Scope of resident ophthalmology consultation service and patient follow-up rates at a level 1 trauma center in Brooklyn, New York

The Diagnostic Accuracy of First-Year Ophthalmology Residents on Call: Considerations for Postgraduate Year 2 (PGY-2) Standardizations of Call Structure

Background Ophthalmology is a unique specialty with limited exposure during medical school. To improve the transition to ophthalmology residency, the Accreditation Council for Graduate Medical Education (ACGME) announced in 2017 that all ophthalmology residency programs would move to a combined post-graduate year (PGY) 1 year with mandatory integration by 2023. Currently, there are no standardized guidelines from the American Board of Ophthalmology (ABO) or the Accreditation Council for Graduate Medical Education (ACGME) to address ophthalmology resident competence prior to becoming the primary contact for inpatient and emergency room (ER) consultations as a PGY-2. Novice residents may not be equipped to accurately diagnose vision or life-threatening ocular conditions. A balance between resident autonomy and supervision is required for proper training without increasing patient morbidity and mortality. Objective This study's objective is to examine the diagnostic accuracy of PGY-2 ophthalmology non-integrated residents on call to standardize supervision requirements (through buddy-call) prior to initiating indirectly supervised calls. Methods All inpatient and ER ophthalmology consults for the first seven weeks of the year evaluated by PGY-2 (junior) residents were supervised and graded as "correct" or "incorrect" by PGY-4 (senior) residents. Results One hundred forty-eight consults were seen over 30 call days over a period of seven weeks (4.93 consults per call). The percentage of correct diagnoses increased with each successive week (R2 = 0.9581; correlation = 0.979). The greatest percent increase of correctly diagnosed encounters was between weeks 2 and 3 (19.14%) correlating to call numbers 10-16 and 45-68 patient encounters. The mean percent accuracy surpassed 70% during weeks 3-4, and improvement continued to week 7. High-acuity diagnoses were identified consistently 100% of the time from week 5 onward. Conclusion Our analysis indicated that diagnostic accuracy was greater than 70% between weeks 3 and 4 with high-acuity diagnostic accuracy reaching 100% at week 5. It can be postulated that optimal direct senior resident supervision is needed for at least 3-5 weeks before transitioning to indirectly supervised calls by PGY-2 residents. This standardization would allow junior residents to acquire sufficient clinical experience to accurately make a diagnosis and prevent patient morbidity. Further research nationally is necessary prior to creating a standardized call structure for PGY-2 residents especially with the newly mandatory integrated ophthalmology residency programs.

A Novel Ophthalmic Telemedicine Program for Follow-Up of Minor Ophthalmic Emergencies

Background: Near-term follow-up for minor ophthalmic emergencies is important to ensure positive patient outcomes but can impose logistical challenges for patients and ophthalmology practices. While ophthalmic telemedicine has been used for screening and triage, its feasibility and safety for follow-up care for minor ophthalmic emergencies have not been reported. The objective of this study was to report initial results of a novel virtual emergency department (ED) follow-up clinic. Methods: Retrospective cross-sectional study of patients discharged from the ophthalmic ED who required near-term follow-up and carried diagnoses suitable for virtual evaluation, between December 6, 2021, and June 26, 2022, at a single tertiary eye care center. Main outcome measures included missed appointment rate, time interval between ED encounter and virtual follow-up, clinical diagnoses, and referrals after telemedicine follow-up (including for urgent ambulatory and ED evaluation). Results: A total of 145 virtual visits were scheduled with 99 (68.3%) completed appointments, yielding a no-show rate of 31.7%. Of the completed visits, the mean time interval between ED evaluation and virtual follow-up was 8.3 days (standard deviation ±3.9). Eighty-four (84.9%) visits were video-based and 15 (15.1%) were audio-only. Seventy-nine (94%) had at least one aspect of the ophthalmic examination documented. The most common diagnoses were chalazion (18), conjunctivitis (13), corneal abrasion (12), and encounter after corneal foreign body removal (7). After virtual follow-up, 23 patients (23.2%) had subsequent referrals, and no patients re-presented to the ophthalmic ED. Conclusions: Ophthalmic telemedicine may be a safe and feasible modality for providing timely post-acute near-term follow-up care for patients with appropriate ophthalmic diagnoses.

Interventions to reduce loss to follow up in common retinal pathology: A systematic review

PURPOSE

Loss to follow-up or fragmented follow-up episodes (LTFU) may contribute to suboptimal clinical outcomes, especially when comparing real world data to clinical trials. This systemic review gathers available evidence around interventions meant to decrease the LTFU in AMD, RVO, and DME patients.

PATIENTS AND METHODS

PubMed was queried using a literature search strategy and reviewed by the authors. Studies with interventions aimed at reducing lost to follow up were included.

RESULTS

Ten studies were extracted from 89 candidate publications.

DISCUSSION

Telephone interventions featuring assistance in scheduling in improving LTFU in urban, African American populations over 50 years old with diabetic retinopathy. The same interventions have shown promise in glaucoma, but remain understudied in AMD, RVO, and other geographic, ethnic, and socioeconomic demographics.

CONCLUSION

No sole intervention with efficacy in improving LTFU has been developed. A standardized definition of LTFU, as well as testing interventions across broad age, geography, ethnic, racial, and socioeconomic lines. Longitudinal data would also add credence to the efficacy of purported interventions.

OTHER

No sources of funding for this article.

Improving Compliance to Follow-Up Care After Primary Emergency Department Ophthalmic Consultation

PURPOSE

To identify factors that affect the likelihood of follow-up after emergency department (ED) visit for ophthalmic complaints and to evaluate a protocol to improve compliance.

DESIGN

Prospective interventional study with historical controls.

METHODS

This study was conducted at Jamaica Hospital Medical Center in Jamaica, New York. The study population included 962 patients who presented to the ED and who required ophthalmology consultation. Participants in the control group were given only verbal follow-up instructions. Participants in the intervention group were given verbal instructions, written instructions, telephone calls, and, if not responding to calls, a mailed letter. The primary outcome was the overall follow-up rate. Secondary outcomes were follow-up rate by demographic subgroup.

RESULTS

Patients in the intervention group were significantly more likely to follow up (68.8% vs 42.9%, P < .001). Nearly all subgroups exhibited significantly improved follow-up with the intervention, with the exception of patients 18 to 29 years of age, patients with diagnosis severity class III, patients with no insurance, patients with hospital financial aid, patients paying with workers' compensation, and patients with an unknown employment status.

CONCLUSIONS

Before the intervention, most patients receiving ophthalmology consultation in the ED did not return for follow-up care. These patients tended to be young, unemployed, uninsured or use hospital financial aid, were in the control group, had good visual acuity, reported no change in vision, and had a condition that was not vision-threatening. Follow-up rates were improved in nearly all subgroups by providing written instructions, telephone calls, and mailed letters. Such instructions should be considered in similar populations.

Transition to a Night Float System in Ophthalmology Residency: Perceptions of Resident Wellness and Performance

Purpose The purpose of this study is to characterize the influence of a new night float rotation on resident wellness and performance in the Duke University Eye Center Ophthalmology Residency Program.

Methods We analyzed three classes of ophthalmology residents: one class (n = 4) utilized the new night float rotation with no daytime clinical duties, while two senior classes (n = 12) utilized the traditional call system wherein they had daytime and nighttime responsibilities. Residents completed a questionnaire regarding their perceptions of the night float rotation. Supervising attendings (n = 15) were also surveyed about their perceptions of the new rotation.

Results Zero of the four residents on the night float rotation reported burnout compared with 6 of 11 residents in the traditional call system. Most residents supported the adoption of the night float rotation, but this trend was less apparent among fellows and attendings.

Most respondents believed the new night float rotation reduced burnout, fatigue, and work hours while increasing time for nonclinical activities. Perceived skills gained while on call were felt to be similar between the two call systems. Fellows and attendings believed residents in the night float system performed similarly or better than residents in the traditional system in indicators such as knowledge and enthusiasm. There was no significant difference in the average number of patient encounters (290.8 ± 30.5 vs. 310.7 ± 25.4, p = 0.163), phone encounters (430.8 ± 20.2 vs. 357.1 ± 90.0, p = 0.068), or average hours worked per week (57.3 ± 4.6 vs. 58.0 ± 5.7 p = 0.797) per resident between night float residents and traditional call residents.

Conclusions This study shows resident support for a night float rotation in ophthalmology residency at Duke, with reductions in burnout and more time for nonclinical activities without affecting perceived clinical performance. We hope this study serves as an impetus for other ophthalmology programs considering a transition to a night float system.

Evaluation of Interventions Targeting Follow-up Appointment Scheduling After Emergency Department Referral to Ophthalmology Clinics Using A3 Problem Solving

Importance

Many patients seen for eye-related issues in the emergency department do not receive recommended follow-up care. Prior evidence supports that scheduling appointments is a barrier to accomplishing the transition to outpatient ophthalmology care.

Objective

To evaluate time until appointment scheduling following emergency department discharge with urgent outpatient ophthalmology referral.

Design, Setting, and Participants

The A3 problem solving process was implemented by a multidisciplinary team as part of a structured quality improvement program with the goal of reducing the mean time between urgent referral placement in the emergency department and outpatient ophthalmology appointment scheduling. The study was conducted at Stanford Health Care, an academic medical center in Palo Alto, California, affiliated with Stanford University School of Medicine. Using medical center administrative records, all patients discharged from the adult emergency department with an urgent outpatient referral to the Stanford Department of Ophthalmology from August 9 to September 19, 2020 (baseline; n = 43), and from October 26 to November 29, 2020 (after implementation of all interventions; n = 21), were included.

Interventions

Interventions developed to target the workflow of the ophthalmology resident, emergency department, ophthalmology clinic, and health system schedulers to address key drivers of the referral-scheduling process included medical record documentation guidelines, identification of responsible parties, preidentified appointment slots, patient education materials, and education of stakeholders, and were implemented by October 25, 2020.

Main Outcomes and Measures

Mean time between urgent referral placement (ie, emergency department discharge) and appointment scheduling with outpatient ophthalmology at baseline vs postintervention.

Results

At baseline, appointments were scheduled a mean (range) 2.8 (0-7) days after referral placement. In the 5 weeks following implementation of interventions, the mean (range) decreased to 1.3 (0-4) days, a difference of 1.5 days (95% CI, 0.20-2.74; P = .02). This corresponds to 642 (95% CI, 86-1173) days of reduced patient wait time annually. In addition, there was less variability in the number of days between referral and appointment scheduling after intervention compared with baseline.

Conclusions and Relevance

The results suggest improvement in efficiency of outpatient ophthalmology appointment scheduling of urgent emergency department referrals could be achieved through application of a quality improvement methodology by a multidisciplinary team representing key stakeholders in the process.

Inpatient Ophthalmology Consultations

Comprehensive patient care requires an integrated approach that often includes different specialties. Of these specialties, Ophthalmology stands out with its variable pathologic conditions, unique tools, and special examination techniques, which are not part of the standard training of internal medicine or other specialties. The authors review prior studies focused on inpatient ophthalmology consultations, common reasons for inpatient ophthalmology consultation, and the recommended approach to the most common ocular complaints that could present to the inpatient provider. They also shed light on the basic ocular history and eye examination that should be obtained before requesting an ophthalmic evaluation.

A summary of eye-related visits to a tertiary emergency department

Timely ophthalmologic consultation is important to ensure patients receive high quality ophthalmologic care in the Emergency Department (ED). Tele-ophthalmology may prove useful in safely and efficiently managing ED eye-related complaints. Prior to implementing such a solution, current consultation patterns must be understood. We aimed to assess case-mix acuity and consultation workflow patterns in the ophthalmology consult service at a tertiary emergency department in New York City. The medical records of patients with eye-related complaints who presented to the ED between January 1, 2015 and December 31, 2015 were reviewed. Visits were retrospectively assigned acuities and the ophthalmologic subspecialty involved in the case was recorded. The number of ophthalmologic consultations ordered and consultant response times were analyzed. Patients who were transferred to the ED for eye-related complaints were included. The ED received 1090 eye-related complaints in this period. 60% were retrospectively assigned low acuity, 27% were assigned medium acuity, and 13% were assigned high acuity. Ophthalmology was consulted on 19% of low, 18% of medium, and 48% of high acuity cases. 44% of complaints involved the anterior segment and 30% involved oculoplastics. 2/3 of transfer patients initially assigned high acuity were downgraded to low acuity upon examination. On average, the consult note was created and signed within 109 and 153 min, respectively, after consult order. ED consults are heavily weighted towards pathology of low-to-medium acuity affecting the anterior segment and ocular adnexa. Currently available tele-ophthalmology technology can potentially address a large volume of eye-related visits.

Ophthalmic Emergency Department Visits: Factors Associated With Loss to Follow-up

PURPOSE

To describe follow-up rates for patients referred for outpatient ophthalmic care after emergency department (ED) discharge and identify patient and visit characteristics associated with loss to follow-up (LTFU).

DESIGN

Single-institution retrospective cohort study.

METHODS

We analyzed the medical records of 2,206 patients seen in the ED for an eye-related issue who were subsequently scheduled for ophthalmology follow-up between 2013 and 2019 at a single tertiary health system. The main outcome measures were the frequency of and risk factors for LTFU and ED revisits.

RESULTS

In total, 1,649 (74.8%) patients completed follow-up within 2 months of an index ED visit. In multivariable analysis, younger age (P < .001), a nonurgent ophthalmic condition or nonophthalmic primary diagnosis (P < .001), scheduled follow-up >5 days after the ED visit (P < .001), additional follow-up appointments (<.001), no prior history of ophthalmology appointments (P = .045), a visual acuity of 20/40 or better (P = .027), and having Medicaid or being uninsured (P < .001) were significantly associated with LTFU. The presence of an interpreter significantly increased the likelihood of follow-up among non-English speaking patients (P < .001). LTFU was significantly associated with an ED revisit within 4 months of an index visit, and the ED revisit rate was significantly higher for patients LTFU vs those who completed follow-up (5.7% vs 1.1%; P < .001).

CONCLUSIONS

A quarter of patients referred for ophthalmic care after an ED presentation were LTFU. We identified numerous factors associated with LTFU that could be used to develop interventions to enhance follow-up. In addition, patients who were LTFU were more likely to revisit the ED for the same ophthalmic condition.

Current Models for Inpatient and Emergency Room Ophthalmology Consultation in U.S. Residency Programs

Objective This article examines models of patient care and supervision for hospital-based ophthalmology consultation in teaching institutions.

Design This is a cross-sectional survey.

Methods An anonymous survey was distributed to residency program directors at 119 Accreditation Council for Graduated Medical Education accredited U.S. ophthalmology programs in the spring of 2018. Survey questions covered consult volume, rotational schedules of staffing providers, methods of supervision (direct vs. indirect), and utilization of consult-dedicated didactics and resident competency assessments.

Results Of the 119 program directors, 48 (41%) completed the survey. Programs most frequently reported receiving 4 to 6 consults per day from the emergency department (27, 55.1%) and 4 to 6 consults per day from inpatient services (26, 53.1%). Forty-seven percent of programs reported that postgraduate year one (PGY-1) or PGY-2 residents on a dedicated consult rotation initially evaluate patients. Supervising faculty backgrounds included neuro-ophthalmology, cornea, comprehensive, or a designated chief of service. Staffing responsibility is typically shared by multiple faculty on a daily or weekly rotation. Direct supervision was provided for fewer of emergency room consults (1–30%) than for inpatient consults (71–99%). The majority of programs reported no dedicated didactics for consultation activities (27, 55.1%) or formal assessment for proficiency (33, 67.4%) prior to the initiation of call-related activities without direct supervision. Billing submission for consults was inconsistent and many consults may go financially uncompensated (18, 36.7%).

Conclusion The majority of hospital-based ophthalmic consultation at academic centers is provided by a rotating pool of physicians supervising a lower level resident. Few programs validate increased levels of graduated independence using specific assessments.

The New Ophthalmology Internship: A Trainee Curricular Survey

Background The American Academy of Ophthalmology, in conjunction with the Accreditation Council of Graduate Medical Education (ACGME), has mandated the creation of a linked ophthalmology internship year for all programs by 2021. This mandate provides a unique opportunity to tailor a curriculum specific to the ophthalmology trainee. This study reports the results of a national survey of ophthalmology residents and fellows regarding the relevance and applicability of extramural content to their ophthalmology training.

Methods Using the online portal SurveyMonkey, an anonymous survey was sent to 119 ACGME-accredited ophthalmology residencies. It consisted of nine questions formulated to measure the perceived applicability and relevance of other specialties to ophthalmology training. Responses were summarized with descriptive statistics. Outcomes were compared by one-way analysis of variance with Tukey's post hoc analysis for between group differences and Benjamini–Hochberg for multiple comparisons.

Results Ninety-four respondents (residents and fellows) completed the survey (January–February 2020); 52.1% completed an internal medicine internship, 42.6% transitional, and 5.3% general surgery. Overall, prior internship experience was rated favorably. Otolaryngology and radiology were deemed the most relevant to ophthalmology training. Intensive care unit (ICU) was considered the least beneficial, followed by general surgery, primary care, and pediatrics. Neuroradiology was overwhelmingly preferred over general radiology. The majority of respondents reported minimal exposure to oral and maxillofacial surgery (OMFS) in medical school/internship. When choosing a reason for inclusion in the new curriculum, respondents reported a high level of surgical overlap with otolaryngology, OMFS, and plastic surgery; clinical overlap with neurology; and ophthalmic consultation with emergency medicine.

Conclusion Several specialties—notably otolaryngology, radiology, and neurology—were considered highly relevant but lacking in preresidency exposure. The preference for neuroradiology was almost unanimous. In contrast, general surgery and ICU were found to be minimally relevant. Overall, ophthalmology residents reported a high level of satisfaction with their internship experience, an important consideration when building a curriculum that will appeal to potential applicants. The findings of this survey provide a framework to build a curricular plan based on current resident and fellow experience.

Inpatient and Emergency Room Ophthalmology Consultations at a Tertiary Care Center

Background

An ophthalmology consultation service is of significant benefit to patients in the hospital and is an instructive component of a residency education program. Ophthalmology consultations in a hospital present unique challenges to those seen in an outpatient clinic, for which the consulting ophthalmologist should be prepared. The purpose of this study was to profile the emergency room and inpatient ophthalmology consultations seen at an academic institution.

Methods

A prospective study of 581 patients was conducted on inpatient and emergency room ophthalmology consultations at the University of Illinois at Chicago over twelve months. Characteristics such as the consulting service, type of and reason for consultation, subspecialty staffing service, diagnosis, and suitability for in-hospital evaluation were recorded.

Results

Consultations were received from either inpatient wards (59.4%) or the Emergency Department (40.6%). The most common inpatient consulting services were internal medicine (22%), followed by neurosurgery (16%) and neurology (7%). All the consultations were categorized as acute (72.3%), chronic (6.0%), or screening (21.7%). Consultations categorized as screening included papilledema (31.0%), fungemia (20.6%), syndromic evaluation (19.8%), visual field evaluation (17.5%), and miscellaneous evaluation (11.1%). We classified the ophthalmic diagnoses into 63 unique diagnoses. Amongst the ophthalmic subspecialties, neuro-ophthalmologic diagnoses were the most common (32.0%), followed by retina (20.1%) and cornea (19.4%). Neuro-ophthalmology had the highest proportion of screening consultations (36.6%), while glaucoma had the least overall number of consultations (10.1%), and the least proportion of screening consultations (3.6%). A significant proportion of nonacute consultations (19.0%) was deemed to be more suitable for outpatient evaluation.

Discussion

Consultation databases can be useful in preparing trainees for in-hospital clinical care. A wide range of ocular pathologies may present to the ophthalmology consultant, from acute trauma to screening for systemic syndromes. Some consultations may be more suitable for outpatient evaluation which may help optimize patient care.

Comparison of Pediatric and Adult Ophthalmology Consultations in an Urban Academic Medical Center

PURPOSE

The purpose of this study was to compare pediatric and adult ophthalmology consultations in an urban academic center.

METHODS

A retrospective chart review of patients evaluated by the ophthalmology consultation service from January through June 2014 was conducted.

RESULTS

A total of 751 inpatients and emergency department patients were evaluated by the ophthalmology consultation service, of whom 152 (20.4%) were children and 598 (79.6%) were adults. The emergency department requested most of these consultations (42.8%), followed by internal medicine (39.1%) and pediatrics (18.4%) inpatients. More adult patients (94.5%) than children (76.5%) had abnormal findings on examination (P < .001). Altering management was recommended at a similar rate: 51.6% of pediatric patients and 54.3% of adult patients (P = .59). All children were initially seen by residents; children (38.6%) were more likely than adults (9.0%) to be seen with an attending physician (P < .001). Children (54.9%) were also more likely than adults (42.7%) to attend their recommended outpatient appointments (P = .027).

CONCLUSIONS

The authors identified several interesting differences between the pediatric and adult consultation services. Although adult patients were more likely to have abnormal findings, the ophthalmology team recommended a change in management for more than half of each group. These rates of intervention suggest that it is equally important that children be considered for an ophthalmology consultation and examined as soon as possible. In addition, residents may need particular guidance in evaluating pediatric inpatients. [J Pediatr Ophthalmol Strabimus. 2017;54(1):17-21.].

Relocation consequences on an ophthalmology consultation service from an inpatient to outpatient facility

Importance

This study shows that relocation of an academic ophthalmology residency program from an inpatient to an outpatient setting in western New York does not affect the consult volume but affects management patterns and follow-up rates.

Objective

To investigate the effects on the ophthalmology consultation service of an academic program with relocation from a Regional Level-1 Trauma center to an outpatient facility.

Design

Consultation notes from 3 years before and 3 years after the University at Buffalo’s (UB) Department of Ophthalmology relocation from a Regional Level-1 Trauma center (Erie County Medical Center) to an outpatient facility (Ross Eye Institute) were obtained from hospital electronic medical records and analyzed.

Setting

Hospitalized care and institutional practice.

Participants

All inpatient or Emergency Room Ophthalmology consultation patients from the Department of Ophthalmology at UB from 2004 to 2010 (1,379 patients).

Exposures

None, this was a retrospective chart review.

Main outcome measures

Patient demographics, reason for consult, diagnoses, and ophthalmic procedures performed by the UB Department of Ophthalmology before and after its relocation.

Results

Relocation to the outpatient facility did not affect consult volume (P=0.15). The number of consults focusing on ophthalmic conditions, as a percentage of the yearly total, rose 460% (P=0.0001), while systemic condition consults with ocular manifestations fell 83% (P=0.0001). Consults for ocular trauma decreased 65% (P=0.0034). Consults ending with a diagnosis of “normal exam” fell, as a percentage of the yearly total (56%, P=0.0023), while diagnoses of new ocular conditions rose 17% (P=0.00065). The percentage of consults for Medicaid patients fell 12% (P=0.0001), while those for privately insured patients rose 15% (P=0.0001). The number of ophthalmic procedures did not change, but postconsult patient follow-up fell from 23% at the Erie County Medical Center clinic to 2% after the move to Ross Eye Institute, a ≥97% decrease.

Conclusion and relevance

Relocation of UB’s academic Ophthalmology program from an inpatient department to an outpatient facility had no effect on its consultation patient or procedure volume, but it significantly affected the nature of consult diagnoses and decreased outpatient follow-up by >90% at the latter location. Many hospitals are creating separate outpatient facilities that may experience similar obstacles.