Bacterial endophthalmitis is a sight-threatening eye infection, which may occur after penetrating injuries and ocular procedures. Bacterial load in the eye can double within 30 minutes. For this reason, European guidelines recommend delivery of endophthalmitis treatment within one hour of presentation
. More than 15,000 cataract surgeries and 35,000 injections were performed at central London’s Moorfields Eye Hospital in 2017; an efficient system of diagnosis and treatment is required to manage this devastating condition across the large network of Moorfields satellite sites.
Diagnosis includes sampling intraocular fluid, known as a ‘tap’, for microbiological analysis. Antibiotics are then administered directly into the eye by intravitreal injection. The hub-and-spoke model of care provided by Moorfields meant that standardising an endophthalmitis care package was vital to ensure all patients have immediate treatment across a large network.
Front line staff treating endophthalmitis reported on continuous difficulty in locating required equipment; confusion around locating antibiotic pre-packs and dilution instructions; and poor completion of post procedural paperwork. In an emergency department, this resulted in frequent wastage of antibiotic pre-packs and had a negative impact on antimicrobial consumption reporting for Moorfields.
An audit was conducted to look at the several-hour delays in ‘time taken to treat’. Reporting of treated endophthalmitis cases was poor; it was previously managed by submitting paper ‘pink incident forms’, which were provided with the antibiotic pre-packs. Furthermore, incidences at satellite sites (with either missing equipment or antibiotics) meant patients incurred delays to their treatment owing to transfer to the hospital’s main campus at City Road, London.
To address these issues, we worked towards the following goals:
- To reduce the time from initial diagnosis of endophthalmitis to administration of treatment to less than one hour to ensure best patient outcomes;
- To provide immediate and easy access to all necessary equipment and medication at Moorfields and at all appropriate satellite sites (at least 12) for emergency treatment of endophthalmitis;
- To provide all staff, including rotational staff, with a clear pathway of delivering emergency treatment at all Moorfields sites; easily accessible prepared kit in emergency endophthalmitis boxes; instructions on suitable treatment rooms; and designated and appropriately trained personnel to act as procedural assistants to achieve a defined treatment pathway;
- To ensure a rapid reporting process is in place to guarantee follow-up by relevant teams to all patients presenting with endophthalmitis.
We produced a tamper-proof endophthalmitis treatment pack called the emergency endophthalmitis box (EEB). The EEBs were made available across the wide network of Moorfields satellite sites and contain:
- Equipment to ‘tap and inject’ the eye;
- Antibiotics for treatment;
- Flow diagram of ‘tap and inject’ pathways;
- ‘Documentation of treatment’ sticker for medical notes;
- ‘Documentation of consent’ sticker for medical notes.
A procedure was drawn that described the box assembly process, storage arrangements and transfer pathways for patients from sites that do not stock the EEBs. All clinical staff who may be involved in assembling EEBs, or treating or assisting in ophthalmic emergencies, are required to familiarise themselves with this procedure and the process is promoted at induction.
All endophthalmitis cases are now reported using the electronic incident reporting system, making active surveillance of endophthalmitis cases more efficient.
The antibiotics included in the EEB are aimed at treating bacterial endophthalmitis; however, the equipment included can be used to ‘tap and inject’ the eye in cases of fungal endophthalmitis or acute retinal necrosis; the box is useful during a variety of emergency assessments and procedures.
The two forms of audit were performed before the EEB roll out. Pre- and post-EEB audits demonstrated a dramatic reduction in time to injecting the antibiotics to 20 minutes once the patient’s diagnosis and treatment plan were confirmed.
The first was a retrospective audit of practice before the introduction of packs, which demonstrated that, on average, a case would take 201 minutes from presentation to emergency injection.
The second audit relied on four simulated runs, divided into pre- and post-EEB introduction. The pre-EEBs simulation demonstrated that from presentation to ‘tapping and injection’ the process took anywhere between 80 minutes and 129 minutes. The simulated cases using the EEB prototype showed a dramatic reduction to <60 minutes for tapping and injecting. Furthermore, the time taken to anaesthetise, tap, dilute antibiotics and inject the eye using the kit was <20 minutes, which demonstrated that an EEB can dramatically decrease the preparation time.
Simulated scenarios were also employed with the roll-out of the first EEB version. A fellow presented as a mock endophthalmitis patient to the main hospital emergency department during a four-hour wait period. Time to injection was 73 minutes. Similar unplanned role plays will be repeated with every new intake of fellows, and also at various satellite sites, to ensure improvement in service is observed and consistent across all Moorfields sites and staff grades.
The most important lesson learnt is the need to work in a multidisciplinary team to implement a significant change on a big scale — in our case, across 12 satellite sites in London. Keeping everyone informed every step of the way is not an easy task when performing a service improvement project, and colleagues must be encouraged to express opinions and actively provide feedback. It is everyone’s business to improve patient experiences — service and quality improvement projects nurture effective working relationships between nurses, doctors and pharmacists.
Tanya Serebryanska, antimicrobial pharmacist, and Ronald Kam, consultant ophthalmologist, both at Moorfields Eye Hospital, London
 European Society of Cataract and Refractive Surgeons. ESCRS guidelines for prevention and treatment of endophthalmitis following cataract surgergy: data, dilemmas and conclusions. 2013. Available at: http://www.escrs.org/endophthalmitis/guidelines/ENGLISH_2018_updated.pdf (accessed November 2018)