Sir,

Most eye casualty departments provide a service far in excess of their capacity;1, 2 and review patients having non-urgent problems more appropriate for primary care or outpatient clinics.2, 3, 4, 5, 6, 7, 8 Historically, the accident and emergency (A&E) department at the Wolverhampton Eye Infirmary (WEI) has provided an open access casualty service from 0900–2100, on all days of the week. All patients are triaged at presentation by a nurse practitioner using the local triage practice. We studied the current utilization of our eye casualty services with special emphasis on the out-of-hours attendance.

Methods

All new patients attending the casualty at WEI over a 4-week period (1–31 October 2004) had information collated on: demographic data, referral source, presentation time, symptom duration, diagnoses, and management. Out of hours was defined as after 1700 till 2100.

Results

Out of 2546 patient contacts in the study period, 1597 patients were new and 949 patients had review appointments. Data collection was complete for 1295 (81%) new patients.

The mean daily new patient attendance rate (+/− SD) in the eye casualty was 50 +/− 14 during this period. This was lower on the weekend (Saturday: 39 +/− 7, Sunday: 29 +/− 5).

Time of presentation, duration of symptoms, and diagnosis are shown in Figures 1 and 2 and Table 1, respectively.

Figure 1
figure 1

Eye casualty presentation pattern.

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Figure 2
figure 2

Duration of presenting symptoms in the eye casualty. Symptoms duration categories: 1—up to 6 h, 2—>6 h up to 12 h, 3—>12 h to 1 day, 4—>1 day and up to 2 days, 5—>2 days to 1 week, and 6—>1 week.

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Table 1 Distribution (%) of diagnostic groups in all the patients compared to the out-of-hours subgroup
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Seven hundred and thirty-eight patients (57%) were minor emergencies and discharged at first attendance by nurse practitioners. Four hundred and seventy-nine patients (37%) had further review appointments in casualty, 11 (1%) were admitted for immediate management and 67 (5%) were redirected for management in outpatient, laser, or minor procedures.

Discussion

The demand for out- of -hours emergency care was examined and the number of new patients that registered out-of-hours was much lower than during the regular hours. Furthermore, over half of these patients were found to have had symptoms for longer than 12 h with only three patients needing admission and urgent treatment.

The number of self referrals in our patient group was high as in previous studies (85% versus 58–89%).2, 5 This reflects the historic availability of an open access casualty at WEI and to a lesser extent, the unavailability of direct access dedicated eye casualty after hours in surrounding ophthalmic departments.9

Based on our findings, the eye casualty opening hours have now been reduced to 0900–1700 all days of the week with after hours cover provided by the on-call doctors following review at the Acute Hospital A&E. The authors are aware that limiting the eye casualty hours may influence the utilization of emergency care services by patients with non urgent health problems after hours.10 We also revised the triage criteria with the revised criteria having shortened symptom durations.

In conclusion, a dedicated out-of-hours eye casualty seems to have a limited role We recommend such a reorganization to other units only after the respective units have similarly examined the demand for eye care in their casualty as part of the reorganization process.