Red Eye

New Tools Mean New Roles for Staff in Managing Red Eye

Technicians and front desk personnel collaborate in diagnosis.

By Marguerite McDonald, MD, FACS

Conjunctivitis is a common ocular malady that can be viral, bacterial or allergic in origin. Studies have found adenovirus to be the cause of conjunctivitis in 15 to 70% of cases. Adenovirus is highly contagious and has symptoms such as redness, watery discharge and visible follicles. Bacterial and allergic conjunctivitis also display these symptoms. Unfortunately, this can lead to misdiagnoses, even by the cornea fellowship trained specialists. It’s been shown conjunctivitis is misdiagnosed approximately 50% of the time. Our office has implemented a red eye protocol to better manage conjunctivitis patients. We find this protocol allows us to offer patients an accurate diagnosis and, subsequently, best-in-class care. From a practice management standpoint, using this protocol exemplifies the importance of involving front desk staff and practice technicians effectively.

Identifying Potential Carriers

In my practice, the front desk staff is the first line of defense against conjunctivitis. They’re trained to identify anyone who walks through the door with red, “weepy,” eyes. To minimize the spread of infection, they immediately engage the patient, greeting and ushering him or her to a designated room before they sit down or touch anything on the front desk or in the waiting area.

Once the patient is in the designated “red eye” exam lane, a technician takes the patient’s history. If the technician suspects the patient does, in fact, have conjunctivitis, an AdenoPlus (Nicox, Inc., Dallas, Texas) diagnostic test is immediately performed to determine whether it is viral in origin (see “An Answer for Red Eye in 10 minutes” on page 35). The techs follow the protocol (parameters/symptoms) established by the doctor. It might seem unorthodox to have a technician make a judgment call, but that’s precisely why the test is so popular. It empowers techs, and accordingly, helps the practice run smoother. One example: With this system, the doctor does not have to visit the patient twice, once to order the test and again for final diagnosis. The test strip is not difficult to administer and in 10 minutes, it can confirm or rule out the presence of adenovirus.

The AdenoPlus (Nicox, Inc.) identifies the adenovirus in a matter of minutes.

It is important to note the doctor confirms diagnosis in the exam room and has the final say on diagnosis. The data is entered into EHR while the doctor is present.

Communicating With the Doctor

In my practice, techs who administer the test post a note on the exam room door to let me know precisely when the test was run. I don’t enter the room until at least 10 minutes have passed, so I don’t waste time waiting for results. When I enter the lane, I check the results, perform my slit lamp exam, and prescribe either an anti-viral such as ganciclovir gel for a positive test, or an antibiotic such as besifloxacin for a negative test. Management of these patients provides an opportunity for technicians to take the lead in making an initial diagnosis.

The Cost of Misdiagnosis

Historically, achieving a differential conjunctivitis diagnosis has been problematic. A review of the literature by Rietveld, et. al concluded that symptoms alone do not differentiate viral from bacterial conjunctivitis. While cultures are effective, the delay in receiving results and the self-limiting nature of conjunctivitis has made them highly impractical. Misdiagnosis and the subsequent inappropriate treatment of conjunctivitis cause unnecessary office visits and prescription costs for patients.

The spread of conjunctivitis in the community is better contained by the red eye protocol for conjunctivitis, resulting in fewer people who must lose days from work and school. In addition, inappropriate use of antibiotics has myriad adverse effects on the healthcare system, such as promotion of microbial resistance and medication toxicity. The cost of developing new antibiotics which obsolesce quickly is enormous and drives up the cost of prescriptions for patients and creates a disincentive for pharmaceutical companies to develop new antibiotics.

Teamwork

Point-of-care diagnostics for conjunctivitis fills a huge void in our management and treatment of these patients. Patients are impressed with the technology and appreciate our red eye protocol and both technicians and staff play an integral role in achieving effective diagnosis and treatment. OP

Dr. McDonald is a cornea and refractive surgery specialist at Ophthalmic Consultants of Long Island in Lynbrook, N.Y. She’s also a clinical professor of ophthalmology at New York University Langone Medical Center in Manhattan and an adjunct clinical professor of ophthalmology at Tulane University Health Sciences Center in New Orleans.