CATARACT PATHWAY DECONSTRUCTED - UKOA MEETING 11TH DECEMBER 2020 STEVEN HARSUM MBBS BSC PHD FRCOPHTH

Cataract Pathway
 Deconstructed
  Steven Harsum MBBS BSc PhD FRCOphth

          Consultant Ophthalmologist
             Vitreoretinal Surgeon
             Director Head & Neck
          GIRFT / NHSEI Cataract Lead

 UKOA Meeting 11th December 2020
                                        UKOA 11/12/2020

Cataract Pathway

Cataract Pathway
• 7 Steps in pathway
   •   Referral / Assessment
   •   Patient Selection / POA
   •   Booking / Listing
   •   Admission
   •   Surgery
   •   Post-op
   •   Follow-up / Discharge

• Performance Metrics

1. Referral & Surgical Assessment
• Referral
   • Optom direct OR GP (+Optom Letter)
       • Optom guide Hub / Non Hub pathway
   • Optom, if cataract,  give patient
     standardised SDMA

• Provider
   • SDMA / Covid consent
   • Cataract Booklet (e.g. RNIB)
   • Consent from

• Provider
   • Calls patient
   • Discuss documents above
   • Agreement to Proceed  Book clinic

2. Patient Selection & POA
• POA – may be telephone / in
  advance / on day
• Biometry
   • Toric IOL
• Clinician
   • Consultant / Other
   • Offered ISBCS (no co-morbidities)
• Consent Signed
• Pre-dilation drops given
• Post-op drops prescribed

3. Booking / Listing
• Arrival times
   • 8/ 4hr list – Junior Trainee
   • 10/ 4hr list – Senior Trainee (

4. Admission
• Arrive to leave eye unit 1 hr
    • Tough to achieve if arrive 30mins early
    • Only pre-dilation / intracameral dilation
    • Primary nurse to admit & follow through pathway
         • ↓ exposure, ↑ continuity
         • Marks eye, confirms consent
         • Instil anaesthetic / iodine / check IOL / ‘sign-in’ of WHO check
           (with another HCP)
         • Takes to theatre

• Surgeon meets patient
    • Anaesthetic room / theatre, prior to scrubbing

• Primary Nurse
    • Assists with getting on table

• Team
    • Sign-out, final check of IOL

5. Surgery
• 5 Steps to Safer Surgery
    •   Team Brief
    •   Sign in
    •   Time out
    •   Sign out
    •   Team Debrief

• Scrub team
    • Trained to prep/drape

• Primary Nurse trained to 1st draft Op note

• Surgical Time
    • 10 in 4hrs
          •   Surgery 20mins, 5mins turnaround
          •   Surgery 15mins with 10mins turnaround
    • 8 in 4 hrs
          •   Surgery 20mins x5, 5min turnaround, 3 training cases @ 35mins/case
          •   Surgery 20mins x6, 5min turnaround, 2 training cases @ 43mins/case

6. Post-Op
• BADS
    • British Association of Day Surgery

• Standardised Post-operative Cataract PIL
    • Patients must be given contact details for how to access
      care in-hours and out-of hours for post-operative care

• Emergencies
    • Immediate - Post-operative emergencies that need
      immediate attention (e.g. endophthalmitis) should be
      managed by the patients nearest open eye casualty
    • Urgent - post-operative conditions should be managed by
      the Hub and its contracted casualty, where practical
    • Routine - post-operative conditions should be managed by
      local CUES / MECS providers or by referral to the patient's
      local eye clinic
    • Agreement all Hub patients presenting to other units,
      complications fed back to Hub

7. Discharge & Follow-up
• Listed & dated both eyes separate days
   • Phone call 1wk post-op
   • If happy date confirm swab/date 2nd eye
   • If unhappy, bring to clinic

• 2nd eye / only 1 eye listed
   • Discharge to optom
   • All optoms able to claim fee if post-op
     outcomes fed back to Hub

Performance Metrics

• Unwarranted Variation
                                             www.cataract-hub.com
• Data driven best practice

FAQs
• What is the vision for the future?

• Will this destabilise other cataract surgery or non hub sites?

• What is the difference between a high throughput list and a hub list?

• It isn’t safe…..

• What about prepping instrument trollies in advance?

• Equity of access – what about patients who are not suitable for the high flow/ low
  complexity lists?

• “my manager thinks we can now just put 10 cases on a list without any other changes”

• “this is very dependent on having extra nurses”