Ophthalmic Referral Good Practice Christian Dutton BSc(Hons.) MScClinOpt FCOptom Prof. Cert. Glauc
Guidelines Opticians Act (1989) ‘A written statement that he is referring the patient and the reason for the referral’ GOC Rules Relating to Injury or Disease of the Eye (1999) Reason(s) for referral • Urgency of the referral • College of Optometrists - Guidance for Professional Practice (2014) Relevant details from the eye examination • Reason for referral • Urgency • Patient copy of the referral letter •
Overview • Why Tentative diagnosis • What Signs & symptoms • Who Ophthalmology sub-specialities • When Urgency • How Legibility & route • Helpful Resources Adapted from Clarke, A. (2008) Writing effective referrals, Optician 11-12-08
Why (tentative diagnosis) ✓ Open with a 1-line summary & tentative diagnosis e.g. “Routine referral to glaucoma clinic for ?OHT” ✗ Hide the reason for referral in a wordy paragraph ✗ Leave someone else to infer a tentative diagnosis e.g. “Referring for macular changes”
Guidelines Why (tentative diagnosis) ✗ Hide the reason for referral in a wordy paragraph
Why (tentative diagnosis) ✗ Leave someone else to infer a tentative diagnosis ✓ Describe signs & symptoms ✓ Specify urgency (&reason)
Why (tentative diagnosis) SUMMARY ✓ 1-line summary & tentative diagnosis ✗ Wordy paragraphs
What (Signs & Symptoms) ✓ Describe the signs & symptoms (onset, duration) Concise • Relevant to the referral reason • ✓ Include supplementary data Abnormal field plots, photos, OCT scans etc. • ✗ Confuse the reader with unrelated/unnecessary information
What (Signs & Symptoms) ✗ Confuse the reader with unrelated or unnecessary information
What (Signs & Symptoms) ✗ Confuse the reader with unrelated or unnecessary information
What (Signs & Symptoms) ✓ Describe signs & symptoms ✓ Specify urgency (&reason)
What (Signs & Symptoms) SUMMARY ✓ Describe signs & symptoms ✓ Include supplementary data ✗ Confusing/unrelated information
Who (Ophthalmology Sub-specialities) ✓ Specify the referral reason Reduce time to care • ✓ Prioritise multiple referral reasons e.g. “Routine referral for glaucoma investigation. Also noted mild entropion ” ✗ Leave someone else to infer which clinic is required e.g. “Referral to ophthalmology please”
Who (Ophthalmology Sub-specialities) Cataract Ensure your patient meets CCG criteria Laser (YAG capsulotomy) YAG capsulotomy (not YAG PI) Low Vision LVA’s and SI Registration Squint / Ocular Motility Known/suspected squint or motility defect Orthoptics All non-squint orthoptics Vitreoretinal RD/hole/tear, PVD, ERM, VMT, lattice Diabetic Medical Retina Diabetic retinopathy/maculopathy Wet AMD Likely wet AMD - often local fast-track policy Other Medical Retina Macula, medical retina, pigmented retinal lesions (non-diabetic & non-vitreoretinal) Oculoplastics/Orbits/Lacrimal Eyelid lumps, ptosis, en/ectropion, exophthalmos, epiphora External Eye Disease Anterior eye (e.g. sclera, conjunctiva, dry) including non-oculoplastic lid conditions Cornea Cornea-specific conditions (within external eye disease) Glaucoma Raised IOP, shallow A/C angles and other glaucomatous signs Neuro-Ophthalmology Pupils, disc pathology (non-glaucomatous), neurological field defects, ?nerve palsies Paediatric Under 16 Not Otherwise Specified General ophthalmology (the rest!)
Who (Ophthalmology Sub-specialities) ? ?
Who (Ophthalmology Sub-specialities) ? ✗ Highlighter / marker pens ? ✓ Specify the referral reason
Who (Ophthalmology Sub-specialities) ✓ Prioritise multiple referral reasons ✓ Clarify the primary reason
Who (Ophthalmology Sub-specialities) ✗ Leave someone else to infer which clinic is required
Who (Ophthalmology Sub-specialities) SUMMARY ✓ Specify primary referral reason ✗ Leave someone else to infer which clinic is required
When (Urgency) ✓ Specify an appropriate urgency • ‘Urgent’ or ‘Routine’ ✓ Make it very clear if a letter is: • ‘For information only, no action required’ ✗ Leave the recipient to infer the urgency based on your findings ✗ Send emergency referrals to Evolutio (put patient at risk) ✗ Rely on a ‘soon’ referral being seen quicker than ‘routine’ ✗ Mark referrals ‘routine’ or ‘soon’ with a comment ‘to be seen within 4/5/6 weeks’ [or ‘urgent’ within 2 -3 days]
When (Urgency) Be aware of local protocols and College Guidance (C205) Emergency Vision or life is in imminent danger • Eye casualty / ophthalmic outpatient clinic / A&E • Usually within 0-2 days • Urgent 2 (-4) weeks • Routine Up to 18 weeks • Soon Not in common use (routine vs urgent ophthalmology) • A flagged ‘routine’ so could be up to 18 weeks •
When (Urgency) Emergencies - NOT handled by Evolutio: • Acute glaucoma • Symptomatic retinal breaks and tears • Acute dacrocystitis – if severe or in • Retinal detachment unless this is children longstanding and asymptomatic • Sight threatening keratitis • IOP ≥ 45mmHg (independent of • Sudden severe ocular pain cause) • Chemical injuries • Suspected temporal arteritis • CRAO<12 hours old • Unexplained sudden loss of vision • Hyphaema • Uveitis • Hypopyon • Vitreous detachment symptoms with • Orbital cellulitis pigment in the vitreous • Papilloedema • Penetrating injuries • Unexplained pre-retinal haemorrhage http://guidance.college-optometrists.org/guidance-contents/communication-partnership-and-teamwork-domain/working-with-colleagues/urgency-of-referrals
When (Urgency) ✓ Specify an appropriate urgency • Longstanding floaters • Not increased in size/number • No photopsiae • No suspicious fundus findings
When (Urgency) ✓ Specify an appropriate urgency • IOP 26 / 31 “slightly raised” • Narrow A/C “V/H 1”
When (Urgency) ✗ Leave the recipient to infer the urgency based on your findings ✓ Propose your management plan ✓ Know your local protocols
When (Urgency) ✗ Send emergency referrals to Evolutio (puts patients at risk)
When (Urgency) ✓ Appropriate & consistent urgency ✓ Provide referral reason
When (Urgency) ✗ Mark referrals ‘routine’ or ‘soon’ with a comment ‘to be seen within 4/5/6 weeks’ ✓ Include pertinent clinical data ✓ Urgent (2/52) ✓ Routine (18/52)
When (Urgency) ✗ Mark referrals ‘urgent’ with a comment ‘to be seen in 2 - 3 days’ ✓ Include pertinent clinical data ✓ Urgent (2/52) ✓ Routine (18/52)
When (Urgency) SUMMARY ✓ Specify appropriate urgency ✓ Clarify if no action required ✗ Send emergency referrals to Evolutio ✗ ‘Soon’ usually = ‘routine’ ✗ Specify unrealistic timescales
How (Legibility & Route) ✓ Typed ✗ Hand written unless very clear (up to 6x longer to read) ✓ If using bespoke layout ensure all information is included ✓ Electronic transmission is the gold standard (ERS) Fax if no alternative: ✓ Avoid rescan/copy (each copy/transmission degrades image) ✓ Keep the scanning glass clean ✓ Align the pages carefully ✓ Don’t write in any margins ✗ Sending referrals to the GP Delays patient’s time to care Post, secretary read/scan, GP read/action, sec. forward to us (up to 19 days)
How (Legibility & Route) Generic details (5% of all referrals rejected): Patient Full name DOB Address Phone number GP Name Address Clinician Full name GOC/GMC number Practice name Address Signature Date
How (Legibility & Route) ✗ Hand written unless very clear (up to 6x longer to read)
How (Legibility & Route) ✓ Avoid re- scanning/copying (each copy/transmission degrades image)
How (Legibility & Route) ✓ Align the pages carefully
How (Legibility & Route) ✓ Don’t write in any margins
How (Legibility & Route) SUMMARY ✓ Typed (eRefer/electronic) ✗ Send referrals via GP
Summary Why? Summary & tentative diagnosis What? Concise signs/symptoms & attachments Who? Clinic type When? Urgency How? Current & clear (eRefer)
Helpful Resources Social media – Good referral of the month Glaucoma Choroidal naevus Paediatric neuro-ophthalmology Keratoconus Low vision Oculoplastics Evolutio Affiliate Academy eCare Academy
Helpful Resources Journal publications
Helpful Resources Ophthalmology referral guidance document
How (Legibility & Route) ✓ eRefer Optometry RM software NHS Digital Compliant Track patient journey Reduce TTC Clerical/clinical standards Free for referrers
eRefer
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