“Our hospital services continue to evolve”

The recovery phase for ophthalmology, optometric, orthoptic and diagnostic services started at the Birmingham and Midland Eye Centre (BMEC) in mid-May 2020. The number of in-patients with coronavirus (COVID-19) stabilised and the Government changed the message from ‘Stay home. Protect the NHS. Save lives’ to ‘Stay Alert. Control the virus’ and the easing of national lockdown began.

There continues to be a variation in the delivery of ophthalmology services throughout the UK. Some hospital departments are starting to build on the skeleton service cover they provided during the pandemic. Others continue to suffer from staff redeployment and are only able to offer minimal services. 

As a tertiary service, BMEC needed to support urgent services and develop plans to restore and deliver moderate and routine ophthalmic services. As of 8 July, we are seven weeks into the recovery phase, with most telephone and virtual consultations replaced by face-to-face attendances.

This has not been an easy transition. During the early weeks of the COVID-19 crisis, the multitude of unknowns and a lack of specific government guidance for hospital-based care resulted in a breakdown of normal service delivery. The level of service we were expected to provide as service leads was ever-changing. It was difficult to manage staff concerns and expectations as they made comparisons with colleagues working in other hospitals and the community who had vastly reduced workloads or were working from home.

Redeployment experience

As discussed in our previous article in OT, as the pandemic developed, both locally and nationally, doctors, nurses, optometrists, orthoptists and other allied health care professionals were re-deployed to backfill other clinical roles, enabling nursing and medical staff to move to frontline care.

The fear and anxiety of the early days when the re-deployed staff did not know what level of exposure they would have to COVID-19-positive patients, and whether they would have adequate PPE, was overwhelmingly outweighed by their willingness to help the greater cause. Optometrists and orthoptists moved to non-ophthalmic outpatient specialities and wards, having to adapt to working within different multi-disciplinary teams in very different roles.

Optometrists worked on in-patient wards providing communication links between patients, family members and other healthcare professionals. They played a vital role at a time where there was, and still continues to be, national restrictions on relatives visiting. Patients’ relatives were greatly appreciative of the service. Some of the orthoptic team remain on re-deployment to the Breast service, acting as patient chaperones. These re-deployments, while difficult for us as service leads to manage, have given staff life skills that will have a significant benefit to them as clinicians.

Managing the challenges

Compliance with social distancing rules remains the biggest challenge; it seriously limits the number of outpatients that can be accommodated in our hospital. The reduction of the social distancing rule to one metre has given us the potential to increase our activity.

In addition, we still have staff re-deployed, shielding or restricted to non-patient contact roles. Throughput needs to increase to manage the backlog of patients and the expected surge of referrals from GPs and community optometric practices.

Specialist services such as our paediatric electrophysiology and genetics services have resumed, and we are about to resume clinical trials.

Our services are diagnostic and therapeutic, and as such do not easily lend themselves to telephone and video assessment. The challenge remains to think of innovative methods of delivery, balancing patient and staff safety, without compromising clinical care.

This has not been an easy transition. During the early weeks of the COVID-19 crisis, the multitude of unknowns and a lack of specific government guidance for hospital-based care resulted in a breakdown of normal service delivery

Personal protective equipment guidance has changed significantly over the course of the pandemic, with hospital staff officially informed that face masks were not required in the early stages of the pandemic unless staff were working directly with COVID-19-positive patients, to the current guidance that makes face masks/coverings mandatory for all staff, clinical and non-clinical. Reducing the minimum social distance emphasised the need for adequate facial coverings, particularly in ophthalmology.

A path to the new normal

Patients attending our Trust are offered face masks at the point of entry into the hospital. However, at present they do have a right to refuse. Clinical staff must wear appropriate PPE including surgical face mask, face shield or goggles, apron and gloves, at all times. Additional protection in the form of a Perspex shield has been fitted to all slit lamps in line with guidance from the Royal College of Ophthalmologists.

Our Trust has agreed to provide KN95 face masks, which we believe are necessary for close diagnostic examination such as paediatric examination.

There are practical challenges that arise from the use of PPE. Surgical face masks do not fit tightly to the face. Adjacent surfaces, such as goggles or face shields, steam up and make examination very difficult.

Optometrists have also complained about distorted retinoscopy reflexes using goggles or face shields. Contact lens fitting can be challenging when wearing gloves, with contact lens removal being particularly difficult.

The fear and anxiety of the early days when the re-deployed staff did not know what level of exposure they would have to COVID-19-positive patients, and whether they would have adequate PPE, was overwhelmingly outweighed by their willingness to help the greater cause

Paediatric patients in particular are often frightened by staff in uniform, and the addition of face mask, gloves and goggles heightens the level of fear. We have all been issued with badges to wear over our PPE that show patients what our face actually looks like.

It is likely that face masks and other PPE being used currently in ophthalmology will become a permanent feature of a post COVID-19 world, as community immunity does not exist now or in the foreseeable future.

In addition to changes in clinical services, the replacement for meetings has been provided by software such as WebEx, Microsoft Teams and Zoom. This has been a positive outcome from the pandemic; there are distinct advantages in holding meetings and webinars remotely, and it greatly reduces the need to increase our carbon footprint by travelling or the time spent finding meeting and conference rooms. However, it is challenging to be able to contribute to a group discussion. You are required to wave your hand to draw attention to yourself or wait for your turn, making it difficult to provide constructive criticism. And the loss of networking opportunities has changed the interaction needed in multi-disciplinary teams such as ours.

Our hospital services continue to evolve – as we do with them. But we are open for business and encourage all of the community optometrists in our catchment area to refer patients through the normal pathways including urgent and routine.