES. This is deemed important enough to occasionally reduce the number of elective outpatient clinics to ensure a senior doctor’s presence. The benefits to patients are significant: consultant input allows faster, more comprehensive assessment and management; AES reviews and unnecessary investigations are minimised; and follow-up in speciality clinics is hastened. Thus, the clinical roles have returned to a junior doctor/nurse/optometrist-delivered service that is consultant-led

Secondary triage is performed by the senior doctor, with patients typically allocated to junior doctors, clinical nurse practitioners and optometrists, depending on the complexity of their presenting complaint and the experience of the clinician. This allows for more effective patient management as the Greenlane Clinical Centre is a tertiary referral centre, and training of the next generation of eye professionals is also of paramount importance.

Appropriate investigations (OCT, visual fields, imaging etc.) are done at or prior to assessment by clinical staff, so consultations can be completed as quickly and safely as possible

In summary

The changes in the AES have resulted in a measured improvement in patient wait-times. Having an experienced doctor in the AES has streamlined and enhanced patient care and improved both the physical and mental health of our acute clinic staff.

It is a change that has been long overdue and, despite the demands placed on the regional ophthalmology services, it has only been possible to implement recently with some expansion in the Auckland District Health Board ophthalmology department.

Despite limited resources, the team at Greenlane AES are motivated to providing the best possible service to our patients and, of course, as we move forward and are given more time and with more experience, we will continue to improve the AES still further.

Dr Shanu Subbiah is a consultant ophthalmologist at Greenlane Clinical Centre and Eye Institute with specialist knowledge in cataract, corneal and laser surgery and retinal diseases.