As the primary eye care provider, our practices provide the majority of eye and vision care to the public, but it is important for patients to know we also provide emergency eye care services. By providing emergency eyecare, we lessen the burden on urgent care facilities and emergency departments, as shown by data from 2010 to 2017 which reported that 44.8% of eye-related emergency department visits in the United States were for non-emergent conditions.1 In this article, we will review the steps needed to introduce ocular emergency care to a clinical practice, and it starts with creating a well-trained and knowledgeable triage staff.
OFFICE TRAINING & PROTOCOLS
When training staff for triaging, a general lesson on eye anatomy is a necessary foundation. The key ocular structures to review with staff include the lid adnexa, conjunctiva, cornea, anterior chamber, iris, lens, vitreous, macula, optic nerve, and retina. This will become important when interviewing patients, as discussed later.
Another important step in preparing staff for urgent care is to create office protocols for triaging emergencies, which will lead to a more effective office flow. Office protocols include exam blocks for scheduling “emergency,” “non-urgent/follow up” and “routine” exams. Staff should always inquire whether a patient is referred from another provider and have previous notes faxed or scanned prior to the visit.
The triage call documentation is the most important step for an efficient clinic flow. It’s important for staff to clearly record the visual complaints of patients, including onset of symptoms and ocular history. The first prompt for front desk staff to investigate involves vision status, including questioning the patient on when, where, and how their vision changed and whether it involves one eye or both. Then staff should inquire about other symptoms, including whether the condition is painful or painless. The phone call information can be placed on a triage form then scanned or into an EHR electronic note. Staff should avoid recording a patients’ complaint in a memo box or sticky note. If this is a new patient, the staff should get the patient’s name, contact information and medical insurance card to properly schedule and create the patient chart.
Once staff has documented the vision complaint and/or problem, they will triage a patient to urgent or non-urgent appointments. The staff involved in triaging can consult a scribe or doctor when unsure on an appropriate referral time. Once a patient is given a scheduled appointment time, it is encouraged that a patient arrives at the assigned time; this is important for maintaining office flow. If it’s a new patient, they should arrive at least 15 minutes earlier to complete the necessary paperwork.
DETERMINING SEVERITY
When interviewing patients, it is important to grade the severity of their complaints to assess the timeline for examination. To determine severity, the triage staff should ask the patient to grade their complaints. Grading is up to each provider. We grade from one to 10, where a score between one to five indicates mild symptoms, five to seven is moderate symptoms, and scores eight or greater are severe symptoms. Any patient with severe pain or sudden vision loss is a true urgent and possibly an emergent condition that should be seen the same day or next available. The team can always consult with their doctor to see when they would like the patient to come in.
One of the few ocular emergencies that requires immediate attention is a chemical splash into the eye. The patient should be instructed by staff to immediately use copious irrigation for 20 minutes2 prior to immediate arrival for ocular examination. In a retrospective study, 76 % of patients who irrigated their eye prior to seeking medical attention had a minimal grade 1 injury.3
For more information on when to refer certain injuries, please see the table below.
| INJURY SEVERITY | GENERAL REFERRAL TIME | INJURY EXAMPLES |
| Emergency | Immediately | Chemical burns; Central retinal artery occlusions (sudden, painless vision loss) |
| Very urgent | A few hours | Corneal perforation (open globe due to ulcers, trauma, surgery, etc.); Rupture globe (Usually trauma related); Acute glaucoma (high pressure); Sudden proptosis (eye bulge) |
| Urgent | Within a day | Corneal ulcer; Orbital cellulitis; Orbital injury; Corneal abrasion; Hyphema; Intraocular foreign body; Retinal detachment; Macula edema |
| Note: Generally speaking, any conditions not included in this table can be seen outside of the listed timeframes. | ||
COMMON MISTAKES
The number one common mistake when triaging is scheduling non-urgent appointments in emergency spots or double-booking appointments for non-emergent cases. Often, this is due to lack of triaging patient complaints and assessment. If there are open appointment slots, then this isn’t an issue and we are happy to see the patient. The patient care/clinic flow issue occurs when non-emergency patients are added to a fully booked schedule.
For example, a common complaint from patients is dry, burning, irritated eye. Often, these patients may be unnecessarily added as “emergency” patients to a busy schedule. However, if properly triaged and addressed by staff, artificial tears could have been recommended as the proper first step. If the symptoms did not improve in a few days, the patient can call back and we can see them the next available appointment.
Another example is a patient who has reported decreased vision for several months and calling for an emergency appointment. Many times, if the vision has been reduced for several months, it isn’t an emergency and patients can be scheduled the next available appointment. These examples are just a couple that can have a significant impact on clinic flow and the overall patient experience. Patients without severe vision loss or pain are generally placed in a less urgent appointment time, instead of “emergency” time slots. (See sidebar “Additional Tips for an Efficient Triage Work Flow” below for more information.)
Trauma Case Reports
THESE TWO CASE REPORTS INVOLVE OCULAR TRAUMAS WITH DIFFERENT SYMPTOMS AND VISUAL OUTCOMES. PHONE TRIAGE INCLUDED A SAME-DAY EMERGENCY APPOINTMENT.
CASE 1
A 24-year-old Hispanic female presented for a new emergency visit. The patient complained of blurred vision and pain. The onset was 10 days prior; the patient reported trauma to her left eye with a pen while at work. The patient did not seek any eye care prior to the exam. Her entering visual acuity without correction was 20/25 OU. The patient had a closed corneal perforation with grossly negative Seidel sign. The patient was seen the same day and consulted for surgical repair urgently. This was a true ocular emergency due to the risk of endophthalmitis. Following corneal perforation repair, at two-month post-op her best corrected visual acuity without correct was 20/25 OU.
CASE 2
A 68-year-old Black male presented for an established emergency exam. The patient reported painful and blurry vision to the right eye. The patient’s visual acuity without correction was 20/80 and pinhole 20/40. The patient three days prior had a fall involving a knife to the neck. This patient was rushed to the shock trauma unit due to the life-threatening condition. Upon examination, the lens was dislocating and causing acute angle closure. A laser peripheral iridotomy was performed the same day and was not successful in opening the angle. Patient was scheduled for complex cataract surgery with a sutured lens. This was a true ocular emergency due to increasing risk of angle closure glaucoma. At four-month post op, his best corrected visual acuity was 20/40 OD.
Additional Tips for an Efficient Triage Work Flow
CREATE EFFICIENT PHONE PROCESSES
It is still essential to create an effective phone line answering protocol and/or automated call menu for your patients and practice. This is the foundation of the effective scheduling, communication and helps with triage services to ensure patients receive a timely response. If you have team members answering the phone line, they should know the proper protocols of when, where, and how soon to schedule visits. If you use an automated voice prompt, the call menu should have several prompt buttons to direct the patients to scheduling, pharmacy refills, referrals from a physician’s office, and voicemail prompts to leave a message for the doctor/staff. It is especially important to have staff members regularly check the prescription refill lines especially prior to the weekend. Many patients may consider being out of drops as an emergency and will try to contact the office multiple times if they are out of refills or their prescriptions weren’t sent to the pharmacy. This leads to more inefficient use of staff time checking voicemails and contacting pharmacies. It is also a burden for the doctor on call. For example, an established primary open angle glaucoma patient that has no refills on their drop therapy will call the office and on-call doctor for an emergency. In the patient’s mind, this is a true emergency, however this often will cause frustration between providers, patients, and pharmacists.
For any patient who calls the practice, staff members should answer the call with an introduction that includes their first name and the question, “How may I assist you?” which is addressed appropriately. For emergencies, the staff member should ask the appropriate questions such as: Duration of the event? When did it start? How often does it occur? Where is it bothering you? Associated symptoms? And what have they done for relief? If the emergency event happened after hours, the office voicemail should give patients directions on what to do in a case of an emergency. If it is a medical emergency, many patients are directed to call 911 or go to the nearest emergency room. Otherwise, patients may be provided the on-call providers contact information or an answering service could be used to triage calls as necessary after hours and weekends. Often, these services will help to document and triage call appropriately and/or contact the provider on call.
PARTNER WITH REFERRING PROVIDERS
It is important to establish and build a network of surrounding clinics and emergency departments for clinician referrals. Providing assistance for ocular emergencies will reduce nonemergency patient encounters in emergency departments. Referring providers may include optometrists, urgent cares, primary cares, emergency departments, or nursing home facilities. Referring providers will typically send patients with eye conditions including, but not limited to: trauma, chemical burns, orbital cellulitis, retinal occlusions, retinal detachments, and acute angle closure.1 Establishing a good rapport with referring doctors involves, but is not limited to, an urgent referral time, proper treatment, and faxed examination notes to the referring doctor. In the end, communication is the key to success with patients, staff and referring providers to ensure our patients are getting the proper emergency care in a timely manner at the right time and the right place.
REFERENCE
- Saumya SM, Khanna CL. Ophthalmic Emergencies for the Clinician. Mayo Clin Proc. 2020;95(5):1050-1058. doi:10.1016/j.mayocp.2020.03.018.
BUILDING RELATIONSHIPS
For many ocular conditions, time is precious to preserving vision loss. Several conditions are not only vision-saving but, additionally, life-saving. Establishing emergency eye care services creates “forever patients” for your practice. This includes the patient who has Friday evening red eyes and macula-on retinal detachments.
Providing emergency care builds relationships from referring providers and lessens the burden on emergency departments. To avoid burn out, the practice must establish a rotation for doctors taking emergency appointments and on-call appointments. Additionally, a well-trained triage staff, call menus, and proper protocols will aid in triaging and treating ocular emergencies. OM
REFERENCES
- Mir TA, Mehta S, Qiang K, et al. Association of the Affordable Care Act with Eye-Related Emergency Department Utilization in the United States [published online ahead of print, 2022 Jul 2]. Ophthalmology. 2022;S0161-6420(22)00498-5. doi:10.1016/j.ophtha.2022.06.038.
- Bowling B. “Chapter 21: Trauma.” Kanski’s Clinical Diagnosis in Ophthalmology, Mosby, 2006, pp. 862–885.
- Pokhrel PK, Loftus SA. Ocular emergencies. [published correction appears in Am Fam Physician. 2008 Apr 1;77(7):920]. Am Fam Physician. 2007;76(6):829-836.
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