all Flashcards
GMC Guidance: Doctors Use of Social Media 2013
Facebook: Patient Asking to Add You As a Friend
on Facebook
• It is important that doctors maintain a professional boundary between themselves and their patients, however minimal the professional contact may be. This professional boundary is important to maintain trust
• If the boundary is breached, whether the breach is deliberate or accidental, this can undermine a patient’s trust in their doctor, and society’s trust in the medical profession more widely
• Using social media also creates risks, particularly where social and professional boundaries become unclear
•If a patient contacts you about their care or other professional matters, through your private profile, you should indicate that you can’t mix social and professional relationships and, where appropriate, direct them to your professional profile
• You must consider the potential risks involved in using social media and the impact that inappropriate use could have on your patients trust in you and society’s trust in the medical profession.
• Social media can blur the boundaries between a doctor’s personal and professional lives and may change the nature of the relationship between a doctor and a patient
Facebook: Posting Messages on a Groups Facebook Page
• Doctors must be careful not to share identifiable information about patients
• Although individual pieces of information may not breach confidentiality on their own, the sum of published information online could be enough to identify a patient or someone close to them. This would be in breach of the GMC’s guidance on Confidentiality, Social Media and Good Medical Practice
• Doctors must also ensure that their tone online is in keeping with professional practice and that their comments don’t risk damaging public trust in the profession
• The standards expected of doctors do not change because they are communicating through social media rather than face to face or through other traditional media
• You must make sure that your conduct justifies your patient’s trust in you and the publics trust in the profession
• When communicating publicly, including
speaking to or writing in the media, you must maintain patient confidentiality
• You should remember when using social
media that communications intended for friends or family may become more widely available
• You must not use publicly accessible social media to discuss individual patients or their care, with those patients or anyone else
• Many doctors use professional social media sites that are not accessible to the public. However, you must still be careful not to share identifiable information about your patients. Although individual pieces of information may not breach confidentiality on their own, the sum of published information online could be enough to identify a patient or someone close to them.
Twitter: Doctor Tweeting Messages on Twitter
• You must make sure that your conduct justifies your patient’s trust in you and the publics trust in the profession
• When communicating publicly, including speaking to or writing in the media, you must maintain patient confidentiality
• You should remember when using social media that communications intended for friends or family may become more widely available
• Using of social media has blurred the boundaries between public and private life, and online information can be easily accessed by others
• You should be aware of the limitations of privacy online and you should regularly review the privacy settings for each of your social media profiles. This is for the following reasons:
– Social media sites cannot guarantee confidentiality whatever privacy settings are in place– Patients, your employer and potential employers, or any other organisation that you have a relationship with, may be able to access your personal information
– Information about your location may be embedded within photographs and other content and available for others to see
– Once information is published online it can be difficult to remove as other users may distribute it further or comment on it
• Using social media also creates risks, particularly where social and professional boundaries become unclear.
• You must not use publicly accessible social media to discuss individual patients or their care, with those patients or anyone else
• You must consider the potential risks involved in using social media and the impact that inappropriate use could have on your patients trust in you and society’s trust in the medical profession.
• Social media can blur the boundaries between a doctor’s personal and professional lives and may change the nature of the relationship between a doctor and a patient
• If doctors are using social media to comment on health or healthcare issues, it is good practice for them to say who they are.
GMC Guidance — Consent: Patients and Doctors Making Decisions Together 2008
• Assess capacity for patient to consent to investigation or treatment, starting from the presumption that the patient has capacity
• You must work on the presumption that every adult patient has the capacity to make decisions about their care, and to decide whether to agree to, or refuse, an examination, investigation or treatment.
• You must assess a patient’s capacity to make a particular decision at the time it needs to be made. You must not assume that because a patient lacks capacity to make a decision on a particular occasion, they lack capacity to make a decision at all, or will not be able to make similar decisions in the future
• You must give patients the information they want or need to know in a way they can understand. You should make sure that arrangements are made, wherever possible, to meet patient’s language and communication needs.
• How you discuss a patient’s diagnosis, prognosis and treatment options is often as important as the information itself. You should share information in a way that the patient can understand and, whenever possible, in a place and at a time when they are best able to understand and retain it
• You should check whether the patient needs any additional support to understand the information, to communicate their wishes, or to make a decision. You must make sure, wherever practical, that arrangements are made to give the patient any necessary support. This might include, for example: using an advocate or interpreter; asking those close to the patient about the patient’s communication needs; or giving the patient a written or audio record of the discussion and any decisions that were made
• Ask the patient if there is anything that would help them remember information, or make it easier to make a decision; such as bringing a relative, partner, friend, carer or advocate to consultations, or having written or audio information about their condition or the proposed investigation or treatment
• If a patient is likely to have difficulty retaining information, you should offer them a written record of your discussions, detailing what decisions were made and why.
• You must only regard a patient as lacking capacity once it is clear that, having been given all appropriate help and support, they cannot understand, retain, use or weigh up the information needed to make that decision, or communicate their wishes by whatever means possible.
Patients Who Lacks Capacity to Consent
• In England and Wales (under the Mental Capacity Act 2005) and in Northern Ireland (under the common law), decisions must be made in a patient’s best interest
• Best interest can be assessed by evidence of patients previously expressed preferences (e.g. advance directive) and by consulting those who are familiar with the patient e.g. relatives or carers
• Independent mental capacity advocates (IMCA) must be instructed in relation to individuals who lack capacity and who have no family or friends whom it is appropriate to consult when:
– An NHS body is proposing to provide, withhold or withdraw “serious medical treatment”; or
– An NHS body or local authority is proposing to arrange accommodation, or a change in accommodation, in a hospital or care home, and the stay in hospital will be more than 28 days, or the stay in the care home more than 8 weeks
The IMCA cannot make decisions, but represents the patient by bringing to the attention of decision makers the important factors that need to be considered, such as the patient’s beliefs, feelings, and values
• In making decisions about the treatment and care of patients who lack capacity, you must:
– Make the care of your patient your first
concern
– Treat patients as individuals and respect
their dignity
– Support and encourage patients to be
involved, as far as they want to and are able, in decisions about their treatment and care
– Treat patients with respect and not discriminate against them
• You must also consider:
– Whether the patients lack of capacity is
temporary or permanent
– Which options for treatment would provide overall clinical benefit for the patient
– Which option, including the option not to treat, would be least restrictive of the
patient’s future choices
– Any evidence of patient’s previously
expressed preferences, such as an advance statement or decision (advance directive)
– The views of anyone the patient asks you to consult, or who has legal authority to make a decision on their behalf, or has been appointed to represent them (lasting powers of attorney)
– The views of people close to the patient on the patient’s preferences, feelings, beliefs and values, and whether they consider the proposed treatment to be in the patients best interest
– What you and the rest of the healthcare team know about the patients wishes, feelings, beliefs and values
• Unless the patient has signed an advance directive, the management decisions will rest with the doctor. Legally, relatives and others only have an advisory role.
Delegating Consent
• Clinical, legal and professional responsibility for ensuring that valid consent has been obtained before treatment is provided rests with the person carrying out the procedure
•The GMC’s guidance states:
–
If you are the doctor undertaking an investigation or providing treatment, it is your responsibility to discuss it with the patient. If this is not practical, you can delegate the responsibility to someone else, provided you make sure that the person you delegate to:
is suitably trained and qualified
has sufficient knowledge of the proposed investigation or treatment, and understands the risk involved understands, and agrees to act in accordance with the GMC’s guidance
If you delegate, you are still responsible for making sure that the patient has been given enough time and information to make an informed decision, and has given their consent, before you start any investigation or treatment
–Capacity in Children
• All children aged 16 or above can be assumed to have the capacity to make decisions about their care, and to decide whether to agree to, or refuse, an examination, investigation or treatment (i.e. essentially they can be treated in exactly the same way as an adult)
• Children under the age of 16 can give consent to an examination, investigation or treatment if they are deemed to be Gillick competent
• A child is deemed Gillick competent if they can understand, retain, use and weigh the information given and their understanding of benefits, risks and consequences.
• Even if a child is competent enough to make a decision to consent to a given procedure or treatment, you should make every effort to encourage the child to involve their parents. Whatever their involvement, parents cannot override consent given by a competent child
Children Refusing Treatment
• Parents cannot override the competent consent of a young person to treatment that you consider is in their best interests. You can rely on parental consent when a child lacks the capacity to consent.
• In Scotland, children can refuse treatment and the child’s decision cannot be overridden by the parents
• In England, Wales and Northern Island, the law on parents overriding young people’s competent refusal is complex. You should involve other members of the multidisciplinary team, an independent advocate, or a named or designated doctor for child protection or seek legal advice if you think treatment is in the best interests of a competent young person who refuses.
GMC Guidance — Confidentiality: Good
Practice in Handling Patient Information 2017/Breaching Patient Confidentiality
• Not leaving computers with patient records unattended
• Not leaving patient details showing on screen where they can be viewed by others
• Not letting patient notes lie around and not taking notes home with you unless they have been anonymised
• Not leaving handover sheets where they can be seen by patients and their families
• Ensuring you check the identity of patients, particularly if you are discussing matters over the phone
• If the patient comes accompanied, asking the patient if they are comfortable with a third person sitting in on the consultation
• Not using the public as translators, even if they offer. There are a number of commercial interpreters available via telephone (e.g. LanguageLine)
• If an adult who has capacity to make the decision refuses to consent to information being disclosed that you consider necessary for their protection, you should explore their reasons for this. It may be appropriate to encourage the patient to consent to the disclosure and to warn them of the risks of refusing to consent.
•You should, however, normally abide by the patients refusal to consent to disclosure, even if their decision leaves them (but no one else) at risk of death or serious harm.
You should do your best to give the patient the information and support they need to make decisions in their own interests e.g. by arranging contact with agencies to support people who experience domestic violence
Breaching patient confidentiality
There are various legal requirements (e.g. court order) to disclose information about adults who are known or considered to be at risk or, or to have suffered, abuse or neglect. You must disclose information if it is required by law.
You should:
– Satisfy yourself that the disclosure is required by law
– Only disclose information that is relevant to the request, and only in the way required by the law
– Tell patients about such disclosures whenever practicable, unless it would undermine the purpose of the disclosure to do so
• You must not disclose personal information to a third party such as a solicitor, police officer or officer of a court without the patients explicit consent, unless it is required by law or can be justified in the public interest. You may disclose information without consent to your own legal advisors.
• In very exceptional circumstances, disclosure without consent may be justified in the public interest to prevent a serious crime such as murder, manslaughter or serious assault even where no other than the patient is at risk. This is only likely to be justifiable where there is clear evidence of an imminent risk of serious harm to the individual, and where there are no alternative (and less intrusive) methods of preventing that harm
• Disclosing information about serious communicable diseases:
– You may disclose information to a known sexual contact of a patient with a sexually transmitted serious communicable disease if you have reason to think that they are at risk of infection and that the patient has not informed them and cannot be persuaded to do so. This guidance applies, even if the sexual contact is not a patient
In such circumstances, you should tell the patient before you make the disclosure (and should consider any reason the patient gives for refusing to consent), if it is practicable and safe to do so.
You must be prepared to justify a decision to disclose personal information without consent
GMC Guidance: Financial and Commercial Arrangements and Conflicts of Interest 2013
GMC APPRAISAL REVALIDATION/ APPRAISAL/ UK Government Guidance: Parental Rights and Responsibilities
• You must be honest in financial and commer- cial dealings with patients, employers, insurers and other organisations or individuals
• You must not allow any interests you have to affect the way you prescribe for, treat, refer or commission services for patients
• If you are faced with a conflict of interest, you must be open about the conflict, declaring your interest formally, and you should be pre- pared to exclude yourself from decision making
• You must not ask for or accept — from patients, colleagues or others — any induce- ment, gift or hospitality that may affect, or be seen to affect, the way you prescribe for, treat or refer patients or commission services for patients. You must not offer these inducements
• You should use your professional judgement to identify when conflicts of interest arise
• Avoid conflicts of interest wherever possible
• Declare any conflicts of interest to anyone affected, formally and as early as possible, in line with the policies of your employer or the
organisation contracting your services
• Get advice about the implications of any
potential conflict of interest
• Make sure that the conflict does not affect
your decisions about patient care
Revalidation:
• The process by which all licensed doctors are required to demonstrate on a regular basis that they are up to date and fit to practice in their chosen field and able to provide a good level of care. This means that holding a licence to practice is becoming an indicator that the doctor continues to meet the professional standards set by the GMC
• All doctors who wish to retain their licenses to practice are now legally required to be revalidated every 5 years as proof that they are up to date and fit to practice.
• Revalidation aims to protect patients from poorly performing doctors, promote good medical practice, and increase public confidence in doctors.
• Revalidation is based on annual whole practice appraisals, usually carried out by someone from the doctor’s workplace.
• Each doctor needs to collect evidence and examples of his/her work throughout the year. At the appraisal, the doctor is expected to reflect on these and identify strengths and any areas that need development.
• There are three ways to get revalidated:
– Responsible Officer:
For the vast majority of doctors, this decision is based on a recommendation from a senior doctor in their organisation called a Responsible Officer (RO)
The RO bases their recommendation on the doctor’s appraisals and any relevant evidence such as clinical governance information
– Suitable Person:
For a small number of doctors who don’t have a RO, another senior doctor is needed to take on their duties, known as a Suitable Person (SP)
– Annual return:
For doctors who do not have an RO or SP, the individual will need to send the GMC an annual return showing that he/ she has annual appraisals and that there are no outstanding concerns about your practice
In this case, the GMC may ask the doctor to sit a written knowledge test
• Definition of appraisal: A constructive discussion with a senior colleague during which doctors reflect on their performance over the last 12 months and consider their future development needs (PDP, CME, CPD)
• There are three stages in the appraisal process:
– Inputs to appraisal, including a record of the doctors scope and nature of work and relevant supporting information
– The confidential appraisal discussion
– Outputs of appraisal, including the doctors PDP and a summary of the appraiser discussion and the appraiser’s statements
Parents rights and responsibilities
• Defined as “all the rights, duties, powers, responsibilities and authority which by law a parent of a child has in relation to the child and his property”
• This can include:
– Consenting to a child’s operation or certain medical treatment
– Accessing a child’s medical records
• Mothers automatically have parental responsibility and will not lose it if divorced
• Married fathers automatically have parental responsibility and will not lose it if divorced
• Unmarried fathers do not automatically have parental responsibility:
– If an unmarried father has a child after 1st December 2003 and he is registered on the birth certificate, he will have parental responsibility
– If a child’s birth was registered before 1st December 2003 and the father was not named on the birth certificate, the birth can be re-registered to include the father’s name — the father will then have parental responsibility
– If a child’s birth was registered before 1st December 2003 and includes the name of the unmarried father, the father will not have parental responsibility (unless obtained by other means)
• Step fathers and step mothers do not automatically have parental responsibility
• Grandparents do not automatically have parental responsibility
UK Government Guidance: Driving Eyesight Rules
•Group 1 drivers (car and light vehicles)
– Vision requirements:
BCVA of at least 6/12 with both eyes open (or in the only eye if monocular) AND
Read a standard number plate at 20 m
– Visual field requirements (Esterman programme on the Humphrey analyser — maximum of 20% false positives is allowed):
At least 120° on the horizontal, with at least 50° left and right AND
No significant defect on the binocular field encroaching within 20° of fixation above or below the horizontal meridian
Significant defect:
• A cluster of four adjoining points
that is either wholly or partly
within the central 20°
• Loss consisting of both a single
cluster of three adjoining missed points up to and including 20° from fixation AND any additional separate missed point within the central 20° area
• Any central loss that is an extension of hemianopia or quadrantanopia of size greater than three missed points
Where a driver has fully adapted to a static long-standing defect, the DVLA may consider them as an exceptional case and perform a practical driving assessment
• Group 2 drivers (large goods vehicles [LGV] and passenger-carrying vehicles [PSV])
– Vision requirements:
BCVA of at least 6/7.5 in the better eye AND
BCVA of at least 6/60 in the worst eye AND
Glasses, if required, should be up to
+8 D in strength
– Visual field requirements (Esterman programme on the Humphrey analyser — maximum of 20% false positives is allowed):
At least 160° on the horizontal, with at least 70° left and right and 30° above and below AND
No defects in the central 30°
• Monocularity
– Group 1 drivers: do not need to tell DVLA
if the other eye satisfies the usual vision and visual field requirements and may drive when clinically advised that they have adapted to the disability
– Group 2 drivers: must not drive and must inform the DVLA
• Diplopia
– Group 1 drivers: must inform the DVLA,
driving may be resumed if diplopia controlled — patching is acceptable (must not drive if diplopia uncontrolled)
– Group 2 drivers: must not drive and must inform the DVLA, patching not acceptable
• Blepharospasm
– Patients with severe blepharospasm must not drive. Patients with mild treated blepharospasm may drive subject to consultant approval
– Group 1 drivers: must inform DVLA
– Group 2 drivers: must inform DVLA
• TIA
– Group 1 drivers: must not drive for 1 month and only restart when the doctor tells the patient they are safe to resume driving; do not need to inform DVLA if patient had a TIA and have recovered
– Group 2 drivers: must inform the DVLA and must not drive for 1 year following a TIA, and can only restart when the doctor tells the patient that he/she is safe to resume driving
• Glaucoma
– Group 1 drivers: do not need to inform
DVLA if glaucoma affects only one eye and your other eye has normal vision and visual field
– Group 2 drivers: must inform DVLA if glaucoma affects one eye or both eyes
Diabetic retinopathy
Group 1 drivers: must inform DVLA only when both eyes affected
Group 2 drivers: must inform DVLA if one or both eyes affected
UK Government Guidance: Registering Vision Impairment as a Disability
Sight impaired
– VA 3/60 to 6/60 with full field
– VA 6/60 to 6/24 with moderate constriction of field (superior or patchy loss), media opacities or aphakia
– VA 6/18 or better with marked field defect (e.g. homonymous hemianopia advanced glaucoma, RP)
Severely sight impaired
– Legally defined as “so blind that they cannot do any work for which eyesight is
essential”
– VA worse than 3/60
– VA 3/60 or better but worse than 6/60 with contraction of their visual field
– VA 6/60 or better with a clinically significant contracted visual field which is functionally impairing the person (e.g. loss of inferior field or homonymous or bitemporal hemianopia)
– Homonymous or bitemporal hemianopia is specifically excluded unless VA worse than 6/18
UK Government Guidance: Data Protection Act 2018
•Data protection is the fair and proper use of information about people (ensuring people can trust you to use their data fairly and responsibly)
• If you collect information about individuals for any reason other than your own personal, family or household purposes (e.g. personal social media activity, private letters and emails, or use of your own household gadgets), you need to comply
• The data protection act 2018 is the UK’s implementation of the European General Data Protection Regulation (GDPR forms part of the UK law)
• The Information Commissioner’s Office (ICO) regulates data protection in the UK
• Everyone responsible for using personal data has to follow strict rules called Caldicott principles or “data protection principles”
– Personal data processed lawfully, fairly and in a transparent manner
– Purpose limitation:
Data collected for specified, explicit and legitimate purposes and not further processed in a manner that is incompatible with those purposes
– Data minimization:
Adequate, relevant and limited to what is necessary in relation to the purposes for which they are processed
– Accuracy:
Inaccurate data should be erased or rectified without delay
– Storage limitation:
Kept in a form which permits identification of data subjects for no longer than is necessary or the purposes for which the personal data are processed
– Integrity and confidentiality (security): Appropriate security of the personal data, including protection against unauthorized or unlawful processing and against accidental loss, destruction or damage, using appropriate technical or organizational measures
– Accountability
• The data protection officer (Caldicott Guardian)is responsible for providing advice, monitoring compliance, and is the first point of contact in the organisation for data protection matters
UK Government Guidance — Safeguarding Policy:
Protecting Vulnerable Adults and Children
• Safeguarding is about protecting an adult’s or child’s right to live in safety, free from abuse and neglect
•Vulnerable adult :
person aged18 or over who is or may be in need of community care services by reason of mental or other disability, age or illness; and who is or may be unable to take care of him or herself, or unable to protect him or herself against significant harm or exploitation
• Neglect: persistent failure to meet a person’s basic physical or psychological needs to a level that is likely to result in serious impairment of the persons health or development
• Alert the adults safeguarding team for vulnerable adults — contact the named nurse for adult safeguarding and named doctor who lead on issues related to adult safeguarding
• Alert the child protection team for vulnerable children — contact the named nurse and named doctor who lead on issues related to child protection
Never Events
NHS Improvement Never Events Policy and Framework 2018
• Never events are defined as serious incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented and followed by all healthcare providers
• Never events list applicable to Ophthalmology include
– Wrong site surgery
– Wrong implant/prosthesis: an error in IOL choice after the time out WHO check is a never event. An error in IOL choice up to the time out WHO check is a serious incident (The RCOphth Ophthalmic Service
Guidance for Correct IOL implantation in
cataract surgery 2018)
– Retained foreign objects post procedure
• Never events require full investigation (completed within 60 days) under the Serious Incident Framework
– Describes the process and procedures to
help ensure serious incidents are identified correctly, investigated thoroughly and, most importantly, learned from to prevent the likelihood of similar incidents happening again
– Incident report required within 2 days on Strategic Executive Information System (StEIS) and National Reporting and Learning System (NRLS)
– Disclose information to patients as soon as possible
– Organisational leaders must undertake with the whole multidisciplinary team a root-cause analysis to determine the reasons for the incident
– Leaders must then establish strategies and implementation tools to stop it from happening again
Non-Accidental Injury (NAI)
The Royal College of Paediatrics and Child Health and The Royal College of Ophthalmologists Guideline on Abusive Head Trauma and the Eye in Infancy 2013:
• When to suspect a NAI
– There is a delay between injury and seek-
ing medical advice (if there is a delay, and
there is no satisfactory explanation)
– History is not consistent with the injury — parents have given different accounts at
different times
– On examination, the child has unexplained
injuries and there are patterns of injury typical of abuse (e.g. multiple facial bruises, scalds, cigarette burns, any unex- plained injuries in non-ambulant babies, bites, hand or implement marks, head inju- ries with intracranial haemorrhages in babies, multi-layered retinal haemorrhages, unexplained abdominal or genital injuries or long bone fractures especially in babies)
– The child’s behaviour and interaction with parents/carers is not appropriate
– Any children who presents with unex- plained injuries or a history that is incon- sistent with the injury should be referred to the named doctor and named nurse who lead on issues related to child protection
Recording of ophthalmological features in suspected NAI
– The most senior ophthalmologist available
should be examining a child as part of child
protection investigations – Document:
VA
Ocular motility
Pupil size and pupillary reflexes Periocular bruising
Subconjunctival haemorrhages Anterior segment
Retinal haemorrhages (see Fig. 4.1):
• Number: few (1–10), many (10– 20), too numerous to count
• Location: preretinal, intraretinal, subretinal, multilayered
• Distribution: posterior pole (zone 1 ROP), periphery (outside zone 1)
• Size: small (<1 DD), medium (1–2 DD), large (>2 DD)
• Morphology: white centered
Macular retinoschisis Perimacular folds Optic disc
– If a digital photographic system is used, an unmodified printout should be made at the time and signed by two witnesses
• Communication with parents
– It is important that parents are kept
informed about the child’s medical care
throughout any investigations
– Parents prefer honest, clear, and early com-
munication on what a child protection enquiry means; what referral to social ser- vices or the police means; whether emergency proceedings are taking place; what the child protection medical examina- tion involves; how long the child has to stay in the hospital; what different tests involve; whether further tests are needed and how long it will take to receive test results
– Sensitively explaining to parents that there is a protocol that the professional has to follow and clearly outlining the process may help parents to accept and understand
– “Examination findings are consistent with a non-accidental injury and it was the pro- cedure in those cases therefore to inform social services and also to do a full skeletal X-ray and dilated fundus examination in those cases”
Approach to Patient with Refractive Surprise
Verify the Problem
• RCOphth guidelines: achieve 85% within 1 D of intended refractive outcome
• What is the postop refraction (have it checked by a clinician experienced at refraction)?
– Causes of a myopic surprise:
Previous hyperopic refractive surprise Error in A constant calculations (e.g. placing IOL with A constant of 118 rather than 113) leading to a higher lens power than required
Capsular block syndrome (capsular hyperextension, IOL displacement ante- riorly, AC shallowing, postop myopic shift)
—Causes of a hyperopic surprise:
Previous unrecognized myopic refractive surgery
Unrecognised staphyloma at most posterior portion of the globe (anatomic axial length may not correspond with the center of the macula i.e. refractive axial length)
Case Note Review
•Was the correct IOL selected intraoperatively?
• Was the preoperative biometry/lens selection valid?
– Check biometry used does indeed belong to your patient
– Look for intraocular consistency in axial length and K values
– Look for interocular consistency in axial length and K values
• Check appropriate formula used
• Had they had previous refractive surgery?
ClinicalExamination
• Has there been a change in the corneal curvature (K) reading since the operation?
– Wounds: poorly constructed wounds or use of LRI’s (hypermetropic effect)
– Corneal oedema
– Other corneal pathology previously unrecognised e.g. keratoconus, previous refractive laser surgery, CL use
• Is the IOL correctly positioned?
– Check IOL centered and completely in the bag
– Is there retention of Healon within the bag?
– Is early capsule healing/phimosis affecting IOL position?
Investigations
• Repeat biometry ± B scan to confirm axial length (on pseudophakic mode)
• Repeat keratometry ± corneal topography
Treatment
• Small errors
– Observation: post-op changes in corneal
curvature may improve as oedema settles
and wound heals
– No treatment: a small myopic refractive
surprise in a non-dominant eye may be useful for reading
– Trial of spectacles
– Intervention for specific problem: surgical repositioning of poorly placed IOL, YAG laser for capsular phimosis
• Large errors
– CL
– Secondary piggyback IOL: IOL power
based on postop refraction
– Laser refractive surgery for residual errors
– IOL exchange: least preferable as carries a greater surgical risk and offers less predictability
Consenting for cataract surgery
• Explain what a cataract is (“clear lens in your eye has become cloudy”) and what the operation does (“operation replaces the cloudy lens with a new clear plastic lens”)
• General risks
– Intraoperative risks:
PC rupture ± vitreous loss
Dropped nucleus with need for a second operation
– Postoperative risks: Endophthalmitis
Retinal detachment/tear
Choroidal haemorrhage
Posterior capsular opacification with need for laser treatment
• Specific risks
–Technical difficulties e.g. patient
positioning
– Guarded visual prognosis e.g. amblyopia, corneal opacity, macular disease, vitreous opacities, optic nerve disease
– Increased risk of sight-threatening complications in certain conditions:
High myopia: RD
Endothelial dystrophy (e.g. FED): corneal decompensation
PXF: zonular dehiscence
Posterior polar: PC rupture
IFIS: iris trauma
• Anaesthetic options
Topical anaesthetic
Subtenon anaesthetic
Globe rupture (0.006–0.1%)
Oculocardiac reflex (0.03%)
General anaesthetic (GA)
• Desired refractive outcome
– Emmetropia: require no/weak glasses for distance but will definitely require reading glasses
– High ametropia:
Aim for emmetropia and perform second eye operation within 6 weeks
Aim to leave ametropic but up to 2 D nearer emmetropia than the other eye Aim for emmetropia and use a CL on the second eye until surgery is indicated
• IOL choice
Monofocal IOL
Toric IOL
Multifocal IOL
Clinical supervision of trainees in difficulty
• Seek information (what is the issue, is there actually a problem, is this a one-off situation or is there a pattern)
– Collate information from consultant colleagues who have worked with trainee
– Initial conversation with the trainee to inform them of the concerns that have been raised and the action that is being taken and also to get their perspective
– Encourage trainee to commit their comments to paper
– Training environment issues:
Mismatches between trainee and trainer
Alleged bullying or harassment
Wrong levels of expertise expected of trainee
Supervision not congruent with level of
expertise expected
– Personal issues:
Partner/spouse relationship Bereavement
Critical family illness VISA problems
– Clinical performance issues: Clinical or surgical skill issues
– Generic professional development issues: Communication issues with patients &/ or staff
Motivation, maturity, a lack of insight Time management and basic organisational skills
– Professional behaviour issues:
Integrity
Probity
Substance abuse
• Patient safety (is patient care compromised)
– Training environment issues:
– Personal issues:
– Clinical performance issues:
– Generic professional development
issues:
– Professional behaviour issues:
Substance abuse: suspension from clinical duties pending full investigation
• Initiative (can you do anything yourself before you escalate the situation)
– Training environment issues:
– Personal issues:
Encourage trainees to access counselling and support services of their deanery through human resources (HR) and occupational health (OH) departments
–
Clinical performance issues:
Increased supervision of trainee SMART (specific, measurable, achievable, relevant, time bound) objectives
-Generic professional development issues: -Professional behaviour issues
–Escalate (involve other colleagues as needed, who will you go to, who is the most appropriate person)
•Support (can you support the individual or team)
Training environment issues:
Discussion with educational supervisor Discussion with training programme director (TPD)
Personal issues:
Discussion with educational supervisor Discussion with TPD
Clinical performance issues:
Discussion with educational supervisor Discussion with TPD
Generic professional development issues: Discussion with educational supervisor Discussion with TPD
Discussion with postgraduate dean
Professional behaviour issues:
Probity — inform GMC
Substance abuse — inform local HR department, medical director, GMC
Training environment issues:
Relocation to a more appropriate training environment
Personal issues:
Arrangements of future placements closer to trainees home or support network
Out of programme career break (OOPC)
Clinical performance issues:
Use of simulator/wet-lab facilities Targeted or repeat training with clear educational objectives and yardsticks of success (SMART objectives)
Generic professional development issues: Behavioural or psychometric assessment through psychologists identified through deanery or NCAS (national clinical assessment service)
Professional behaviour issues: Behavioural or psychometric assessment through psychologists identified through Deanery or NCAS
Stress counselling service
The RCOphth Ophthalmology Service Guidance on Theatre Procedures 2018
• Consent
– Discuss the options of no surgery and of
other or lesser interventions
– Best practice to consent before the day of surgery in all but emergency or minor operation situations
– On the day of surgery, the consent should be rechecked with the patient and resigned by a consenter
– Consent must be obtained in the full knowledge of risks relevant to both the operation and anaesthesia. It is the responsibility of the individual administering the anaesthetic to discuss possible complications of the anaesthetic. A separate consent for the anaesthetic per se is not required, although it is advisable to record the discussion in the patient records
• Pre-operative assessment
– Purpose: identify abnormalities or issues
that might interfere with the safe performance and outcome of the operation and confirm the decisions made at the decision to admit were appropriate and still apply
– Undertaken normally by trained specialist nurses or other trained ophthalmic healthcare professionals with medical anaesthetic input as required
– General medical records should be available. If the relevant information is not available, planned surgery should be deferred
– Should take place before the day of surgery and occur within 3–4 months of the surgery. A telephone call to confirm nothing has changed may be done in the week preceding the surgery if there is a long gap between assessment and procedure
– Telephone pre-assessment may be appropriate when a second procedure is planned in healthy patients (e.g. second eye for cataract surgery) within 3–4 months of the first operation
– Some patients may need help (e.g. friend,relative, carer) to accompany them to surgery and at discharge, or support from the community nursing team at home
– Specific checks to ensure suitability for day case surgery if planned; living alone is not a contraindication but it needs to be confirmed that the aftercare, particularly instilling the eyedrops effectively at the right times, is possible
– Specific checks to highlight any concerns about mental capacity, ability to lie flat and still for the whole duration of the operation, and communication difficulties
– Results should be recorded on a checklist
– Following examinations should be undertaken:
BP, HR and rhythm
Hearing, comprehension, co-operation Tremor and abnormal body movements Infection control screening (e.g. MRSA swabs)
– Following examinations are performed if indicated:
If there is respiratory distress or SOB present, measure the RR, O2 sats, and the patient review by or discussed with a doctor or an anaesthetist
Practice patients ability to lie flat and still in the appropriate position for the duration of the operation
Examination for non-ocular sepsis
Slit lamp examination e.g. blepharitis
– Tests routinely indicated for the following situations:
Clotting profile for those on
anticoagulants (e.g. warfarin)
Electrolytes for patients on dialysis Blood glucose measurement and HBA1C for those with diabetes
• On admission
– Nurses, or HCA’s under the supervision of nurses, will perform the pre-operative patient preparation on wards or day case areas. Results of the preoperative assessment should be available and, together with the following, be recorded on a checklist:
Patients identity should be confirmed and a name badge should be attached to the patient’s wrist
Ensure the next of kin details are documented/updated in the patient’s medical records
Confirm that the patient has been well since the pre-operative assessment visit and does not have any acute illness e.g. URTI
Confirm whether the patient has taken his/her medication
Confirm allergy status as this may affect the order of the list e.g. type I latex allergy
Ensure the patient has provision for a safe return home
BP, HR, temperature and O2 saturation should be checked
Check that the consent form has been signed and rechecked on the day of surgery
Check the marking side forms and biometry/IOL data are present
Ensure that the pre-operative medications including eye drops or inserts are administered
– Any change in the patient’s condition or therapy since pre-operative assessment, or other concerns from these assessments, should be brought to the attention of the surgeon and, where relevant, the anaesthetist
– The findings of the preoperative assessment and checks should be reviewed by the ophthalmologist, and where appropriate, the anaesthetist
– The eye/adnexae should be checked to exclude acute inflammation or infection
and rechecked for other factors that may affect safe local anaesthesia or surgery Preop marking:
Mandatory to mark procedure site shortly before the procedure but not in the anaesthetic room or the theatre
Site marking must be performed by the surgeon or nominated deputy who will be present during the procedure. It is the surgeon’s responsibility to check that he/she is operating on the correct eye/ side
Mark the eye or side/site to be operated on with a clear, indelible mark. This mark should remain visible after surgical cleaning, and after draping if at all possible
Handover to procedure teams:
There must be a formal handover process from the ward or admission team to a member of the theatre team receiving the patient
The handover should include a check of:
• Patient identification (name, DOB, active confirmation), checked against identity band
• Allergies
• Procedure, and site or side
• Site marking
• Whether patient has any plates,
pins, or any metal implants if monopolar diathermy is going to be used
• Fasting status
• Relevant clinical features e.g.
blood sugar for diabetic patients,
INR for warfarin
• An appropriate patient record
• A properly completed consent
form
• A biometry sheet if relevant
•In theatre
Staffing levels:
For most LA ophthalmic lists, the following staff are the minimum acceptable theatre team:
• Two scrub nurses or practitioners: one for the current case and the other preparing the instruments for the next case
• Runner (can be a HCA): role is to supply the scrub practitioner with the necessary equipment and consumables, set up the phaco equipment etc., help position the patient and microscope, adjust the lights and other essential duties.
– Patient monitoring: For LA patients
• Patients should be continuously monitored — clinical observation, communication and pulse oximetry as a minimum, from before the administration of the LA to the end of the operation
• ECG and BP should be monitored in sedated patients and those who are at risk of cardiovascular complications (e.g. hypertensives, patients with pacemaker, diabetics) and higher risk situations such as strabismus surgery, intra-operative use of ocular sympathomimetics (such as phenylephrine and mydricaine)
• In stable patients the non-invasive BP measurements should be kept to a minimum to avoid discomfort and undue disturbance during surgery
• A suitably trained individual must have responsibility for monitoring the patient throughout. This task may be carried out by an anaesthetist, a nurse, an ODP, an ODA, an anaesthetic nurse or, in some cases, a suitably trained HCA as long as they are trained in basic life support (BLS)
• The ultimate responsibility for the patient rests with the operating surgeon and, when present, the anaesthetist
Anaesthetics and resuscitation:
GA and sedation requires the assistance of a trained anaesthetic technician/or anaesthetic nurse as well as an anaesthe- tist. In addition there should be trained recovery staff
An anaesthetist is not essential when topical, subconjunctival or sub- tenon’s techniques without sedation are used
Ideally, an anaesthetist should be avail- able in the theatre complex, particularly when sharp needle blocks such as perib- ulbar, retrobulbar are used, and when complex or long cases are being performed
For any operation, all theatre staff must be regularly trained and able to perform BLS, understand local resuscitation arrangements, and there should be a resuscitation trolley easily and quickly available
Where there is backup from a formal cardiac arrest/medical emergency team, there should be at least 1 person avail- able with immediate life support (ILS), who should be supported by staff with the knowledge and skills to assist in resuscitation
Where the unit is free-standing and there is no immediate access to a formal cardiac arrest team there should be at least one person with advanced life sup- port (ALS)
If an anaesthetist is not immediately available, the operating ophthalmologist is directly responsible for the management of any untoward event and should have the appropriate skills to safely manage resuscitation, or to have these skills within the theatre team
Five steps to safer surgery:
Team brief:
• Performed before the first patient arrives in the theatre area
• Any team member may lead the safety briefing
• As many members of the surgical team as possible should attend the briefing, but it must include the surgeon and anaesthetist who have seen and consented the patients
Sign in (first part of the WHO checklist):
• Performed when patient arrives at the procedure area
• For cataract surgery a specific cataract or ophthalmic checklist is recommended. For other ocular surgery the standard WHO check- list or an ophthalmic specific checklist can be used
• Must be performed by at least two people involved in the procedure. For procedures involving an anaesthetist, these should include the anaesthetist or anaesthetic assistant
• Any omissions, discrepancies or uncertainties identified during the sign in should be resolved before the time out is performed or any procedure starts
• Immediately before the insertion of a block anaesthetic, the anaesthetist and anaesthetic assistant must simultaneously check the surgical site marking and the site and side of the block
Time out (second part of the WHO checklist):
• Must be performed immediately before the start of the procedure
• Any member of the procedure team may lead the time out
• All team members involved in the procedure should be present at the time out. This will usually require that they stop all other tasks and face the time out lead
• The team member leading the time out should verify that all team members are participating
• Any omissions, discrepancies or uncertainties identified during the time out should be resolved before
the procedure starts
Sign out (third part of the WHO checklist):
• Performed at end of procedure before patient is awoken from GA or before the patient leaves theatre
• Any member of the procedure team may lead the sign out
• All team members involved in the procedure should be present at the sign out. This will usually require that they stop all other tasks and face the sign out lead
• The team member leading the sign out should verify that all team members are participating
Team debrief:
• Performed at the end of all lists
• Every member of the procedural
team should take part in the
debriefing
• Any team member may lead the
debriefing, but the surgeon and anaesthetist (if an anaesthetist has been involved) must be present
• If any team member, and especially the senior surgeon, scrub practitioner or anaesthetist, has to leave before the debriefing is con- ducted, they should have the opportunity to feedback any issues they wish to see addressed during the debriefing
Postoperatively
– Pain should be assessed and managed
– After the operation, and before discharge,
the patient should feel well and have stable
key signs
– For patients who have undergone GA,
ensure patient has passed urine before
discharge
– Before discharge the safety arrangements for the patient’s return to home, and the level of support available, should be confirmed
–Information (including written) should be provided about post-operative recovery (post-op instructions, medication dis- pensing and advice, advice on post-op appointments, what to expect during recovery)
Written instructions should be given to the patient about what to do and whom to contact in the event of problems or concerns, especially signs of postop infections such as endophthalmitis
• Organising theatre lists
– There should be unambiguous use of language in all communications relating to the scheduling and listing of procedures. Laterality must always be written in full i.e. ‘left’ or ’right’
– The information to schedule a procedure should include when relevant:
Source of patient e.g. ward or day case area
Significant comorbidities
Allergies e.g. latex or iodine
Unusual infection risk including prion disease
Any non-standard equipment require- ments or non-stock prostheses
Unusual BMI or extreme obesity where normal hospital equipment may have difficulty safely accommodating the patients weight e.g. theatre trolley, mobile patient hoist
– The clinical team performing the procedures is responsible for deciding the order of procedures within a list of cases. In determining the order of a list, priority should be given to clinical criteria e.g. urgency, extremes of age, allergies such as latex allergy, and medical conditions e.g. diabetes
– Late list changes should be avoided if possible. Any list changes made after the deadline for the publication of a final version of the list must be agreed with identified key members of the procedure team, and should be discussed by all members of the procedure team at the safety briefing
Needle Stick Injury
Transmission Rates
• Needle stick transmission rates from infected patients are estimated at around 0.3% for HIV (The RCOphth Ophthalmic Services Guidance on Prevention of transmission of blood-borne viruses in ophthalmic surgery 2010),
up to 10% for Hepatitis C (The RCOphth Ophthalmic Services Guidance on Prevention of transmission of blood-borne viruses in ophthalmic surgery 2010),
and up to 30% for Hepatitis B (The RCOphth Ophthalmic Services Guidance on Prevention of transmis- sion of blood-borne viruses in ophthalmic surgery 2010)
Management
• Immediate
– Encourage the injury to bleed
– Wash under running water
– If body fluids splashed onto eyes, irrigate them copiously
– Incident report
– Inform patient and take patient details
(name, unit number, contact details) – Inform head of department
• Within 1 h
– Report to the occupational health department (or A&E department if out of hours). If high risk (exposure to blood or high-risk body fluid from patient with known or suspected HIV) of HIV transmission, start post-exposure prophylaxis (e.g. TRUVADA once a day) — this should be started within 1 h by the occupational health/A&E physician:
If donor is HIV positive (already known or discovered on testing):
• Continue post-exposure prophylaxis for 4 weeks
• Test recipient for HIV seroconversion at 6 weeks, 3 months, 6 months
• Follow up with occupational health
If donor is HIV negative:
• Discontinue post-exposure
prophylaxis
• Test recipient for HIV seroconver-
sion at 3 months and 6 months
• Follow up with occupational
health
– Store blood from the donor and the
recipient:
Screening for Hepatitis B and HIV (HIV antibody and p24 antigen simultaneously), where appropriate, is generally arranged by the occupational health physician
The donors blood sample should not be taken by the recipient
The donor must be counseled before taking blood samples/testing for HIV (no written consent required but the benefits of testing to the individual and the details of how the result will be given [face to face provision of test result] must be discussed)
