ACE-ing eye exams

Background

Optometrist Kelly Singleton, OD, MS, knew that many of the patients who could benefit from the care she provides to VA patients with low vision weren't accessing it.

“Sometimes when we get a patient, I think, ‘Oh, I could have helped you so much if I had seen you two years ago,’” she said. “We pick up on a lot of patients who got lost to follow-up for their eye care since COVID or patients that didn't know they were eligible for eye care within the VA.” A fall prevention clinic was helping patients who were seen at the hospital after a fall get eye care, but the vision issues of other medical patients mostly went unaddressed.

Meanwhile, hospitalist Alyson Honko, MD, ACP Member, was brainstorming services that the hospital's ACE unit could add to further improve outcomes for its patients. “What are some other cool things that we could do for geriatric patients on the ACE unit that maybe are a little bit different than what we do for our non-ACE patients?” she had wondered.

Bringing these ideas together, Dr. Singleton and the ACE unit task force created a low-vision screening program.

How it works

Launched in February 2023, the program entails Dr. Singleton, an assistant professor at the Medical University of South Carolina, being called for a consult on all patients admitted to the ACE unit. She comes to their bedsides and performs a standardized visual acuity, contrast sensitivity, and ocular health screen. If patients need visual aids during hospitalization, they get them, and if they need outpatient follow-up, it is scheduled.

“It was just a perfect part of how we really want to help patients be independent. Eye health is as important to their functional status as all the other things that we think of,” said Dr. Honko, assistant professor at the Medical University of South Carolina. It's also efficient, she noted. “Waiting around for the five days of diuresis in the inpatient setting, they can check off a couple of things that they have let fall to the wayside.”

Results

During the pilot period of the program, from February 2023 to March 2024, a total of 490 patients were cared for on the ACE unit; of these, 170, or 34%, received a low-vision consult. Forty-two percent of the patients who were seen had a new ocular diagnosis, and 25% of those already known to have vision impairment showed worsening. In all, 61% of the patients were referred for outpatient vision follow-up care, according to results published by the Journal of the American Geriatrics Society on Oct. 3, 2024.

The study also looked at why so many ordered consults didn't happen and found that 72% were due to patients being discharged before they could be seen. Only 14% were missed because of competing acute care procedures or tests.

“I was a little bit worried Kelly [Dr. Singleton] was going to come up and see these people and they're going to be at X-ray or they're going to be at CT,” said Dr. Honko. “For most of our patients, it's just because we don't have enough Kellys that they didn't get seen. That was the part of the data that surprised me. A lot of our patients spend a lot of time doing nothing in the hospital and there's probably a lot more things that we could accomplish for them.”

Challenges

Over the course of the pilot, Dr. Singleton made changes to try to catch more of the patients for a consult. First, she switched from rounding once a week to twice a week on the ACE unit. She also rearranged her schedule on those two days.

“I've moved all my outpatient visits to the mornings, and I spend my ACE time in the afternoons, because most of their procedures and testing and all that occurs in the morning,” Dr. Singleton said. The switch then raised the problem that patients nap during the afternoon, she continued. “I didn't want to wake them up if there wasn't a specific reason to. Recently, I've been trying to go by their rooms in the morning and say, ‘We're going to come this afternoon. If you're sleeping, do you want me to wake you up?’ They all say yes.”

Other hospital medicine programs might face more logistical barriers to integrating vision care, Dr. Honko acknowledged. “The VA is kind of uniquely aligned to do more outpatient-focused things for patients while they're inpatient,” she said. “Our inpatient unit sits right on top of all our outpatient clinics.”

Next steps

Although the low-vision screening program remains exclusive to the ACE unit for now, its effects have crept into other parts of hospitalist care. For one, Dr. Honko is more likely to call Dr. Singleton for a consult on a non-ACE unit patient who she thinks needs vision care.

Dr. Singleton also gives a lecture to residents who rotate on the ACE service, which includes demonstration goggles that simulate patients' visual impairments. “One day, we had a patient that was legally blind, living at home, doing his own insulin,” said Dr. Honko. “We had the residents practice drawing up insulin, and none of them could even get the number correct, wearing the goggles. It's really helpful for us to get a little bit of the patient perspective.”

Words of wisdom

“If you can think of something you can do in the inpatient hospital setting that's going to help make your patients stay more functional as outpatients, try to do it,” said Dr. Honko.

She offered another project of the ACE unit as an example. “We used to just go up and scream in all of the patients' ears because none of the veterans can hear,” Dr. Honko said. Then the team looked into potential solutions for patients with no or malfunctioning hearing aids. “Now we have amplifiers that we're getting our patients that honestly a lot of them like more than their hearing aids, because they feel like there's not as much to mess around with.”