Saifuddin Aamir, Brookes Rachel
King's College Hospital, London.
BMJ Qual Improv Rep. 2014 Jun 13;3(1). doi: 10.1136/bmjquality.u201656.w1962. eCollection 2014.
Anecdotal evidence suggested that the management of patients with eye complaints in the Emergency Department (ED) at King's College Hospital, London was suboptimal. Acute ophthalmology is often poorly covered at undergraduate level in the United Kingdom which can affect patient safety. Furthermore, it was notoriously difficult to obtain specialist advice within working hours. Contact lens (CL) wearers are prone to Pseudomonas conjunctivitis which requires certain antibiotics and mismanagement of this has led to sight-threatening consequences locally. Junior doctor surveys suggested under-confidence in managing eye problems and initial audit showed that eye assessments are frequently incomplete during ED clerkings. For example, CL status and visual acuity were documented in 63% and 77% of cases respectively; however, these were increased when a dedicated pro forma was used. To address these multiple issues, a new 'eye examination pro forma' was created, along with integrated clinical guidelines based on local expert practice. This would prompt staff to elicit key information to help guide management. A new referral pathway was also introduced to facilitate access to ophthalmology services. On re-auditing seven months later, the new pro forma was completed for only 28% of patients, though this was associated with a higher rate of documentation of all parameters. The referral pathways worked efficiently and patients with red flag features were identified and managed more appropriately than before. We learnt that it is important that someone personally drives the innovations from the outset, otherwise prolonged change is difficult. Secondly, junior doctors may not be proficient with slit lamp use, for instance, so targeted teaching is required, not simply new pathways. Full engagement with the pro forma and effective patient management should then improve simultaneously. Specific teaching is now being implemented and permanent staff have been recruited to oversee the project. We plan to re-audit in November 2014.
轶事证据表明，伦敦国王学院医院急诊科对眼部不适患者的管理欠佳。在英国，本科阶段对急性眼科的教学往往不足，这可能会影响患者安全。此外，在工作时间内很难获得专家建议。隐形眼镜佩戴者易患铜绿假单胞菌性结膜炎，这需要使用特定抗生素，而对此的管理不善已在当地导致了威胁视力的后果。初级医生调查显示他们在处理眼部问题时信心不足，初步审计表明在急诊科问诊期间眼部评估常常不完整。例如，分别有63%和77%的病例记录了隐形眼镜佩戴情况和视力；然而，当使用专门的检查表时，这些记录有所增加。为解决这些多方面的问题，创建了一种新的“眼部检查检查表”，以及基于当地专家实践的综合临床指南。这将促使工作人员获取关键信息以帮助指导治疗。还引入了一条新的转诊途径，以方便获得眼科服务。七个月后重新审计时，仅28%的患者完成了新检查表，不过这与所有参数记录率的提高相关。转诊途径运行高效，具有警示特征的患者得到了比以前更恰当的识别和处理。我们认识到从一开始就有人亲自推动创新很重要，否则长期变革会很困难。其次，例如初级医生可能不熟练使用裂隙灯，所以需要有针对性的教学，而不仅仅是新途径。然后，对检查表的充分应用和有效的患者管理应同时得到改善。目前正在实施特定教学，并招聘了固定工作人员来监督该项目。我们计划在2014年11月进行重新审计。
