Author: Krystal Gayle (United Kingdom)
Co-authors: Sudeshna Patra, Caleb Roberts, Nigel Griffith, Gabriella Guevara, Taurai Matare
Intra-vitreal therapies delivered through dedicated injection clinics in an out-patient setting are vital sight saving procedures for the treatment of conditions such as age related macular degeneration (AMD), diabetic maculopathy (DMO) and retinal vein occlusion. In pre-COVID 2019, with the aim to improve efficiencies in the injection clinics, we introduced a dedicated Failsafe officer, who joined a wider team, to help track patients. In 2020, the COVID 19 pandemic led to major reorganisation of the service to enable safe and continued care. Social distancing meant that intensive high volume clinics were replaced with high flow clinics. The twin injection room model, running 3-4 sessions per week, was switched to a single injection room model running 10 sessions per week. This actually increased the weekly clinic capacity from 120 to 150 injection slots. The additional workforce challenge was met by using allied healthcare professionals as assessors and dedicated nurse specialists as injectors, with overall supervision delivered by a senior Nurse and a Retina Consultant. In this study we have assessed, over a three year cycle, the impact of COVID 19 on our service.
Barts Health NHS Trust, Whipps Cross University Hospital, Eye treatment Centre
The data was extracted from Medisoft electronic patient records over a three year cycle between 2018-2020. Inclusion criteria: all patients attending the intra-vitreal injection clinics at Whipps Cross University Hospital in the month of September. There was no exclusion criteria. The primary outcome measures included the percentage of patients with delays in follow-up and treatment and an analysis of the level of clinical harm. Secondary outcome measures included causes of delays to treatment, mean changes in visual acuity & central macular thickness (CMT). Delay in follow-up/ treatment was defined as any appointment which exceeded 25% of the requested time interval. Clinical harm was defined as a loss of 15 or more ETDRS letters or 3 lines on the logMAR chart. The cause for delay to follow-up was categorized as patient initiated (ie: patient unwell or unwilling to attend), hospital initiated (rescheduled due to capacity issues, clinic cancellations, administrative errors) or ‘did not attend’ or DNA. For data gathered in 2020 we also identified delays and risks of harm specific to the COVID 19 pandemic. Data analysis was done with Microsoft excel.
Total patients seen in September 2020 following the first COVID surge was 454 compared to 260 (2018) and 285 (2019). The average age group was higher in 2020: 80-89 years versus 70 -79 years (2018 & 2019). In 2018, delays in follow-up were 43% of total. Following the inception of a dedicated Failsafe officer numbers fell significantly in 2019 (9.4%) and remained low in 2020 (9.7%) despite the pandemic. In 2018 & 2019 the follow-up delays were mainly due to hospital rescheduling as a result of capacity issues. In 2020, COVID-19 was the leading cause follow-up delays with most due to patient-initiated rescheduling. Interestingly, the mean duration of delay leading to clinical harm was longer in 2020 (140 days compared with 44 days in 2018 and 28 days in 2019). The overall proportion of patients that suffered clinical harm was low (0.7%-1.0%) for all time points with an average of 19 ETDRS letters lost. Of these patients, the mean CMT increased for those with RVO (278 µm) and DMO (164.67µm). However, with AMD, CMT either increased or decreased. Only 2 persons in 2020 experienced harm due to follow-up delays because of COVID-19.
The inception of a dedicated Failsafe officer reduced hospital initiated delays but lack of capacity in the service remained a major cause of appointment delays. By reorganising our service in 2020 in response to the COVID 19 infection prevention control policies, we were able to increase capacity and maintain low levels of delays to care . The unit was able to maintain pre and post pandemic efficiency and safety levels as delays to follow-up and care remained below 10% and risk of harm below 1% in 2020.