Reliability of ophthalmic accident and emergency referrals: a new role for the emergency nurse practitioner?

Background and objectives: Annual attendances at the accident and emergency ( A& E) department of St Bartholomew's and The Royal London NHS Trust exceed 100 000 people of which 6% are ophthalmic. This study evaluated the accuracy of eye referrals from A& E senior house officers ( SHOs) and emergency nurse practitioners ( ENPs) and the impact any inaccuracies may have had on out of hours work. Methods: Over a four week period a record of all referrals from the A& E department was made. The doctor receiving the referral made a note of clinical variables as reported by the referring clinician. When the patient was subsequently reviewed by an ophthalmologist, a record was again made of these findings. Any discrepancies were recorded. Results: A total of 67 patients were recruited. ENPs were found to be consistently more accurate than SHOs in every aspect of the assessment, most notably in visual acuity ( p = 0.0029), and provisional diagnosis ( p = 0.012). Furthermore, had the examination findings been accurate, 58% of all SHO referrals seen after hours would have been triaged to the next available clinic but only 10% of ENP referrals could have been seen at the next clinic session ( p = 0.027). Conclusion: This study found ENPs to be more accurate than A& E SHOs in history taking, recording visual acuity, describing ocular anatomy, and making provisional diagnoses. A significant reduction in out of hours ophthalmic workload may be achieved in the authors' unit if ENPs were to see all eye emergencies.