COVID-19 has forced the eyecare sector to establish new care models that give equal consideration to timely access and safety, as Royal Children’s Hospital Melbourne chief orthoptist CATHY LEWIS writes.
Since the start of the pandemic, Australian eyecare providers have experienced many workplace challenges. The effect on service provision has varied according to the restrictions in place and patients’ clinical need and urgency, but finding a balance between the appropriate care timeframe and safety has been challenging.
Melbourne has spent more days in lockdown than any other city and orthoptists and ophthalmologists at the Royal Children’s Hospital (RCH) Melbourne have become adept at the constant rate of change, implementing several initiatives, some outlined below.
This has led to a positive work environment and patient experience, and improved collaboration with external eyecare providers.
• COVID-19 triage guidelines for outpatient eye clinics were implemented early on and are constantly adjusted according to the restrictions in place. These dictate whether appointments can be booked for face-to-face or telehealth.
• Telehealth consults: Although not always ideal, tele-consults have become a permanent fixture. They provide an opportunity for parents to ask questions and receive advice, with an interpreter service included when required. The examiner can visually assess and observe the child and advise the family whether they should see an external eyecare provider while waiting for their face-to- face RCH appointment. Interestingly, several families preferred tele-consults as travel time and the cost of face-to-face bookings were eliminated, while providing a calmer experience for children.
• A Home Visual Acuity Test Kit and educational video was created early in 2020 to support tele-consults as there were limited resources to assist families with the home assessment. This is especially difficult for paediatric vision assessments when inducing crowding is essential for amblyopia detection and children often don’t know their alphabet.
This was a time-consuming workflow as families were contacted and emailed a Home VA Test, matching card, instructions, recording sheet and link to the instructional video. Those without a printer were posted packs. The Home VA results were returned to RCH electronically and entered into the child’s electronic medical record (EMR) for reference during the tele-consult.
• eye.clinic@rch.org.au email was created for communication between RCH, families, and external colleagues as the need to co- manage patients increased. This provided a pathway for all involved to exchange scans, results, and information. The RCH EMR also has a patient portal for direct communication between the patient and staff.
• Microsoft Teams virtual daily huddle has been excellent for communicating daily priorities, and just as importantly, enabling our team to feel connected. Running department meetings and internal CPD events virtually has enabled greater access for staff, the majority of whom are sessional, leading to increased participation.
• Co-management with external eyecare providers: Due to COVID, the waitlist to see an RCH orthoptist increased and orthoptic student placements couldn’t be offered throughout much of 2020. In response, La Trobe University (LTU) implemented a student-led orthoptic clinic overseen by an orthoptist (Latrobe University Orthoptic Eye Clinic – LOEC).
The RCH collaborates by referring in patients from the orthoptic waitlist for co-management based on an agreed set of protocols. RCH has referred over 500 patients for co-management. As a result, orthoptic students gain clinical experience, RCH patients receive eyecare in appropriate timeframes while waiting for an RCH orthoptist, and LTU surveys reveal families are satisfied.
Approximately 11,500 patients are booked into the RCH eye clinic each year. This has remained stable during the pandemic, but the booking types changed. Tele-consults weren’t booked pre-pandemic, whereas 3,950 were booked in 2020 and 2,950 in 2021, with the pattern continuing in 2022. Although useful, tele-consults cannot compare with in-clinic examinations, resulting in a huge back log waiting for face-to-face appointments.
In response, RCH increased the number and types of orthoptist-led clinics which has been invaluable for service provision – and as we revise care models internally this may be expanded. Also, based on the success with LOEC, RCH will continue to investigate additional options for co-management with external eyecare providers.
It will take time to fully understand COVID’s impact on patients, but as it continues, and with limited public health funding, the current care models will struggle to meet the increased demand on surgical waitlists and outpatient clinics, so we must be innovative to ensure service delivery is sustainable and timely.
ABOUT THE AUTHOR: Cathy Lewis is the Chief Orthoptist at the Royal Children’s Hospital Melbourne and a casual lecturer in orthoptics at La Trobe University.
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