Reception_Led_Triage_for_Eye_Conditions

RECEPTION LED PATHWAY FOR EYE PROBLEMS IN ED   The practice development proposal I have chosen is to implement a new pathway for reception led eye assessment in the emergency department (ED) that I work in as a staff nurse.  The rationale behind my choice is due to the need to try and redirect patients that attend the ED with eye problems as a single complaint to the eye casualty which is on the same grounds as the trust that I work in. This deals with two current problems which are, minimising delay between door to assessment by appropriate healthcare specialist and utilising the already available facility of an eye casualty to its maximum. It also offers to help in the ED   meeting its four hour target as they have fewer patients to attend to. More importantly is to minimise the number of healthcare professionals assessing the patient with a single complaint which improves the patient’s hospital journey as they are directed to the appropriate speciality.   In this essay I will attempt to critically discuss the implementation of this proposal using Lewins’ change model (1951), as I found it appropriate for use. It has the force field analysis as a tool to weigh the negatives and positives in order to meet on neutral ground which other models like Bullock and Battens’ planned change (1985) or Kotter’s eight steps lack hence make understanding the implementation for them difficult to work with. Also Lewin’s three step model of unfreeze, move and refreeze is quite comprehendible in conjunction with the force field analysis as you are given the opportunity to stop old practices in order to implement new ones in this case, the eye assessment tool. Lewin’s theory requires that driving forces must outweigh resisting forces for in any situation if change is to happen. It can be argued nonetheless that Lewins’ theory does not tackle resistance as it does not leave room for much negotiation though it still proves the most straightforward and likely to succeed as Kotter for example tends to have a burst of energy at the beginning, i.e. urgency for change to follow in later steps by planning and consolidating which would almost drain enthusiasm. According to Cameroon and Green 2004 (pg101), this implies that change can be managed lower down the hierarchy whereas change is a challenging and exciting process to work through and in essence needs to work form the top.  According to Khaw and Elkington 1994, eye injuries are common and the A&E nurse will see many patients who present with a wide variety of eye complaints of a non-traumatic origin, although eye trauma will remain the single most likely reason for attendance. An audit done on eye presentations  for the month of June showed that of the 110  ED attendances ¾ of these attended between working hours 9am – 5pm when the eye casualty was open, the majority of which were young and fit i.e. between 17 and 64 years old and only presenting with eye problems as a single complaint. About ½ of these patients waited for over an hour with no initial assessment, unless they were coming in with an obvious eye trauma e.g. chemical eye injury or penetrating eye trauma which in this case was only 3 patients. They were then usually referred to the eye casualty by attending physician within ED. Because other presenting complaints to the Ed e.g. Chest Pain , Shortness of Breath or Abdominal pain are considered higher priorities on the triage list as they could be life threatening, eye problems usually rank lower than these . By implementing a questionnaire for patients to fill in at reception it will hopefully redirect the majority of these patients to the eye casualty. According to the Manchester triage group (2006), patients who have relatively minor injuries or illnesses can be streamed i.e. referred on and this is usually delivered as a planned intervention. In implementing this proposal I took into account the potential barriers. These were:  1.      Patient expectations on arrival to the department as they want to be seen as soon as possible and attempting to reroute them is usually a source for potential conflict as they may feel that there is a delay in treatment taking into account their anxiety levels 2.      Acceptance by auxiliary staff who will need to be at the forefront of the implementation. They may object as this is more work and also more responsibility in assessing whether the patient is well enough to be referred on to the eye casualty. 3.      Inter-departmental objections. Issues that might be raised are patient safety and the cost effectiveness of this process i.e. financially with regard to manpower, time and resources. 4.      Loss of ophthalmic emergency practice for the healthcare professionals. 5.      Only works within business hours, that is, (9am – 5pm).   The potential drivers of this implementation were: 1.      The patient experience is improved as they are seen by the appropriate specialist. Even though it might be initially difficult to explain the need for them to go to the eye casualty, the experience would prove better as they are in the correct area for their problem 2.      Heightened patient awareness of local eye casualty, in the hope that most if not all patients with eye problems will go directly to the eye casualty in future. 3.      Reduce waiting times in the ED department and the strain on the department 4.      Reduce ED ophthalmic referrals as patients will be presenting to the eye casualty. 5.      Will be eventually phased out as the idea of it is to make patients aware of the existing eye casualty facility.   In implementing change a guiding principle according to Cameroon and Green, 2004 (pg93) is that there must be participation and involvement, an awareness of the need for change and that people need to be supported through change. In following Lewin’s model I would look to planning when this tool will be implemented and how long for by meeting with the auxiliary staff, ED consultant and service manager for consultation on their thoughts regarding the proposed idea based on the noted problem and have the questionnaire at hand for them to examine and feedback on. We would consider the need for training and development and how much manpower might be needed to initially start the programme for the tool to work at its optimum, we would then move to initiate the programme and establish this as the new way for the proposed length of time with the appropriate support. After the agreed time has passed an audit would take place to establish its’ effectiveness and decide on whether to stop or carry on. To minimise risk to patient safety the tool was modelled around the guideline taken from the Oxford eye hospital which give guidelines for ocular referrals. I found the tool to extremely helpful as it gave timelines for referrals and presentations to the eye casualty. See appendix 3. Although the Manchester triage shows the categories for eye problems from emergency to minor, it does not give a timeframe whereby the patient can be referred or seen by an ophthalmologist. This can cause great difficulty for the assessor as they are not aware to what degree the problem might be serious for example sudden loss of vision. The guidelines would state that an immediate referral is warranted is vision loss has occurred in less than 6hrs whereas within 24 hours  if it has occurred over 6hours. Consideration for patient safety would be paramount as Walsh and Boaden (pg9), suggests that any decision making has the significant potential for something to go wrong and hence a better understanding can be gained from disciplines such as research, sociology and psychology to try and prevent things from going wrong. By assessing the problem that needs change and working as a team to implement and ensure safety I cam credit the positive progress of this tool.  The tool itself is quite self explanatory. There is the criterion for reception staff to follow in assessing the questionnaire handed out to the patient. Appendix 1 and 2. This is not exhaustive as the reception staff would need to be advised that if in any doubt about a patients’ health to put them via triage or seek help from one of the healthcare workers i.e. doctor or nurse The criteria takes into account that the assessor i.e., reception staff are limited in their capabilities to ascertain the patients health.  In determining the number of complaints the patient is presenting with, it lowers the risk of sending a patient of to the eye casualty with problems that might need assessing in the ED for example blurred vision following a head injury. The priority in this case would be the head injury and the repercussions of that ranging from a concussion to a haemorrhage. (Walsh and Kent, 2002.)   In summary the proposed development in the ED would hopefully serve to be an efficient strategy to prompt referral from the point of access, i.e. reception to the eye casualty (ophthalmology unit) without the patient having to endure a lengthily wait before an initial assessment. I have attempted to highlight the need for my proposed change development, the tools that have used to develop it including the change theory in critically analysing the need for change. The barriers and drivers have been highlighted and taken into account in delivery of the proposal Future recommendations for this would be to spread the questionnaires to other ED departments or walk in centres within the catchment area and hope that patients will maximise the use of the eye casualty by presenting there if they have no other immediate underlying conditions. In concluding Pane and Simcock 2006( pg 9) state that you only have a few minutes with each patient who comes to see you with an eye complaint, a careful history of the patient’s eye symptoms plus looking for a few critical signs of anything serious. These are very valid words, but as we work in an ever increasingly busy ED department this is not always the case. Thankfully we have an eye casualty that patients can go to and receive a more thorough assessment as it is a specialist area.