COVID-19 and its effect on the provision of ophthalmic care in the United Kingdom.

The first quarter of 2020 gave light to a novel virus, Coronavirus 2019 (COVID-19), causing a pandemic of unbridled proportions. The National Health Service in the United Kingdom issued guidance to ensure that capacity was increased in acute medical settings, to prepare for the surge of COVID-19 cases. The Royal College of Ophthalmologists followed suit with guidance on the curtailment of all elective activity, aimed at protecting both patients and staff. Ophthalmology is one of the busiest outpatient specialities, and risk stratification of patients with appointments cancelled or on review lists was paramount to ensure there was no serious, permanent harm to sight. Our way of working, as we knew it, had to change in a short period of time. Local emergency eye care was changed from a walk in service, with the implementation of a strict triage protocol. Ophthalmologists, as well as Otorhinolaryngology colleagues, were identified as being at high risk of infection, due to the close proximity of clinical examination. The redesign of clinical areas to allow for social distancing, slit lamp barriers and personal protective equipment was all implemented. This time of relative pause has provided the opportunity to harness new ways of working, including the streamlining of services, reduction of backlog and the incorporation of telemedicine. Health preparedness is a new lexicon to Ophthalmology departments across the world, and it will now have to be stringently implemented in the ophthalmic setting.

INTRODUCTION

In the first quarter of 2020, the world has seen a pandemic of unbridled proportions. The novel virus, Coronavirus 2019 (COVID‐19) caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), has gridlocked the world, prompted social distancing measures to reduce its spread, paralysed industry and non‐essential services, and grounded international travel. As of Easter Sunday 2020, there were over 1 792 899 cases worldwide, with a total of 110 042 deaths. The pandemic has been a catalyst for innovation and investment in health services around the world, and clinical practices across outpatient specialties have evolved to respond to the challenges of COVID‐19 within the space of a few weeks. The changes were instigated not only to protect vulnerable patients and reduce the spread of COVID‐19 but also to protect key healthcare workers in these specialties.

The National Health Service (NHS) in the United Kingdom (UK) instructed all hospitals to increase capacity within acute medicine to prepare for the surge of COVID‐19 cases. The Royal College of Ophthalmologists (RCOphth) issued guidance on Ophthalmology services during the pandemic, with the curtailment of all elective activity with immediate effect. The RCOphth guidance weighed the risk of patients acquiring COVID‐19 by attending hospital appointments against the risk of harm by postponing treatment.

ELECTIVE ACTIVITY: RISK STRATIFICATION AND VIRTUAL CONSULTATIONS

Ophthalmology is recognised as the busiest outpatient department within the NHS, accounting for nine million outpatient appointments per year, and 6% of all surgical procedures. New ways of working have emerged as departments across the country adapt to reduce the infection risk to healthcare staff and patients while ensuring that patients are protected from serious, permanent harm to their sight.

From days filled with back to back clinics and operating sessions, Ophthalmologists now spend much of their time assessing cancelled clinic lists, telephone triaging patients and risk stratifying those with cancelled appointments or on review lists based on underlying ocular morbidity. The risk stratification process is subspecialty specific, dividing patients into high, medium and low risk. High‐risk patients remain face to face, medium‐risk patients are contacted via video or phone consultations and rebooked for within 3 months once standard operations recommence, and low‐risk patients are deferred for 4‐6 months, following video or phone consultation if required. Moorfields Eye Hospitals NHS Foundation Trust have developed a useful triaging tool to facilitate this process. Risk stratification allows the staggering of reviews to minimise overwhelming capacity in the immediate months following the pandemic. Furthermore, risk stratification and virtual consultations have proven a useful exercise to identify patients who can be discharged from the hospital eye service, to the care of their optometrist. Issues with shortcomings in capacity, commonplace in ophthalmic units across the country, have been highlighted; review lists are mounting, with insufficient numbers of clinicians to see the backlog of patients already waiting to be reviewed. With the cessation of routine surgical activity, and streamlined theatre lists for emergency and urgent cases, a new problem arises with the backlog generated once standard surgical operations resume. Surgical capacity will need to increase, and it needs to be ascertained if pre‐pandemic capacity and surgical flow will be adequate in the post‐pandemic era.

EMERGENCY EYE CARE

As optometrists limit their opening hours and move to phone triaging services, general practices reduce face‐to‐face consultations and patients delay presentation in fear of contracting COVID‐19, the need for efficient emergency eye care provision has pressured a dramatic evolution. The emergency eye care service local to the authors of this article halted their usual walk‐in service until further notice. Communication of this change was made to local primary services and displayed on the hospital's website. A strict triage protocol was implemented with screening questions about any COVID‐19 symptoms. Patients either referred themselves or through their general physician or optometrist, all via telephone. The service remained coordinated by senior trainees, with consultant support. If a patient presents to the department without referral, they are triaged in a strategically placed examination room near to the entrance of the department, to ascertain if emergency care is required and what personal protective equipment (PPE) precautions need to be taken based on their COVID status. A highly robust telephone triage system has been implemented to deal with the high number of calls, with a dedicated nurse practitioner answering calls, assessing the clinical need and documenting the consultation and advice directly on to the electronic health record of the patient.

PROTECTING PATIENTS AND STAFF

The close proximity of examination, and the droplet fashion by which COVID‐19 is spread, has suggested that Ophthalmologists, along with Otorhinolaryngologist colleagues, are at high risk of infection. A Norwegian Ophthalmology department had their own outbreak of COVID‐19 which saw services shut down completely for a total of 2 weeks. Limiting the number of patients and staff within the department at any given time, spaced seating arrangements, preventing COVID‐19 symptomatic patients from attending unless absolutely necessary, and the use of PPE including face masks and slit lamp barriers is essential component to minimising transmission in an otherwise high volume, crowded clinical setting.

IMPLICATIONS FOR THE FUTURE

Healthcare preparedness is a concept reserved for emergency and critical care in more acute clinical settings, and its aim is to reduce risk ; rarely is it described for outpatient services. The formation of protocols and guidance for ophthalmic services have been reactionary to the emerging challenges of the pandemic, as there was no document on “what to do if you have to shut down your service due to a pandemic.” Lessons learnt from COVID‐19 will inevitably drive change in healthcare preparedness for ophthalmic and other outpatient services, aiming to reduce risk through strategy, and formalising guidelines in preparation for such eventualities in the future.

This somewhat surprising pause in service has given us the perfect opportunity to adapt and discover ways of running the Ophthalmology service more efficiently. More resources have become available to enable us to deliver Ophthalmology care differently. Virtual clinics are already in place to varying degree in Ophthalmology departments around the UK. The current pandemic may be an opportunity to implement more robust virtual services, which would be instrumental in alleviating the backlog for patients with chronic ophthalmological conditions such as age‐related macula degeneration and glaucoma, and not just for stable chronic patients. With areas in the UK such as Scotland and Wales already using virtual consultation technologies, alongside higher levels of community optometry collaboration due to the pressures of geographical location, the pandemic has forced the rest of the UK to follow suit with an increase in telemedicine and videoconferencing utilisation to deliver essential consultations.

As the lockdown is eased and Ophthalmology services are gradually reinstated to their pre‐pandemic status, the challenge will be to examine which of these novel ways of working are here to stay. How do we continue to protect our patients, minimise the risk of virus transmission and ensure that we deliver much‐needed treatment in a timely manner?

In conclusion, COVID‐19 will have a significant and lasting impact on how we deliver healthcare. Ophthalmology clinicians around the world should use this opportunity to harness new ways of working, streamline services, reduce backlog, increase capacity and enhance positive patient experience. Healthcare preparedness, the new lexicon to Ophthalmology departments across the world, will now need to be stringently implemented in the ophthalmic setting.

DISCLOSURES

The authors declare that they have no conflict of interests and no funding has been received for this work.

AUTHORS’ CONTRIBUTIONS

Both authors were equally involved in concept and drafting of this article.