Disruption and Rapid Recovery of Emergency Ophthalmic Services Amidst the COVID Pandemic: An English Teaching Hospital Experience

Purpose: To share our experience of emergency ophthalmic services at a major Tier 2 emergency department in the UK National Health Service, including; emergency department attendances in eye casualty, urgent intravitreal injection services and emergency ophthalmic surgery during the COVID pandemic. We also share our experience of urgent cataract and adnexal surgery work during and after the easing of COVID pandemic restrictions. Methods: Using electronic patient records (EPR) we analysed data for emergency eye clinic attendances and surgical work over a 12 week period during the COVID pandemic from March until May 2020. Emergency surgical work and emergency eye clinic attendance numbers, including type of diagnoses seen were analysed and compared to pre-COVID months. Furthermore, we analysed the data after gradual resumption of routine elective cataract and adnexal surgery from June 2020 onwards. Results: A 73% reduction in patient attendances in the emergency eye clinic and six-fold reduction in surgical work in comparison to the previous year was observed during the height of the pandemic. Our recovery phase elective surgical work demonstrates a 55% and 62% reduction in cataract and adnexal surgical volume respectively, in comparison to preCOVID numbers. Conclusion: At the height of the COVID pandemic we witnessed a significant drop in emergency eye attendances and a complete cessation of elective eye surgery. Investment in Telephone Triage allowed > 70% of emergency patients to be managed without attendance to hospital. It was safe to restart urgent surgery almost immediately after lockdown finished. Check for updates Citation: Jawad M, Joganathan V, Zaidi FH (2020) Disruption and Rapid Recovery of Emergency Ophthalmic Services Amidst the COVID Pandemic: An English Teaching Hospital Experience. Sch J Emerg Med Crit Care 4(1):90-95 Jawad et al. Sch J Emerg Med Crit Care 2020, 4(1):90-95 Open Access | Page 91 | had to make adjustments to our HEES at the door triage. All patients are asked to clean their hands with alcohol gel on arrival and asked to wear a surgical mask to cover the mouth and nose. Patients are asked screening questions and have their body temperature recorded. Any patients suspected of having COVID are redirected to an isolated area in the hospital for further assessment. Those subsequently found to be infected with COVID are examined and managed in a separate ‘hot’ area of the hospital. Patients with no suspicion of COVID infection were either seen on arrival or allocated an appointment in the HEES clinic at a later date depending on urgency. This was in order to minimise the number of patients in the department and adhere to social distancing rules. All staff with patient face to face interaction were required to undergo ‘fit testing’ for personal protective equipment (PPE) face masks. Doctors and other staff who were seeing patients were provided with face masks, disposable gloves and aprons, and protective eye goggles. Slit lamps were fitted with protective plastic shields to prevent droplet transmission. These protective measures are similar to what other units have reported [7-10]. Additionally, we invested heavily in a telephone consultation service for patients with urgent eye conditions to avoid unnecessary attendance to hospital. A pre-existing telephone triage service was bolstered with two full time staff (specialist nurses) to handle incoming calls. There were an average of 44 telephone calls a day and an average of 23 clinical ‘call backs’ a day. Investment in Telephone Triage allowed > 70% of emergency patients to be managed without attendance to hospital. This was supported by re-deploying staff to this key area. This necessitated adjustments to the Patient Electronic Patient Record (EPR) (Symphony) and support by doctors, aided by in a small number of cases video-conferencing in common with other units. Video consultation was found to be useful for external diseases in computer-literate patients. Anecdotally, we found telephone consultation was faster and easier to use, especially in elderly patients and most cases regardless of age group could be managed with it. Photos sent by patients to a secure Trust email address often equally sufficed for video consults. We acknowledge there are validated triage tools for ophthalmic emergencies in the literature such as the Alphabetical Triage Score for Ophthalmology (ATSO) [11] or the Rome Eye Scoring System for Urgency and Emergency (RESCUE) [12], which have been found to be accurate and useful for risk stratification of ophthalmic emergencies. In our case staff performing triage adhered to locally drafted hospital protocols. Initially all elective surgery was cancelled except for patients in urgent cancer pathways. Emergency Eye Clinic Attendances during the COVID Pandemic Using our electronic medical records, we analysed 12 weeks of data from our HEES attendances beginning from the 16th of March 2020 (Table 1). This corresponds to the week we began to cease all elective and non-urgent clinical and early as 1st June 2020. Social lockdown measures in the United Kingdom came into effect on the 23rd March 2020. Impact of Pandemic on HEES Reasons for increased pressure on the UK National Health Service (NHS) during this time have included i) An anticipated surge in walk-in and referred emergency patients due in part to closure of community optometric practices enrolled with the Southampton Minor Eye Conditions Service (MECS), as well as an initial limited general practitioner (GP) service; ii) Re-deployment of key frontline staff away from ophthalmology to other specialties; iii) Pressure from patients whose routine hospital eye appointments have been postponed owing to COVID and who have clinically seriously deteriorated. MECS was the local version of other nationwide schemes but for the South-East NHS Region it offers patients an alternative to attending the HEES and also includes some general practices (GPs) [4] with 6 optometric practices and 27 GPs enrolled with the scheme [5]. The MECS scheme was replaced by the COVID-19 Urgent Eye Service (CUES) based in the community which started in June 2020, going fully live in July 2020 [6]. The CUES scheme supported our HEES by having a nationally-linked trained group of optometrists see less serious urgent conditions including even anterior uveitis, preseptal cellulitis and microbial keratitis supported by independently prescribing opticians who were networked on a national level within England. In terms of HEES staffing, the COVID pandemic provisions were shaped at this university teaching hospital by the presence of a relatively large number of junior doctors in ophthalmology training posts in anticipation of the pandemic these doctors were prepared for re-deployment to hospital wards, the main emergency department and intensive care, leaving only consultant ophthalmologists to deliver eye services. There was a significant reduction in staff due to shielding or sickness and due to a significant portion of nursing staff having been redeployed to other departments within the hospital. This has affected triage and led to loss of nurse practitioners from HEES. In addition patient flow pathways were adjusted into COVID positive and negative areas as in many hospitals, but with the Eye Casualty suite temporarily vacated to allow physical distancing of elderly patients undergoing intravitreal injections in the adjacent intravitreal suite as the waiting rooms were shared. A number of emergency kits were distributed into key areas with slit lamps in the hospital e.g. for intravitreal injections (for endophthalmitis) and lateral canthotomy (for oculoplastic/orbital emergencies), and emergency eye care pathways clarified for consultants. However, the eventual pandemic was not as severe as had been prepared for, so at the 11th hour the department retained its junior medical staff. We have had to cope with the restrictions in terms of physical space, HEES being moved temporarily into paediatric eye clinics. Measures Taken to Help Reduce Spread of the Virus In order to reduce the spread of the pandemic we have Citation: Jawad M, Joganathan V, Zaidi FH (2020) Disruption and Rapid Recovery of Emergency Ophthalmic Services Amidst the COVID Pandemic: An English Teaching Hospital Experience. Sch J Emerg Med Crit Care 4(1):90-95 Jawad et al. Sch J Emerg Med Crit Care 2020, 4(1):90-95 Open Access | Page 92 | The most commonly recorded diagnoses for HEES attendances are recorded in Table 2, as well as the corresponding diagnoses for the previous year. In comparison to the previous year, during the pandemic the percentage of patients seen with less serious conditions in eye casualty such as conjunctivitis and blepharitis fell by 5.9% and 2.4% respectively. The increase in vitreoretinal emergencies (such as retinal detachments) that was anticipated but not realised, by some tertiary hospitals due to satellite unit closures [3], was not seen in our unit. This is most likely due to our neighbouring units continuing emergency surgical work. Forty-two cases of retinal detachment attended the HEES in the 12 weeks of surgical work (lockdown). We observed that weekly HEES attendances gradually declined for the first four weeks of the lockdown and began to steadily rise from mid-April onwards. Comparison is made with the corresponding weeks from the previous year, which at one point in early April showed a 73% reduction in attendances compared with the same time the previous year. In the 12 weeks we analysed during the pandemic, the HEES observed 3427 attendances and telephone consultations in total. In the corresponding period from the preceding year, the HEES received 6826 patient visits and telephone consultations in total. Table 1: Total visits to University Hospital Southampton emergency department, from week of 15th March 2020 compared with 2019.