How to triage a hospital’s ocular emergency
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As more optometrists become an integral part of hospital systems, we are becoming the first, and sometimes only, eye care specialist for patients presenting with ocular emergencies after hours to emergency departments and hospital urgent care centers.
Physicians in the ED and urgent care often rely on optometrists as a resource. However, it can take time to become comfortable conversing with ED or urgent care doctors and determining what pertinent information or testing you may need from the medical provider. You will also need to determine which patients need to urgently be examined by you, who needs to be sent directly to ophthalmology, and who can wait until the next business day and be seen in the clinic.
When a provider in an ER or urgent care calls after hours with the intention of seeking your medical advice about an ocular condition, there are a couple of things to remember.
Credentialing, terminology
First, you need to ensure you are credentialed with the facility at which you plan to examine the patient. This is especially important in the hospital setting when you will be evaluating the patient in their ED, urgent care center or eye clinic within the hospital. A clinical provider cannot examine a patient in that facility without obtaining credentialing privileges by that hospital’s administration.
Second, it is important to remember to use terminology that the medical provider will understand, avoiding acronyms and complex ocular anatomy. As we all know, ocular anatomy can be tedious, and most medical providers get only a snippet of ocular anatomy and disease in their 4 years of medical school, residency and fellowship.
Third, remember to get a thorough history from the medical provider, including the patient’s complaints, the duration of their symptoms, pain level and change in vision. Do not be afraid to ask them to check their last eye note if they have been seen by the hospital’s eye clinic to give you more information about their history. All of this information will be important for you to assess the urgency of the patient’s issue.
Requesting information
Different medical providers have different comfort levels when dealing with ocular emergencies, so request more information if necessary, but do not be frustrated if they are unable to provide it.
For example, if a patient presents with ocular trauma, it would be helpful for them to obtain imaging of the patient’s head and orbits. This can tell you if they have an open globe or retrobulbar hemorrhage fairly quickly and is especially helpful if their eyelids are too swollen to fully assess the eye, thereby expediting an emergency referral to ophthalmology. Any pupil changes would also warrant neuroimaging.
Medical providers can perform corneal staining and check the IOP as well, usually with a Tono-Pen (Reichert). Most clinics should be equipped with fluorescein strips, a wood lamp or a direct with blue light capability and a Tono-Pen; however, not every provider is at ease performing these tasks. If a provider is uncomfortable, and urgent ocular pathology cannot be ruled out over phone consultation, the optometrist should go into the clinic to fully assess the urgency of the patient.
Sometimes medical providers will call you with a diagnosis but want your input on medications and/or follow-up. In these cases, make sure that you listen to the provider and their justification for the diagnosis and treatment. If their rationale makes sense, and it is a condition that you both think can wait until the next day to be evaluated, it would be reasonable to allow the medical provider to discharge the patient at that time and have them follow-up with you the following day.
Historically, if a patient’s symptoms have been going on for a week, especially with no vision changes, the patient can usually wait to be evaluated. Most conjunctivitis or dry eye symptoms can be started on eye drops and followed up at a later time. If Tono-Pen was performed, and the IOP was found to be severely elevated, it would be prudent to go into the hospital to re-evaluate the patient’s pressure and lower it if necessary.
Remember that the ED staff can assist in administering eye pressure-lowering drops until you arrive. You would not want to wait to assess a patient if they are complaining of retinal complaints such as a new onset of flashes. Many medical providers are not comfortable removing ocular foreign bodies, and most have difficulty in assessing nuanced conditions such as iritis. If either of these are suspected, it is best for the optometrist to examine the patient. Many patients will not be straightforward, so you must trust your medical judgment and the medical provider to assess the urgency.
On-call duties for the optometrist can seem intimidating and challenging, but they can also be fun. Use your clinical experience to make good judgment calls and ask appropriate questions. There is a great responsibility in knowing medical professionals look to you as their eye care expert.
For more information:
Rachel Stephan, OD, FAAO, completed an ocular disease/primary care residency at a Navajo Nation Hospital and is now serving the Alaska Native population at an Indian Health Services Health Center. She can be reached at: thele1rl@gmail.com.
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