Fundus Photography in the Emergency Department: Saving lives, sight and time

Dr Hamish Dunn1,2,Ms Julia Costello1,2, Ms Megan Greig1, Mr Jason Montgomery1, Clin A/ Professor  Andrew White1, Dr Matthew Vukasovic1, Ms Alison Pryke1, Ms  Lakni Weerasinghe2, Dr Kai Zong Teo2, A/Prof Clare Fraser2
1Westmead Hospital, Westmead, Australia, 2University of Sydney, Camperdown, 2006

Around the world, Emergency Department’s (ED) are missing up to 13% of patients with clinical signs of blinding and life-threatening pathologies. These missed neuro-ophthalmic and ophthalmic emergencies are avoidable because they are detectable using fundoscopy.

Fundoscopy, looking at the back of the eye, gives a live picture of the brain and blood vessels, revealing critical information including detecting vascular changes, and raised pressure around the brain. However fundoscopy in ED with the direct ophthalmoscope is awkward to use and hard to interpret. A groundbreaking study in Atlanta found ED doctors were only examining 14% of patients who needed fundoscopy and were missing 100% of the pathology which would change their emergency management.

Westmead ED and Ophthalmology Departments collaborated on a research project which implemented the use of a portable non-mydriatic fundus camera (NMC) to take fundus photographs without the need for pupil dilation drops in the ED.

The project recruited a core group of Nurse Practitioners (NP) and doctors to highlight patients needing fundoscopy early in their ED journey, and conduct NMC photography. The photos taken were uploaded to the eMR and reviewed by the Ophthalmology team within 24 hours. The detection of neuro-ophthalmic emergencies by ED improved from 0.06% to 11.9% within two months. The fundoscopy rate improved from 6.4% during the same period the previous year to 89.5% during the trial.

This was the first portable NMC fundus photography program in Australia and demonstrates the value of collaborative fundus imaging for the safety of patients presenting to ED. It lead to rapid translation of evidence-based best practice at Westmead ED.

I am a Nurse Practitioner (transitional) at Westmead Hospital in the Emergency Department (ED). Westmead is an adult tertiary referral hospital in Western Sydney providing expertise in many diverse fields of medical care. One of the largest hospital complex’s in Australia serving a population of over 1.5 million people with one of the busiest ED’s seeing upwards of 65, 000 adult patients each year. My role operates within a multidisciplinary environment working as an advanced clinician primarily from the Urgent Care Centre (UCC) where the majority of the ophthalmic presentations are seen. Eyes are a not-so-secret passion of mine and I have done post-graduate qualifications in Ophthalmology and have previously worked in The Westmead Eye Clinic as well doing formal and opportunistic teaching on the subject of Emergency Eye presentations for both nursing and medical staff. I was the ED clinical lead on the FOTO-ED study.