Almost no health-care profession that I can think of has experienced the rapid amount of change and enhanced scope of practice that optometry has over the past century. This metamorphosis continuesoptometrists are now not only recognized as valuable members of the health-care community, but in many cases, optometrists are joining emergency room (ER) health care teams.
The 2006 AOA Scope of Practice survey showed that 11% of O.D.s in the
I am part of this growing trend.
An Unspoken Plan
In 1995, I moved to a rural area of
To that end, I harbored a personal desire to provide emergency care in the local hospitals. While this goal seemed lofty, in my mind, it represented true acceptance of optometrists as part of the medical health care team.
My unspoken plan to obtain hospital privileges was a one-year plan. During this year, I wanted to meet and begin a relationship with the five primary health-care providers in my new hometown. I wanted to tell them about the services that my office provided and let them know that I was competent, compassionate and cooperative.
I planned to write letters to each of them whenever I saw one of their patients in my office. With this correspondence, I would demonstrate the level of care that I provided for their primary care patients. I also wanted to point out my role in caring for patients with diabetes, hypertension and other systemic conditions.
As with many great plans, however, this one proved unnecessary.
Send Them Right Over!
On my second day in practice, I received a call from a local M.D., who asked if I would see a patient with a metallic foreign body in his eye. Of course, I responded. Please send him right over!
My hands shook as the 3-year-old boys mother carried him in. Thankfully, with a little luck and some good anesthetic, I was able to calm the boy and successfully remove the metal. I followed up this visit, according to my plan, with a letter to the M.D. thanking him for the referral.
Four weeks later, the chief of staff at the local hospital made an appointment at my office for a comprehensive examination. This doctor had practiced in my new hometown for more than 12 years and was well known by everyone. After the exam, I walked him up to the dispensary to look at spectacle frames. As we sat at the dispensing desk, he asked if I would be willing to help with eye emergencies at the ER.
Of course, I replied.
Great, he said. Well have to get you staff privileges first. Ill send someone over with the application this afternoon so we can get that done.
I cannot remember what I said nextI was too amazed at my good fortunebut I think it was Thank you. I completed the application, and within the next week, it was approved. Many years later, I understood that my presence at this rural hospital was a win-win situation. My services expanded the scope of service that the hospital could offer to patients, and my testing brought in revenue.
ER Jargon A lot of people work in the ER, and all of them serve a different purpose when it comes to providing patient care. If you want hospital privileges, make certain that you know whos who and whats what in the ERand make certain that you know what youre asking for. Emergency Room (ER). This section of the hospital is equipped and staffed to provide prompt treatment for patients who present with acute illness, trauma and other medical emergencies. Hospital Privileges. Hospital privileges allow a practitioner to tend to his or her patients while they are hospitalized. Also, these privileges allow a practitioner to tend to patients in the ER, if such care is within his or her scope of practice. Director of Nursing (DON). The director of nursing, or nursing director, supervises the staff of registered and practical nurses in their care of the hospitals patients. Registered Nurse (RN). A registered nurse implements the patients care regimen in the hospital and assists the managing doctor as needed. Licensed Practical Nurse/ Vocational Nurse (LPN/LVN). LPNs (also known as LVNs) work under the supervision of an RN or physician. The difference between an RN and an LPN is the duration and intensity of the certification program. Chief of Staff. The chief of staff organizes the doctors in the hospital, resolves day-to-day complications, handles interstaff conflicts, oversees physician credentialing and aids in creating and enforcing hospital rules. On-Call Physician. The physician on call is the doctor who will be notified first if an emergency occurs at the hospital. This doctor responds to the call and then requests specialized assistance, if needed. Trauma Room (TR). Patients who arrive at the ER with severe trauma are treated here. This room has the equipment and the space neccessary for the patient to be treated by a team of medical professionals and specialists. Standard Operating Procedure (SOP). SOP is a set of rules, usually written, that detail normal operating procedures and policies for hospital employees and those doctors who have hospital privileges. Rounds. The regular visiting of patients by doctors, nurses and the other health-care professionals in the hospital to discuss the condition and care of patients who are in the hospitals in-patient care centers. Code Blue. This emergency code is used when a patient is in cardiopulmonary arrest and needs immediate, life-saving response.
"Eye Stuff"
During my first visit to the emergency room, the director of nursing and I looked through a box labeled Eye Stuff. It contained many odd things, including two Schiotz tonometers, Fox shields, rolls of litmus paper, sterile eye pads and iris scissors.
We also created an updated list of ophthalmic medications that I recommended be kept on hand. I asked the nursing director to order homatropine 5% instead of atropine sulfate, Tobradex (tobramycin and dexamethasone, Alcon) instead of Vasocidin (sulfacetamide sodium and prednisolone sodium phosphate, Novartis Ophthalmics), and Ciloxan (ciprofloxacin, Alcon) instead of Neosporin (neomycin and polymyxin B, King Pharmaceuticals). We also reviewed the ER examination form and the documentation requirements. Their requirements are the same as everyone elses, so I could easily comply with the paperwork needed for each emergency visit.
During this visit, I also learned that one of the physicians had a slit lamp in his office. Surprisingly, they rolled out an older Haag-Streit slit lamp. The physician happily offered to put the slit lamp in the ER full time, explaining that it only collected dust in his office.
On Call
Now, I felt confident that I was ready to begin seeing patients at the ER. The next evening, after receiving the call from the ER, I scrambled to my office to gather some extra items. I loaded my briefcase with a Perkins tonometer, ophthalmoscope, 90D lens, foreign-body kit, Alger brush and bandage contact lenses, and raced to the hospital. The nurses directed me to the trauma room, where they had neatly arranged every item from the Eye Stuff box along the top of the cabinets. After speaking with the patient, I diagnosed viral conjunctivitis.
Although this case was not overly challenging, I felt good knowing that the patient and the nurses seemed to appreciate my clinical skills.
Over the next 10 years, I was always on call for the emergency room at my hometown hospital. Often, when my telephone would ring during the night, it was the primary-care physician on the other end. He or she would always give me a history about the patient and was appreciative when I said, Ill be right there.
I managed a wide variety of emergencies over the years. Many times, patients presented with acute conjunctivitis or foreign bodies, but we also had a number of chemical splashes to the eyes. I established a protocol with the nurses on duty that in case of a chemical splash, they were to begin a normal saline rinse until I arrived. On more than one occasion, towels covered the floor of the trauma room because so much saline had been utilized. So, we purchased Morgan lenses for the eye stuff box, and the director of nursing and I trained the trauma nurses how to utilize this lens for extensive irrigation.
On several occasions, I had to refer the patients to area ophthalmologists for further care. These included penetrating injuries from BB guns, a perforated globe from a fence wire, blow-out fractures from trauma, and a complete hyphema with uncontrolled intraocular pressure. Most emergency calls, however, were within my scope of optometric practice.
Most Memorable Cases
My most memorable ER stories both involve painful trauma. In one case, a patient accidentally touched a curling iron to her cornea while styling her hair. The on-call physician called me at home to tell me that her eye was fried. I completely debrided the burned epithelium, applied a pressure patch and instructed the patient to return to my office for follow-up in 24 hours.
After the patient left, the on-call physician sat down next to me at the nurses station, where I was completing the chart. That was gross, he said. You were making me sick, peeling that ladys cornea off!
I laughed. How can you take care of car accident victims, gunshot wounds, and other blood-and-guts stuff when that bothered you? I asked. He did not know why the debridement bothered him so much, but his eye hurt now after watching the procedure.
In another memorable case, one of my employees called me one night and told me that her grandmother had fallen through a glass window and was severely cut on her arms. She said that the ambulance was on its way and that she knew that some of the glass had gotten in her grandmothers eyes. I arrived at the emergency room ahead of the ambulance, much to the surprise of the nurses and physician, as they had not called me. I explained that the incoming patient was the grandmother of one of my employees and that I might be needed. The grandmother did have multiple pieces of glass in her eye. I carefully removed the glass while the on-call physician began the long process of stitching up her arms.
Only once did I ever admit a patient into the hospital. The patient, a widower, had a postoperative uveitis. I instructed him to use prednisolone acetate drops every hour for 24 hours, but when he returned to my office for follow-up, he stated that he forgot to use the drops other than two or three times. After discussing his options, I decided to admit him to the hospital for treatment. The nurses kept the drops on schedule, and within 48 hours, his uveitis improved to a level that I thought he could care for on his own.
The Advantages and Disadvantages
One real advantage of holding hospital privileges has been access to laboratory facilities. In many cases of corneal ulcers or acute conjunctivitis, I send samples to the hospital laboratory for culture and sensitivity. The laboratory provides the sterile swabs with transport media. The lab faxes a report with preliminary findings within 24 hours and a final report with antibiotic sensitivities the next day. I also send patients directly to the hospital laboratory for blood work, especially if I need an immediate erythrocyte sedimentation rate or blood glucose level.
Record keeping in the emergency room has a learning experience. As a solo practitioner, I was accustomed to writing everything down at the end of a procedure, but in the emergency room, one of the nurses recorded each procedure as I performed it. Any time I used a cotton swab or bottle of normal saline, the nurses removed a tag from it and placed it on the patients record. This is added into their billing and inventory control system.
I adopted a style of calling out my findings to the nurse for transcription and then performing a thorough review of the record after the patient was discharged. By reviewing the chart immediately, I could check for completeness and comply with the hospital requirements. Each chart must be signed and time-stamped at the time of admission and the time of discharge. This took a little time to get used to, but the nursing staff always helped keep me in compliance.
Optometrist Kerry L. Beebe, in a recent article, cites additional income as another advantage of hospital practice.2 However, getting paid for my services has been the only difficulty that I experienced in providing ER care. If the emergency patient has third-party insurance, I can file a claim through my office with the place of service changed to urgent care center. In these cases, I typically receive payment without much trouble.
However, many ER patients may not have health care insurance. In these cases, I often do not receive proper payment. The hospital cannot collect fees for my services directly since I am not a salaried staff member, so the burden for collection was upon my office staff. But, the fees that I was unable to collect were minimal compared with the great benefits I received by truly becoming part of the health care team.
The networking with primary care physicians that occurred by working at the hospital has been invaluable. Area doctors and nurses would often refer patients to my office because they had met me in the emergency room. So, providing emergency room care certainly was a practice builder in the long run.
Dr. Bacigalupi was in private optometric practice in rural
1. American Optometric Association. 2006 Information and Data Committee. 2006 Scope of Practice Survey. Available at: www.optometryjaoa.com/article/S1529-1839(07)00153-4/pdf. (Accessed June 2007).
2. Beebe KL. Optometric hospital practice. Optometry 2007 Apr;78(4):194-6.
