Frequent attenders to ophthalmic accident and emergency departments

Abstract

The issue of recurrent attenders to eye casualties has received little discussion in the ethics and health policy literature. As many ophthalmology departments offer a walk-in emergency service, protocols need to be in place to ensure appropriate use of this resource and also to identify potential psychiatric comorbidity in such attenders. We illustrate the problem with a recent case. A 42-year-old woman self-presented 14 times over a 4-month period to the same ophthalmic accident and emergency (A&E) unit. On each occasion, she complained of a recurrent eye infection or requested removal of bandage contact lenses and instillation of topical fluorescein. Corrected visual acuity was 6/6 in each eye. The eyes were white and not infected or inflamed and no contact lens was found at any visit. It is likely that she was also co-attending a separate ophthalmic A&E unit. Ophthalmologists are perhaps unique in the UK in providing a casualty service distinct from the main accident and emergency department. This service is often ''walk-in'' and ''free at the point of delivery'' so that the normal gatekeeping mechanisms within the NHS are bypassed. Whether a walk-in service is right or wrong remains a contentious issue and is closely linked with patient empowerment and the recent drive toward a patient-centred health service. The need for an ophthalmic opinion is also fuelled by the general lack of specialist ophthalmic knowledge among general practitioners, casualty officers and other colleagues due to limitations in the undergraduate curriculum. The patience of both staff and fellow patients is often tested when such clients attend in an inappropriate and recurrent manner. It has been shown that increasing attendances are positively associated with older age, male gender and living locally, and inversely associated with being married. 1 Additionally, psychiatric illness has been shown to be twice as frequent among frequent attenders than controls. 2 To address this issue, appropriate hospital information systems and continuous departmental audit should be in place to allow early identification of such patients. Ophthalmology trainees should be competent in recognising common psychiatric syndromes, performing a mental state examination and be familiar with the Mental Health Act 1983 and associated law. 3 In particular, a psychiatry liaison service is an expanding and invaluable resource 4 , and early referral will result in better meeting the true needs of the patient and more efficient utilisation of ophthalmic A&E units.

Patterns of ophthalmological complaints presenting to a dedicated ophthalmic Accident & Emergency department: inappropriate use and patients' perspective

“…In addition, some patients with a non-acute condition such as blepharitis might not have had their condition fully explained to them initially to allow them to self-manage when their symptoms worsened. Other factors such as increasing age, living locally and psychiatric comorbidity have all been reported as potential reasons for frequent attenders 8 9…”