Increasing Specialised Care for Eye Patients

PEER REVIEW: OPHTHALMOLOGY

Planning for our Future - Reconfigured Model of Eye Care Increases Specialist Care for Patients in the Community

‘Delivering Integrated Care in Ireland’

Pictured at the ICO Annual Conference 2022, which took place in the Kilkenny Convention Centre from May 16-18th were, Mr Tim Fulcher, President, Irish College of Ophthalmologists and Consultant Ophthalmic Surgeon, Mater Misericordiae with keynote speakers at the ‘Delivering Integrated Care in Ireland’ Symposium: Dr Margaret Morgan, Consultant Medical Ophthalmologist, Royal Victoria Eye and Ear Hospital, Dublin and CHO7; Prof William Power, Clinical Lead for Ophthalmology and Consultant Ophthalmic Surgeon, Royal Victoria Eye and Ear Hospital, Dublin; Ms Chriosa O’Conoor, Optometrist, Mater Misericordiae University Hospital, Dublin; Prof David Keegan, UCD Clinical Professor of Ophthalmology and Retina, UCD School of Medicine, University College Dublin. National Clinical Lead for Diabetic Retinopathy Screening.

The Irish College of Ophthalmologists (ICO) and the Clinical Programme for Ophthalmology continue to deliver the National Education Series for the Integrated Eye Care Team in 2022 in support of the expansion of specialist ophthalmic care to patients in the non-acute setting.

The National Education Series aims to support the implementation of the Integrated Eye Care Team model, highlighting the key rationale for establishing the team which is to deliver a health service that is patient focused, promotes evidence based practice, decompresses hospital based eye services and improves timely access to care for patients.

The specialty of ophthalmology has experienced rapid advances and innovations over the last two decades which now provide prevention and treatment for a significant proportion of sight threatening diseases.

The anticipated five fold increase in the elderly population by 2040 coupled with advances in treatment has demanded a reconfiguration of eye services countrywide.

The ICO and the National Clinical Programme for Ophthalmology is working extensively with the HSE and with the Department of Health to ensure the existing and projected future demand for eye care services in our population can be delivered.

The Clinical Programme has determined that, in line with Government policy, the majority of services should be provided within the community setting. As such, integration of acute and community services is essential in order to allow for rebalancing of access and delivery of eye care services from acute hospitals to the community. The aim is to provide high-quality, consistent, efficient and effective care. The development of a regionalised model appears to be the best means of achieving this aim.

Central to the reconfigured Model of Eye Care is the implementation of the Integrated Eye Care Team which will extend the delivery of specialist ophthalmic care in the non-acute setting.

The ICO fully supports this policy for increased patient care in the community, with clear referral pathways to acute hospital care.

Priorities for the Integrated Eye Care Teams include the management of children referred from the screening programme, collaborating with screeners to improve the accuracy of the referrals and managing adult patients with a focus on medical retina, glaucoma and the delivery of pre and post operative cataract care. The teams will provide ongoing care for patients diagnosed in the community or ongoing care for patients transferred from the acute hospital.

Consultant Medical Ophthalmologists lead and work as part of the Integrated Eye Care team and are co-located across the acute and community setting, to ensure access to acute inpatients services if required, subspecialty resources for more complex cases and cross specialty multidisciplinary care.

Allied health professionals working as part of the team include ophthalmic nurses, orthoptists, optometrists and ophthalmic technicians.

The delivery of the model of care is underpinned by clinical governance oversight promoting patient safety and the sustainability of a patient-centered model.

ICO and Clinical Programme National Education Meeting Series for the Integrated Eye Care Team

To support the implementation of the Model of Care recommendations, the ICO in

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Abbreviated Prescribing Information Telfast 120 and 180 mg film-coated tablets Each tablet contains 120 or 180 mg fexofenadine hydrochloride. Presentation: Telfast 120 mg: Peach, capsule-shaped, film-coated tablet with 012 on one side and a scripted e on the other side. Telfast 180 mg: Peach, capsule-shaped, film-coated tablet with 018 on one side and a scripted e on the other side. Indications for Telfast 120 mg: Telfast 120 mg is indicated in adults and children 12 years and older for the relief of symptoms associated with seasonal allergic rhinitis. Indications for Telfast 180 mg: Telfast 180 mg is indicated in adults and children 12 years and older for the relief of symptoms associated with chronic idiopathic urticaria. Dosage: Adults and children aged 12 years and over: One tablet once daily before a meal. Not recommended for children under 12 years. Studies in special risk groups (elderly, renally or hepatically impaired patients) indicate that it is not necessary to adjust the dose of fexofenadine hydrochloride in these patients. Method of administration: Oral. Contraindications: Hypersensitivity to the active substance or any of the excipients. Warnings and precautions: There is limited data in the elderly and renally or hepatically impaired patients. Fexofenadine hydrochloride should be administered with care in these special groups. Patients with a history of or ongoing cardiovascular disease should be warned that, antihistamines as a medicine class, have been associated with the adverse reactions tachycardia and palpitations. Interactions: Fexofenadine does not undergo hepatic biotransformation and therefore will not interact with other medicinal products through hepatic mechanisms. Coadministration of fexofenadine hydrochloride with erythromycin or ketoconazole has been found to result in a 2–3 times increase in the level of fexofenadine in plasma. The changes were not accompanied by any effects on the QT interval and were not associated with any increase in adverse reactions compared to the medicinal products given singly. Animal studies have shown that the increase in plasma levels of fexofenadine observed after coadministration of erythromycin or ketoconazole, appears to be due to an increase in gastrointestinal absorption and either a decrease in biliary excretion or gastrointestinal secretion, respectively. No interaction between fexofenadine and omeprazole was observed. However, the administration of an antacid containing aluminium and magnesium hydroxide gels 15 minutes prior to fexofenadine hydrochloride caused a reduction in bioavailability, most likely due to binding in the gastrointestinal tract. It is advisable to leave 2 hours between administration of fexofenadine hydrochloride and aluminium and magnesium hydroxide containing antacids. Fertility, pregnancy and lactation: Fexofenadine hydrochloride should not be used during pregnancy unless clearly necessary. Fexofenadine hydrochloride is not recommended for mothers breast-feeding their babies. No human data on the effect of fexofenadine hydrochloride on fertility are available. In mice, there was no effect on fertility with fexofenadine hydrochloride treatment. Driving and operation of machinery: On the basis of the pharmacodynamic profile and reported adverse reactions it is unlikely that fexofenadine hydrochloride tablets will produce an effect on the ability to drive or use machines. In objective tests, Telfast has been shown to have no significant effects on central nervous system function. This means that patients may drive or perform tasks that require concentration. However, it is advisable to check the individual response before driving or performing complicated tasks. Undesirable effects: Headache, drowsiness, dizziness, nausea. Refer to Summary of Product Characteristics for other undesirable effects. Pack size: 30 tablets. Marketing authorisation holder: Opella Healthcare, 82 Avenue Raspail 94250, Gentilly, France SAS T/A Sanofi. Marketing authorisation number: PA23180/003/002-003. Medicinal product subject to medical prescription. A copy of the SPC is available on request or visit www.clonmelhealthcare.ie. Last revision date: March 2022.

PEER REVIEW: OPHTHALMOLOGY

collaboration with the Clinical Programme for Ophthalmology introduced the National Education Series for the Integrated Eye Care Team in 2019.

The overarching aim of the series is to provide a platform for ongoing engagement and wider consultation with all key stakeholders to facilitate their contribution to the development, delivery and outcome evaluation of the reconfiguration of services.

The series is designed to inform stakeholders of the latest developments in the expansion of ophthalmic services, and to share examples and results from Community Healthcare Organisations (CHO’s) where the reconfiguration of services is being implemented.

The initial sessions concentrated largely on developments in the three Dublin CHOs (CHO6, CHO7 & CHO9) where new Consultant Medical Ophthalmologists have been appointed.

The series continued in 2020 and 2021 in a virtual format, due to COVID 19 public health restrictions. A number of meetings are taking place throughout 2022.

The 2021 webinar provided an update from the ophthalmic consultant team on the progress for the development of regional ophthalmic services in Cork/ Kerry to integrate hospital and community service and plans for the future. The meeting was chaired by National Clinical Lead Prof. Billy Power.

The team discussed the new Community Centre in Ballincollig, due to open later this year with 20 clinical rooms, which can accommodate 36 newly recruited staff and will allow over 30,000 patients a year to be seen at the facility. Two dedicated purposebuilt injection clean rooms are designated for intravitreal injections, which will provide the potential for 280 injections per week. This future additional capacity would provide a threefold increase to current injection capacity. The new clinic will be an enormous benefit to the current congestion in the hospital and community services, allowing access for patients with stable glaucoma, AMD and paediatric conditions to be seen, thereby restoring access for patients with surgical needs, including cataract, in the acute system.

Plans for the development of a second eye-theatre in South Infirmary Victoria University Hospital, Cork will also improve access for patients requiring cataract and other surgeries. A third dedicated eye theatre at the hospital, is in the business case plan for the expansion of services in 2021-2031, to accommodate ongoing growth in demand for cataract surgery.

The latest webinar in the National Education Series took place on April 28 this year, returning to Dublin with an update on the implementation of the Integrated Eye Care Team in CHO6 / Community Healthcare East.

ICO Annual Conference

The ICO Annual Conference, held in May this year, included symposia on “Delivering Integrated Care in Ireland” and “Planning for the Future” dedicated to the changing environment of eye care in Ireland and the future plans to manage the demand for services in light of our expanding and aging population, and the incredible new sight saving therapies available.

Despite the challenges of the past two years, much progress has taken place in the specialty of ophthalmology with investment into the new Integrated Eye Care Teams at community and hospital level, and the establishment of dedicated cataract theatres. There is much more to be done to address the waiting lists in ophthalmology and the ICO focus, alongside the work of the National Clinical Programme, remains on delivering a service equipped to manage the areas of greatest patient demand.

Save the Date: Eye Care in Focus Conference

The ICO is excited to announce plans for our first conference for the extended eye care team, which will take place in The Gibson Hotel, Dublin on Tuesday, October 4th, 2022.

The conference will be a full day meeting delivered via clinical symposia, guest lectures and panel discussion. The conference programme will be of interest to ophthalmologists, general practitioners, optometrists, orthoptists, nurses and technicians.

The conference programme and registration details will be shared via the ICO website www.eyedoctors.ie and Twitter @eyedoctorsirl over the coming weeks.

News - New Research on Willebrand Factor

New research from RCSI University of Medicine and Health Sciences has found that high levels in the bloodstream of a key protein involved in blood clotting called von Willebrand Factor can lead to poorer outcomes for breast cancer patients. The findings will help researchers and doctors to better understand and treat breast cancer to reduce the risk of life-threatening blood clots and cancer spread in patients. Published in the Journal of Thrombosis and Haemostasis, the research found that patients with breast cancer had very high levels of von Willebrand Factor in their blood and that patients with the highest levels had the poorest outcomes. This work suggests that analysis of von Willebrand Factor levels may be useful to help predict clinical outcomes in patients with breast cancer. The study also examined how breast cancer triggers high levels of von Willebrand Factor and found that breast tumour cells cause release of the clotting protein which helps the breast tumour cells to circulate in the blood stream and may aid breast tumour spreading to other organs in the body. Anticoagulant medication or blood-thinners which are already used to treat blood clots, could inhibit this effect by reducing levels of von Willebrand Factor and also preventing the spread of cancer cells in the blood stream. The findings of the research will help doctors to better understand why patients with breast cancer have increased risk of blood clots and also why this may contribute to worse disease, cancer progression and spread throughout the body. Dr Jamie O’Sullivan, Irish Centre for Vascular Biology, School of Pharmacy and Biomolecular Sciences, RCSI, said, "Our findings now show, for the first time, that this blood clotting may be caused by increased levels of a key pro-clotting protein, von Willebrand Factor and that the breast tumour cells directly interact with the blood vessel wall to promote release of this protein. Interestingly, this not only increases risk of blood clotting for these patients, but may also promote breast cancer cells spreading throughout the body via the circulation. Our work helps to better understand why patients with breast cancer have increased risk of blood clots and also why this may contribute to worse disease, cancer progression and spread throughout the body which will have a huge impact on the treatment of breast cancer and the outcomes for patients worldwide."

PEER REVIEW: MEDICAL TRAINING

Advanced Training for Medical Workers

The use of case method in the learning process of advanced training courses for medical workers in Ukraine and worldwide

Written by Tatiana Iarmak – http:// orcid.org/0000-0001-5371-2958; iarmak.tat@gmail.com; Lecturer of the Department of Advanced Training of Junior Medical Specialists at the Municipal Health Care Institution “Kharkiv Regional Medical Vocational College”, Kharkiv, Ukraine. Corresponding Author details: iarmak.tat@gmail.com

Key words:

Case method, case study, interactive technologies, education, educational process, innovations, medical workers

The aim of the study:

Show the importance of applying the case method in the educational process of advanced training courses for health professionals as a method of correlation between theory and practice which activates and optimizes the educational process; develop an ability to analyze; to draw conclusions, make independent decisions in particular in critical, atypical situations; form critical thinking; build confidence in making responsible decisions which will result in improving the professional level of every health worker.

Brief summary:

This article researches the use of case method in the learning process of advanced training courses for medical workers; displays the results of the optimization of the learning process using the case method and the prospects of their use in the learning process. The case method is an interactive technology aimed at forming new qualities and skills in students. Nowadays the case method is actively used in leading educational institutions in Europe and America and has its specifics of use in teaching of various disciplines. The case method is a specially prepared educational and methodical material which contains a structured description of situations taken from real practice. It is based on the solution of a specific problematic situation on the basis of a real case - a situational task. For medical workers, this is a real medical situation which is presented in the form of an educational task. For example, a real clinical case where a doctor or a nurse needs to diagnose a patient - prescribe tests, examination methods, treatment. Or it can be a case from medical practice during surgery, childbirth etc. The case method activates mental activity, reveals and improves students' learning abilities, creates conditions for creativity, increases the ability to analyze information, develops professional competence, ability to solve various problems, expands the scope of understanding of real situations at work. Students learn how to communicate, discuss, express their opinion, find the most correct and effective solution to the problem. This method has a great educational potential.

Background:

The case method first originated in 1870 in Harvard Law School. In 1912 the Harvard School of Business introduced a compulsory course - a method of situational analysis called "The Art of Doing Business". Students were given tasks and offered different solutions. It was necessary to choose the optimal one. The students were solving existing practical problems during classes. In Harvard, this method is called "situational decision-making exercises". Today it is used in the educational process of many educational institutions around the world in almost all fields.

The Case Clearing House of Great Britain and Ireland (European Case Clearing House (ECCH) since 1991), established in 1973 at the initiative of 22 higher education institutions is the leader in collecting and distributing cases. ECCH is a non-profit organization that is affiliated with organizations located in different parts of the world which spreads and uses case studies. ECCH currently consists of about 340 organizations, including The Harvard Business School Publishing, the London Business School in England, INSEAD, Fontainebleau in France, the Institute for Management Development (IMB) in Lausanne, Switzerland, the School of Management in Cranfield IESE in Barcelona, Spain. Each of these organizations has its own collection of unique cases, which ECCH has the right to distribute.

Specialists of the School of Public Administration J. Kennedy of Harvard University at the National Academy of Public Administration under the President of Ukraine (formerly the Institute of Public Administration and Local SelfGovernment) presented the case method in Ukraine in 1992. In 1996, the Center for Innovation and Development introduced the case method into the Ukrainian education system. In recent years, Ukraine has been paying more and more attention to innovative technologies in education. The need for innovative interactive approaches to learning is due to the intensity of information flows. Innovation in the educational process is a necessity. Modern innovations help to increase the efficiency of the educational process. Interactive learning technologies are one of the most effective modern methods for improving the quality of education, so the introduction of the "case method" or "situational methodology" in the practice of modern education is very important. Case study is becoming one of the promising learning technologies as it is aimed at the development of professional competencies and improvement of professional skills. According to the Strategy for the Development of Higher Education in Ukraine for 2021-2031 "The mission of higher education is to ensure sustainable innovative development of Ukraine through the training of highly qualified specialists, the creation and dissemination of knowledge ..."; "Priority principles of higher education development in Ukraine: professionalism, focus on achieving the highest quality of education ...".

In medical education, at the training courses for health professionals, the essence of the method consists in the following - the students are offered a real clinical situation from their professional profile which can have several solutions. The main thing is to find the best, most effective, i.e optimal solution to the problem presented. Students are divided into groups. The group analyzes the situation, discusses possible solutions to the problem for that finds out the causes of certain symptoms, makes up a plan of examination, suggests laboratory diagnostics, suggests a possible preliminary diagnosis, prescribes the most effective treatment, develops preventive measures and makes optimal decisions. When

solving the problem the students are active, exchange their points of views, analyze, give advice which helps a group to come up with an optimal solution to the problem and accelerates the uptake of the material. The peculiarity of the case method is that the problematic situation is created on the basis of a real clinical case, so that the students gain practical experience in solving problems with further use in the work. Thanks to the case method, the learning process is organized in a new way that students become active participants, motivated and involved in vivid discussions. It is a creative insightful process and at the same time a complex system, which includes modeling, method of a problem-based learning, imaginary experiment, method of description. The introduction of the case method or case study changes the role of the teacher – a teacher becomes an expert - assistant guiding students in solving the proposed tasks.

The case method as an interactive method of teaching promotes the formation and development of creative clinical thinking in medical professionals. This method allows to unleash the potential of a doctor or nurse to think creatively from a professional point of view, considering the individual characteristics of each patient. Today it is necessary to make decisions quickly, especially in critical situations, to have readyto-go methods of action, to own a situation. Every time prescribing treatment, examination diagnosing a patiant, the doctor solves the case. The nurse participates in the treatment of the patient together with the doctor. She performs all medical procedures and manipulations prescribed by a doctor and is responsible for the quality of their conduct, which depends on her competence, skills and abilities.Therefore, a nurse should be able to make her "nursing diagnosis" and prescribe "nursing treatment". Today, there are many definitions of a nursing diagnosis, which are recognized as a part of the professional activities of a nurse. “Nursing diagnosis” is “The patient's state of health established as a result of a nursing examination and requiring intervention by a nurse” (Carlson, Kraft, & McGure, 1982). The Classification of Nursing Diagnoses (McLain) was first proposed in 1986. "A nurse must always perform her duties professionally, continuously improve their special knowledge and skills, improve their cultural level" (Article 3. "Code of Ethics for Nurses"). Competence, expertise, qualification of both the doctor and the the nurse allow to analyze clinical cases and situations in the best way and make an optimal decision. And the case method is of great help here.

Conclusions:

The use of the case method or case study in the educational process of advanced training courses for health professionals is a necessity. It is very important in education for adults. Adults already have professional and life experience, skills, abilities, which contributes to a greater understanding of situational problems, their solution. The method allows to develop creative and critical clinical thinking in both the teacher and students; activates, stimulates, motivates to learn. The method opens prospects to significantly improve the quality of education, to fill the educational process with creative content. Advantages of use - interactivity, efficiency, optimization of educational process. Advantages of the case method - it develops problemsolving and decision - making skills, initiative, individual and collective responsibility, working with the team, argument skills to defend one’s point of view, improves communication and presentation skills, makes everyone an active participant, increases interest in the material learned, links theory with practice. The case study method brings novelty to the teaching and learning process and increases the efficiency of the educational process. The case method in the educational process performs such important functions as educational, analytical, research, training, prognostic.